Progress in managing testicular cancer over the last 2 decades has produced survival rates of well over 90% using a multidisciplinary approach that serves as a model for other tumors. Improved imaging techniques permit more accurate clinical staging, allowing the clinician to select, for each patient, the sequence of surgical and chemotherapeutic modalities that maximizes survival while keeping morbidity within tolerable limits. Current investigators are attempting to refine treatment protocols so as to maintain or improve survival while reducing morbidity and costs.
Surgical resection of the retroperitoneal lymph nodes has been an important tool in managing testicular cancer for many years. In this excellent review, the authors describe the history, techniques, and rationale for the use of retroperitoneal lymph node dissection (RPLND). The effectiveness of RPLND as primary or adjuvant therapy for low-stage disease or as an adjunct for the resection of residual tumor following chemotherapy in advanced disease represents a standard by which all other management approaches should be measured. However, there is no consensus as to which patients should undergo RPLND or the most effective sequence of treatment modalities.
Role of RPLND in Low-Stage Disease
The majority of patients with clinical stage I testicular cancer have tumor confined to the testicle. A number of studies have shown that tumor relapse develops in approximately one-quarter of patients managed by orchiectomy alone by 3 years (range, 20% to 40%) and in one-third by 4 years. In 80 stage I patients followed by surveillance for a mean of 83 months, relapses were identified in 36.3%.
Using current imaging techniques, accurate staging is possible for the majority of patients in whom additional treatment would be unnecessary. Even though RPLND is associated with low morbidity and mortality, subjecting all patients with stage I disease to this procedure in order to benefit a minority is difficult to justify if accurate methods exist to stratify patients for risk of relapse and effective salvage therapy is available.
Various pathologic factors have been associated with an increased risk of recurrence and, when one or more are present, relapses will be seen in 52% (range, 36% to 96%). As the authors point out, the absence of these risk factors does not relieve the clinician of the responsibility to perform careful follow-up on a surveillance protocol, as relapses will be seen in 10% to 69% of patients without risk factors (mean, 22%). Risk stratification allows the clinician to offer RPLND to patients most likely to benefit from the procedure, while those with lower risk may benefit from a less aggressive approach.
Surveillance as an Option
Surveillance requires that a patient be stable and willing to adhere to the more intense follow-up required. Although difficult to predict and monitor, compliance has been studied in this population. In one study, compliance with scheduled clinical visits was less than 80% in 57% of patients with stage I disease, whereas the authors of another study found no major problems in management related to compliance. In our own patient population, compliance is well over 85%.
Surveillance has no physical impact on quality of life and does not appear to be associated with an excess of psychological disorders. In one group of 102 patients, stress due to disease-related anxiety was reported to be minor in 46% of patients and a source of major distress in only 4%.
When relapses occur, effective salvage therapy is available. Cisplatin(Drug information on cisplatin) (Platinol)-based chemotherapeutic protocols produce complete responses in the majority of patients with retroperitoneal lymphadenopathy. Survival rates of 80% to 96% are reported for bulky retroperitoneal disease and over 95% for smaller-volume tumors.[1,5,6]
When considering treatment, it is important to keep in mind that most studies report retroperitoneal relapse alone in the minority of cases, while pulmonary recurrence, alone or in combination with retroperitoneal disease, or biochemical relapse is seen in 55%. Although tumors at these sites exhibit a more complete response to treatment than does retroperitoneal disease, they should not be regarded as of little importance.
Of interest, the authors report that only 5% of their stage I patients experienced an extraperitoneal relapse following RPLND. The authors are probably correct in assuming that treatment success is greater when provided by clinicians with greater experience in dealing with this disease. Illustrative of the effectiveness of salvage therapy is the reported survival rate of 95% to 99% reported for patients with stage I testicular cancer who enter surveillance protocols.[2,4]
The overall costs associated with patient care for surveillance vs RPLND appear to be identical. More difficult to gauge are the costs to society and the individual of the loss of productivity following surgical or chemotherapeutic interventions.
Therefore, as the authors correctly point out, surveillance is a viable option for a select group of patients without adverse histologic parameters who are reasonably compliant. Patients who do not meet these criteria should be advised to undergo RPLND. Using this approach, survival should be maintained at a high rate, with morbidity minimized and costs stabilized.
Role of RPLND in Advanced-Stage Disease
Either RPLND or chemotherapy can be used as initial treatment of testicular cancer in the presence of detectable retroperitoneal disease. Both appear to be effective in eradicating smaller-volume disease. Reported relapse rates following RPLND vary, and the role of adjuvant chemotherapy is controversial. In 174 patients with stage II disease treated initially by RPLND, no relapses were seen in the 59 who received adjuvant chemotherapy, whereas the relapse rate in untreated patients was 37%.
If initial treatment is chemotherapy, a complete response requiring no adjuvant surgical intervention is seen in 40% to 71%. Certain histologic parameters can be used to predict the failure of chemotherapy to produce a complete response; these include teratomatous elements in the primary tumor and the presence of larger tumor masses.
Careful application of these two treatment modalities can produce similar survival results regardless of the sequence used. Finally, in selected cases where tumor markers fail to normalize, excision of the residual retroperitoneal mass may improve survival potential.
Initial use of chemotherapy will eradicate disease in less than half of patients with stage IIA-B disease, requiring adjuvant RPLND. Conversely, a substantial percentage of patients who initially undergo RPLND will experience relapse and require additional chemotherapy. Thus, therapy should be tailored to individual circumstances. Some degree of patient selection can be employed, and each patient should be carefully counseled regarding treatment options.