Primary retroperitoneal lymph node dissection in patients with clinical stage IS testis cancer

Initial management for clinical stage IS (persistently increased tumor markers) nonseminomatous germ cell tumor has evolved from primary retroperitoneal lymph node dissection to induction chemotherapy at most medical centers. We analyzed the outcome in patients treated with primary retroperitoneal lymph node dissection.

We reviewed the charts of patients who underwent retroperitoneal lymph node dissection at Brigham and Women's Hospital, and Dana Farber Cancer Center from 1993 to 2008. All patients with clinical stage IS were identified and perioperative data were obtained.

A total of 280 patients who underwent retroperitoneal lymph node dissection were identified, of whom 24 identified with clinical stage IS underwent primary dissection. Median followup was 2.9 years. Histopathology revealed an embryonal carcinoma component in 24 orchiectomy specimens (100%) with associated teratoma in 15 (63%). Positive lymph nodes were identified at retroperitoneal lymph node dissection in 9 patients (38%), including pure embryonal carcinoma in 6 (67%), combined embryonal carcinoma and teratoma in 1, embryonal carcinoma, choriocarcinoma and teratoma in 1, and only teratoma in 1. Of the patients who underwent primary retroperitoneal lymph node dissection 5 (21%) also received chemotherapy postoperatively, which was due to persistently increased tumor markers in 3 (13%). No retroperitoneal recurrence was noted on followup imaging. At surgery estimated blood loss was 175 cc, operative time was 3.1 hours and hospital stay was 3.9 days. There were no deaths.

Patients with clinical stage IS are at significant risk for metastatic disease and can be successfully treated with primary retroperitoneal lymph node dissection, thereby sparing chemotherapy in most of them. Retroperitoneal recurrence is essentially eliminated when retroperitoneal lymph node dissection is performed in this select patient group.