title: Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: impact of patient selection factors on outcome.
abstract: OBJECTIVE
  To investigate the impact of patient selection criteria on the outcome of patients with nonseminomatous germ cell testicular cancer (NSGCT) treated by primary retroperitoneal lymph node dissection (RPLND). Since 1999, our criteria have excluded patients with persistent postorchiectomy elevation of serum tumor markers (STM) or clinical stage (CS) IIB disease from RPLND.
  
  
  METHODS
  Between 1989 and 2002, 453 patients underwent primary RPLND at our institution for CS I to IIB NSGCT. Patient information was obtained from a prospective database. Retroperitoneal pathology and relapse rates were compared for patients treated before and after application of the current selection criteria in 1999.
  
  
  RESULTS
  By excluding patients with elevated STM or CS IIB disease after 1999, the proportion of pathologic stage II patients with low-volume (pN1) retroperitoneal disease increased significantly (40% before 1999 v 64% after 1999; P = .01), without significantly affecting the rate of retroperitoneal teratoma (21% v 22%, respectively; P = .89) or pathologic stage I disease (56% v 67%, respectively; P = .06). For patients who did not receive adjuvant chemotherapy, the 4-year progression-free probability improved significantly from 83% before 1999 (95% CI, 79% to 88%) to 96% after 1999 (95% CI, 91% to 100%; P = .005). Elevated postorchiectomy STM (P < .0001), clinical stage (P = .0002), and pre-1999 RPLND (P = .05) were independent pretreatment predictors of progression.
  
  
  CONCLUSIONS
  Excluding patients with CS IIB disease or elevated postorchiectomy STM from primary RPLND has had a favorable impact on the extent of retroperitoneal disease and has significantly reduced the risk of relapse after RPLND. For patients with normal STM and CS I to IIA disease, the low rate of systemic progression and 22% incidence of retroperitoneal teratoma supports RPLND as the preferred primary intervention.
authors.affiliation: Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Stephenson
authors.forename: George J
authors.initials: GJ
authors.lastname: Bosl
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Motzer
authors.forename: Michael W
authors.initials: MW
authors.lastname: Kattan
authors.forename: Jason
authors.initials: J
authors.lastname: Stasi
authors.forename: Dean F
authors.initials: DF
authors.lastname: Bajorin
authors.forename: Joel
authors.initials: J
authors.lastname: Sheinfeld
mesh_terms: D014408:Biomarkers, Tumor / Q000032:analysis; D018450:Disease Progression; D006801:Humans; D008197:Lymph Node Excision; D008297:Male; D009367:Neoplasm Staging; D009373:Neoplasms, Germ Cell and Embryonal / Q000473:pathology* / Q000601:surgery*; D009919:Orchiectomy; D018579:Patient Selection; D011379:Prognosis; D012189:Retrospective Studies; D013736:Testicular Neoplasms / Q000473:pathology* / Q000601:surgery*; D016896:Treatment Outcome
chemical_list: D014408:Biomarkers, Tumor