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UROSCAN
Year : 2006  |  Volume : 22  |  Issue : 1  |  Page : 81-82
 

Who benefits more from primary RPLND?


Department of Urology, Christian Medical College, Vellore, India

Correspondence Address:
J Chandra Singh
Department of Urology, Christian Medical College, Vellore
India
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How to cite this article:
Singh J C, Kekre NS. Who benefits more from primary RPLND?. Indian J Urol 2006;22:81-2

How to cite this URL:
Singh J C, Kekre NS. Who benefits more from primary RPLND?. Indian J Urol [serial online] 2006 [cited 2019 Sep 20];22:81-2. Available from: http://www.indianjurol.com/text.asp?2006/22/1/81/24670

Stephenson AJ, Bosl GJ, Motzer RJ, Kattan MW, Stasi J, Bajorin DF et al.Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: impact of patient selection factors on outcome.J Clin Oncol. 2005;23:2781-8.



   Summary Top


The objective of this paper[1] was to evaluate the impact of modified selection criteria for primary retroperitoneal lymph node dissection (RPLND) in men treated for nonseminomatous germ cell tumour (NSGCT). Since 1999, patients with persistent postorchiectomy elevation of serum tumor markers (STM) or clinical stage (CS) IIB were excluded for primary RPLND. Clinical information was obtained from a prospective database for 453 patients with CS I to IIB NSGCT who underwent primary RPLND between 1989 and 2002. Induction chemotherapy followed by post-chemotherapy RPLND was offered to those with Clinical Stage (CS) II B or elevated serum tumor markers (STM) following orchiectomy since 1999. Overall, 187 patients (41%) had positive retroperitoneal nodes (PS II) at RPLND. Though the rate of retroperitoneal teratoma remained constant (21% before 1999 v 22% after 1999; P =0.9), the pathologic findings at RPLND were more favorable for patients treated after 1999. This was because significantly more post-1999 PS II patients had low-volume disease (pN1) compared with the pre-1999 PS II patients (64 v 40%, respectively; P =0.01). 40% of those with CS II A had pathologically negative nodes and 30% of those with CS I had PS II, similar to other series.[2] Among patients who did not receive adjuvant chemotherapy, those treated after 1999 had a significantly better prognosis. The 4-year risk of systemic progression was 14% before 1999 (95% CI, 12% to 15%) versus 1.3% after 1999 (95% CI, 0.5% to 2%; P =0.002). A trend towards improved 4-year overall survival and disease specific survival was observed among patients with elevated STM or CS IIB disease who were treated by induction chemotherapy after 1999 versus primary RPLND before 1999.


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As 22% of those with CS I or IIA had retroperitoneal teratoma and the systemic progression was low after RPLND, the authors have suggested primary RPLND as preferred primary intervention for patients with CS I to IIA. Also, though 52% of post-1999 pN1 patients received adjuvant chemotherapy, the authors feel it could have been avoided in 90% of those patients if it had been withheld until evidence of relapse. It was observed in other studies also that retroperitoneal lymph node dissection alone is adequate treatment for the majority of patients with pathologic stage B1 testicular cancer.[3] RPLND followed by adjuvant chemotherapy is an alternative strategy for patients with CS IIB disease or elevated STM.[4],[5] But the authors feel there is a small but potentially significant risk of disease progression if chemotherapy is delayed because of perioperative complications or prolonged convalescence after RPLND. Though Weissbach et al[6] recommend primary RPLND for CS IIB as the morbidity of post-chemotherapy RPLND will be more, the authors of this paper[1] feel morbidity of primary RPLND may be increased in this setting because of extensive retroperitoneal disease as opposed to RPLND after chemotherapy for minimal residual masses.

Thus the authors conclude that excluding CS IIB or elevated postorchiectomy STM from primary RPLND for NSGCT has favorable impact on the extent of retroperitoneal disease, significantly reduces the risk of relapse after RPLND. The 22% incidence of retroperitoneal teratoma and low rate of systemic progression supports RPLND, as the preferred primary intervention in CS I and CS IIA.

 
   References Top

1.Stephenson AJ, Bosl GJ, Motzer RJ, Kattan MW, Stasi J, Bajorin DF, et al . Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: impact of patient selection factors on outcome. J Clin Oncol 2005;23:2781-8.   Back to cited text no. 1    
2.Donohue JP, Thornhill JA, Foster RS, Rowland RG, Bihrle R. Primary retroperitoneal lymph node dissection in clinical stage A non-seminomatous germ cell testis cancer. Review of the Indiana University experience 1965-1989. Br J Urol 1993;71:326-35.   Back to cited text no. 2  [PUBMED]  
3.Richie JP, Kantoff PW. Is adjuvant chemotherapy necessary for patients with stage B1 testicular cancer? J Clin Oncol 1991;9:1393-6.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Kondagunta GV, Sheinfeld J, Mazumdar M, Mariani TV, Bajorin D, Bacik J et al . Relapse-free and overall survival in patients with pathologic stage II nonseminomatous germ cell cancer treated with etoposide and cisplatin adjuvant chemotherapy. J Clin Oncol 2004;22:464-7.  Back to cited text no. 4    
5.Oosterhof GO, Verlind J. Testicular tumours (nonseminomatous). BJU Int. 2004;94:1196-201.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Weissbach L, Bussar-Maatz R, Flechtner H, Pichlmeier U, Hartmann M, Keller L. RPLND or primary chemotherapy in clinical stage IIA/B nonseminomatous germ cell tumors? Results of a prospective multicenter trial including quality of life assessment. Eur Urol 2000;37:582-94.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]




 

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