Is there still a place for retroperitoneal lymph node dissection in clinical stage 1 nonseminomatous testicular germ-cell tumours? A retrospective clinical study

Abstract

Background: Primary retroperitoneal lymph node dissection (RPLND) ultimately lost its role as the standard management of clinical stage (CS) 1 nonseminomatous (NS) testicular germ cell tumours (GCTs) in Europe when the European Germ Cell Cancer Consensus Group released their recommendations in 2008. Current guide-lines recommend surgery only for selected patients but reasons for selection remain rather ill-defined. We evaluated the practice patterns of the management of CS1 patients and looked specifically to the role of RPLND among other standard treatment options.

Methods: We retrospectively evaluated the treatment modalities of 75 consecutive patients treated for CS1 NS at one centre during 2008-2017. The patients undergoing RPLND were selected for a closer review. Particular reasons for surgery, clinical features of patients, and therapeutic outcome were analyzed using descriptive statistical methods.

Results: Twelve patients (16%) underwent nerve-sparing RPLND, nine surveillance, 54 had various regimens of adjuvant chemotherapy. Particular reasons for surgery involved illnesses precluding chemotherapy (n = 2), patients´ choice (n = 4), and teratomatous histology of the primary associated with equivocal radiologic findings (n = 6). Five patients had lymph node metastases, two received additional chemotherapy. Antegrade ejaculation was preserved in all cases. One patient had a grade 2 complication that was managed conservatively. All RPLND-patients remained disease-free.

Conclusions: Primary RPLND is a useful option in distinct CS1 patients, notably those with concurrent health problems precluding chemotherapy, and those with high proportions of teratoma in the primary associated with equivocal radiological findings. Informed patient's preference represents another acceptable reason for the procedure. RPLND properly suits the needs of well-selected patients with CS1 nonseminoma and deserves consideration upon clinical decision-making.

Keywords: Lymph node dissection; Nonseminomatous tumour; Teratoma; Testicular germ cell tumour.

Fig. 1

Histology and clinical stages in 378 patients with testicular germ cell tumours treated in a single institution, 2008–2017 (numbers of patients). GCT germ cell tumours; S seminoma; NS nonseminoma; CS clinical stage

Fig. 2

Intraoperative site during right sided nerve sparing retroperitoneal lymph node dissection of pt #12 showing two lumbar postganglionic sympathetic nerve fibres between inferior vena cava and aorta. IVC inferior vena cava

Fig. 3

Intraoperative site during RPLND of a patient #5 with polycystic kidney disease. IVC inferior vena cava; LRV left renal vein

Fig. 4

(left) abdominal computed tomography (pt #9) showing lymph node of equivocal size (arrow) in the para-aortal template (axial scan). (right) same patient, CT showing suspicious para-aortal lymph node in coronal scan. Histologically, no metastasis was found in this lymph node

Fig. 5

Histologic section of lymph node specimen from RPLND (pt #11). Metastasis consisting of pure teratoma with cystic elements lined by squamous cell epithelium (left side of figure). Intact lymph node tissue on the right side. Hematoxylin eosin stain, original × 100