Stage II nonseminomatous germ-cell testicular tumors--the Indiana experience and risk-benefit analysis

Controversy exists in the appropriate management of patients with nonseminomatous testicular cancer presenting as clinical stage B disease. Traditional treatment in the United States has included retroperitoneal lymph-node dissection (RPLND). Conversely, in Europe and other places some of these patients have been managed with primary chemotherapy. The experience with RPLND in clinical stage B disease at Indiana University from 1965 to 1989 was reviewed. A total of 174 patients were considered to be in clinical stage B prior to RPLND. After RPLND, 23% of these patients (n = 41) were found to have pathological stage A disease. In all, 77% (n = 133) were determined to be in pathological stage B. Of those pathological stage B patients who did not receive adjuvant chemotherapy, 65% were cured by RPLND alone. The pathological stage B patients who went on the receive postoperative adjuvant chemotherapy displayed an overall 14% chance of relapse. (Patients treated early in the series did not receive cisplatin-based chemotherapy.) The overall survival over the entire period was 96%. In the more modern era, during which cisplatin-based chemotherapy was available, the overall survival was 98%. RPLND is an effective procedure for the management of clinical stage B nonseminomatous testicular cancer. It provides excellent survival in patients found to have pathological stage B disease; additionally, it avoids the unnecessary toxicity of chemotherapy in the 23% of patients who in fact are in pathological stage A.