Patient selection for retroperitoneal lymph node dissection after chemotherapy for nonseminomatous germ cell tumors

The indications for retroperitoneal lymph node dissection (RPLND) after chemotherapy for nonseminomatous germ cell tumor of the testis vary widely. We reviewed our experience with 122 patients who underwent RPLND within 6 months of receiving cisplatin-based chemotherapy for bulky (greater than 3 cm) retroperitoneal metastases. Pathologic findings were necrotic tissue in 57 (47%), teratoma in 48 (39%), and residual malignancy in 17 (14%). The size of the retroperitoneal mass after chemotherapy (p = 0.001) and the degree of shrinkage that occurred with chemotherapy (p = 0.0001) were both strongly correlated with the histologic findings at RPLND. The presence or absence of teratomatous elements in the pretreatment orchiectomy specimens was only weakly correlated (p = 0.06). Multivariate logistic regression found shrinkage and the size of the residual mass to be independent predictors of finding only necrotic tissue. We were unable to identify preoperatively a group of patients in which some did not have teratoma or malignancy ultimately resected. Of 39 patients who had a residual mass less than 1.5 cm, and 43 patients whose residual mass was less than 1.5 cm or whose mass had shrunk by greater than 90%, 3 had residual malignancy, and 5 had teratoma resected. Among these 8 patients, 7 had prechemotherapy masses greater than 3 cm. Even with stricter criteria, of 17 patients with no testis teratoma initially and a residual mass less than 1.5 cm which had shrunk by greater than 90%, 5 (30%) had teratoma or malignancy resected. Postchemotherapy RPLND is recommended for all patients with a prechemotherapy mass greater than or equal to 3 cm, irrespective of the radiographic findings.