Surgical management of low-stage nonseminomatous germ cell testicular cancer.
The optimal treatment of low-stage nonseminomatous germ cell testicular cancer (NSGCT) is controversial. For clinical stage (CS) I NSGCT, retroperitoneal lymph node dissection (RPLND), two cycles of chemotherapy and surveillance are all accepted treatment options. For CS IIA-B, standard treatments include RPLND (+/- adjuvant chemotherapy) and induction chemotherapy (+/- RPLND). The long-term survival rate is >97% for CS I and 95% for CS IIA-B NSGCT, regardless of the treatment received. The risk of retroperitoneal metastasis varies by clinical stage (25-35% for CS I, 65-85% for CS IIA-B), and the presence of lymphovascular invasion and percentage of embryonal carcinoma in the primary tumour. Patients with elevated serum tumour markers (STMs) and adenopathy of >3 cm are at high risk of having occult systemic disease. Compared with chemotherapy, RPLND is associated with a considerably more favourable long-term morbidity profile and is the most effective method for controlling the retroperitoneum. Surveillance is associated with the lowest risk of long-term complications. As such, we favour surveillance for low-risk CS I, induction chemotherapy for those at high risk of systemic disease (elevated STM, adenopathy >3 cm), and RPLND for all others. Modified template dissections reduce the risk of ejaculatory dysfunction, but might increase the risk of local recurrence. Therefore, we favour a full-bilateral template dissection with nerve-sparing in patients with low-stage NSGCT. The therapeutic efficacy of laparoscopic RPLND is not proven and currently should be considered a staging procedure only. Adjuvant chemotherapy after RPLND is typically restricted to patients with pathological stage N2-3 disease.
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195-0001, USA. stephea2@ccf.org
Andrew J
AJ
Stephenson
Eric A
EA
Klein
D017024:Chemotherapy, Adjuvant; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008197:Lymph Node Excision / Q000379:methods; D008207:Lymphatic Metastasis; D008297:Male; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control; D009373:Neoplasms, Germ Cell and Embryonal / Q000473:pathology / Q000601:surgery*; D009919:Orchiectomy / Q000379:methods; D012186:Retroperitoneal Neoplasms / Q000601:surgery; D018570:Risk Assessment; D012307:Risk Factors; D013736:Testicular Neoplasms / Q000473:pathology / Q000601:surgery*