Role of retroperitoneal lymph node dissection

The current ''gold standard'' to accurately stage and treat nonseminomatous germ-cell tumors (NSGCT) is a thorough dissection of retroperitoneal lymph tissue, or RPLND. With the availability of effective chemotherapy and enhanced imaging techniques used during surveillance, the indications for RPLND have been debated; however, at present, lymphadenectomy is integral to the successful management of this disease. RPLND has a clear role in the primary therapy of selected high-risk clinical stage I (CS I) patients, CS IIA (single lymph node ! 2 cm), and CS IIB (single or multiple lymph nodes 2 to 5 cm) patients with normal tumor markers. Residual retroperitoneal disease postchemotherapy with normal tumor markers is also an indication for RPLND, while for patients with seminoma, there is a limited role for RPLND after chemotherapy [2,3]. The role and efficacy of RPLND is addressed elsewhere in this supplement and has been reviewed recently [4]. This review will focus on the role of LRPLND.

The retroperitoneum is often the first site of metastatic spread in 75% to 90% of cases [5] and the overall cure rate after primary RPLND is 99% [6,7]. However, 65% or more of CS I NSGCT

patients will not have metastatic disease in their retroperitoneum at surgery, and thus benefit little, while being exposed to the potential morbidity of surgery [6-8]. Thus, the challenge is identifying which patients will benefit from surgery. With 20% to 30% of patients inaccurately labeled as having a negative retroperitoneum by abdominal axial imaging, a niche for LRPLND was identified: a staging technique with greater sensitivity and specificity than imaging but less morbidity than open RPLND [9-11]. Some would argue that the role for LRPLND has advanced little past an expensive staging technique, while others believe it has valuable therapeutic potential.

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