Extent of surgery after chemotherapy

Historically, RPLND encompassed a full bilateral suprahilar dissection from ureter to ureter, from the crus of the diaphragm to the bifurcation of the common iliac arteries [63]. In the early 1980s it was shown that right testicular tumors were more likely to have metastatic tumor deposits in the interaortocaval zone, just below the left renal vein. Left-sided primary testicular tumors were more likely to have tumor spread in the preaortic and left para-aortic areas. The right and left suprahilar zones were rarely involved in low-stage disease [64]. Surgical techniques were modified to omit routine suprahilar dissection for low-volume disease [65]. Earlier treatment of lower-stage, low-volume disease with smaller residual masses led to an increase in the role of template dissections and nerve-sparing techniques, which improved the chance of retaining antegrade ejaculation [2,66]. These template approaches are balanced with the risk for residual germ cell tumor or teratoma outside the field of resection, however.

Multiple institutions have examined the role of limited RPLND in the post-chemotherapy setting. Aprikian and colleagues [67] from Memorial Sloan-Kettering Cancer Center studied the use of intraoperative frozen section analysis to dictate the extent of surgery in 40 patients who had met-astatic NSGCT. If frozen section revealed necrosis, then a modified template RPLND was performed; however, if teratoma or viable tumor was found, then a bilateral RPLND was attempted. Twenty-one patients (53%) had necrosis

Table 2

Complicated retroperitoneal lymph node dissection after chemotherapy

Study

Clinical

Year N stage

Tumor marker levels

Residual masses (cm)

Salvage

Donohue et al [33] 1998 80 II-III

Normal

Hendry et al [16] 2002 112 II-IV

46% normal, 54%elevated

Normal and elevated

Desperation

Elevated

Eastham et al [60] 1994 16 B3 Coogan et al [61] 1997 15 B = 7.

Elevated Elevated

NS NS

Median

Necrosis N Teratoma N Carcinoma N follow-up Survival (%) (%) (%) (months) (%)

NS NS

NS NS

NS NS

NS 108

12/15 3-127

99/180 (60%) NED, 3/180 (2%) AWD, 64/ 180 (39%) DOD 62% 5-y NED, 56% 5-y overall survival 28/90 (31%) NED, 5/90 (6%) AWD, 55/90 (61%) DOD,

2 postoperative deaths

11/15 (73%) NED, 1/15 (7%) AWD, 3/15 (20%) DOD 5/10 (50%) NED 11 (73%) NED, 1 (0.05%) relapse,

Donohue et al [33] 1998 152 II-III

Elevated

Albers et al [56] 2000 30 II-IV Elevated

Redo

Waples and 1993 9 Interval 12 NS

Messing [62]

Donohue et al [33] 1998 202 II-III, Interval NS Normal

McKiernan et al 2003 56 Interval 17 (2-324) NS [81]

Heidenreich et al 2005 18 Interval 18 (2-30) Normal [82]

NS NS

7/28 (25%) 3/28(11%) 18/28 (64%) 120 (1-228) 17/30 (57%) NED

NS NS

NS NS

NS NS

32 108

DOD Complication rate 27%, 5-y cancer-specific 56% Complication rate 38.8%, cancer-specific 89%, necrosis 100%, teratoma 85%, cancer 50%

Abbreviations: AWD, alive with disease; DOD, died of disease; NED, no evidence of disease; NS, not specified.

lo o identified in frozen section analysis of the residual masses, with 18 (85.7%) confirmed in permanent section. Two patients had microscopic viable germ cell tumor unrecognized on frozen section, and 1 had microscopic teratoma in the residual mass. Of these 21 patients, 3 (14.3%) experienced recurrences, 2 had germ cell tumors in the chest, and 1 had liver metastasis. The remaining 18 (85.7%) patients had no evidence of disease, with a mean follow-up of 33 months (range, 2460 months). The authors concluded that limited RPLND if frozen section analysis shows only necrosis is a safe alternative to bilateral dissection. Similarly, Rabbani and colleagues [36] studied 50 patients who had metastatic NSGCT after chemotherapy in Vancouver, British Columbia; 39 patients (78%) had bilateral dissection, 9 patients (22%) underwent resection of residual masses and modified-template dissection, and 2 patients had resection of residual masses only. Of the 9 patients who had resection of residual masses and modi-fied-template dissection, all were relapse-free at a median follow-up of 55 months. One of 2 patients undergoing resection of residual mass alone had two recurrences arising from incomplete resection.

There is, however, emerging evidence that a substantial proportion of patients harbor disease, usually teratoma, outside the proposed modified templates. This disease could potentially account for the late recurrence, a formidable and often fatal outcome of the uncontrolled retroper-itoneum. Furthermore, the boundaries of template dissections in the literature vary significantly [68-72]. Carver and associates [73] recently examined 532 men undergoing post-chemotherapy RPLND and found that of the 269 patients who had viable germ cell tumor or teratoma, 7% to 32% had evidence of disease outside the boundaries of a modified template, depending on the definition of the template boundaries. In this study, disease outside the template was associated with a decreased disease-free survival. The incidence of late recurrence is increasing, possibly as a result of these incomplete or inadequate resections, and the authors support the traditional bilateral dissection. These surgeries can often be accomplished with nerve-sparing techniques, even in the post-chemotherapy retroperitoneum.

Coogan and colleagues [74] evaluated 81 patients who underwent nerve-sparing procedure after chemotherapy. At a median follow-up of 35 months, 6 had disease recurrence but none of the recurrences were in-field. Antegrade ejaculation was maintained in 76.5% of the patients. Nonomura and colleagues [75] also showed that nerve-sparing RPLND after chemotherapy could still preserve antegrade ejaculation in 84.6% (22/26) of patients while maintaining disease-free status of 96% (25/26) with a mean follow-up of 25.8 months (range 6-76 months). The study cohorts in these nerve-sparing studies included a mixed group of patients, although NSGCT was the predominant pathology.

In summary, retroperitoneal surgery for testis tumor has evolved over the past 3 decades with increasing knowledge of neuroanatomy and tumor distributions. Some authors have advocated more limited dissections to limit the morbidities of the procedure, whereas others cite the inadequate resections of potentially harmful histologies. As surgical series of limited dissections continue to mature, the extent of post-chemotherapy RPLND still remains controversial.

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