title: Is routine primary retroperitoneal lymph node dissection still justified in patients with low stage non-seminomatous testicular cancer?
abstract: We present 8 years' experience of primary retroperitoneal lymph node dissection (RLND) in 190 patients with low stage non-seminoma; 154 patients had clinical stage I (CSI) and 36 had clinical stage IIa (CSIIa) disease. Of the 154 patients with CSI tumours, 33 had increased serum AFP and/or HCG before RLND (CSIM+) and 121 had normal tumour markers (CSIM-). Retroperitoneal lymph node metastases (pathological stage II) (PSII) were found in 38 of 121 patients with CSIM-, in 19 of 33 patients with CSIIM+ and in 26 of 36 patients with CSIIa. In a multivariate analysis, the presence of small vessel infiltration (demonstrated in histological sections of the primary tumour) and a prolonged tumour marker half-life were predictive factors for PSII. These 2 factors enabled a group of non-seminoma patients with CSI disease to be identified who had a 15% risk of retroperitoneal tumour growth (low risk group) as compared with a high risk group where 60 to 70% of patients had retroperitoneal lymph node metastases. Relapses occurred in 7 of 107 patients with PSI and in 6 of 83 patients with PSII disease; in the latter group, 5 relapses developed before the start of routine adjuvant chemotherapy; 6% of patients developed major post-operative complications. In addition, "dry ejaculation" was the principal side effect following RLND (unilateral RLND: 20/132 patients; bilateral RLND: 50/54 patients). The comparative cost to the health service during the first year of follow-up was estimated for low risk non-seminoma patients with CSI subjected to RLND and for those in whom a surveillance policy was adopted. The latter approach was preferable. It was concluded that a surveillance policy should be followed in low risk non-seminoma CSI patients provided that frequent follow-up is possible. A more active policy is recommended in high risk patients (e.g. adjuvant chemotherapy without RLND). Nerve-sparing RLND may be considered in patients with CSIIa disease and negative tumour markers.
authors.affiliation: Department of Medical Oncology, Norwegian Radium Hospital, Oslo.
authors.forename: N
authors.initials: N
authors.lastname: Aass
authors.forename: S D
authors.initials: SD
authors.lastname: Fosså
authors.forename: S
authors.initials: S
authors.lastname: Ous
authors.forename: H H
authors.initials: HH
authors.lastname: Lien
authors.forename: A E
authors.initials: AE
authors.lastname: Stenwig
authors.forename: E
authors.initials: E
authors.lastname: Paus
authors.forename: O
authors.initials: O
authors.lastname: Kaalhus
mesh_terms: D000293:Adolescent; D000328:Adult; D014408:Biomarkers, Tumor / Q000032:analysis; D004542:Ejaculation; D006801:Humans; D008197:Lymph Node Excision / Q000191:economics; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology; D009367:Neoplasm Staging; D011183:Postoperative Complications; D011237:Predictive Value of Tests; D012187:Retroperitoneal Space; D013724:Teratoma / Q000473:pathology / Q000601:surgery*; D013736:Testicular Neoplasms / Q000473:pathology / Q000601:surgery*
chemical_list: D014408:Biomarkers, Tumor