Williams, S. B. et al. Retroperitoneal lymph node dissection in patients with high risk testicular cancer. J. Urol. 181, 2097–2101 (2009).

Just 3% of patients who underwent first-line RPLND were found to have systemic disease

Men with nonseminomatous germ cell tumors (NSGCTs) who are at high risk of metastasis can benefit from retroperitoneal lymph node dissection (RPLND) as primary treatment, a recent study from Harvard Medical School suggests. “RPLND can offer a chance for cure and spare chemotherapy in the majority of these patients” claims lead author Stephen Williams.

The research team retrospectively identified 133 high-risk individuals—that is, those with >30% embryonal carcinoma, with or without lymphovascular invasion—who had undergone RPLND. Nodes were positive in just over half of these men.

The outcomes of dissections performed as primary treatment (n = 76) were compared with those of surgery carried out post-chemotherapy (n = 57). The most widely used chemotherapy regimen included bleomycin, etoposide and cisplatin. Average percentage of embryonal carcinoma was high; 75.3% for patients undergoing first-line RPLND and 71.2% for those whose nodes were removed after chemotherapy. At surgery, metastatic spread was detected in 49% and 61% of men, respectively. Just 3% of patients who underwent first-line RPLND were found to have systemic disease.

Similarly low rates of recurrence (about 8%), detected using tumor markers and CT, were reported for both sets of patients, indicating that RPLND alone is an effective approach to the management of high-risk NSGCTs. Williams et al. also found that primary RPLND involved less blood loss, a shorter operative time, and fewer postoperative complications than post-chemotherapy surgery. The recent development of safer dissection techniques that reduce the risk of retrograde ejaculation add to its potential as a first-line treatment in testicular cancer. Williams concludes that “our findings highlight the importance of performing a meticulous dissection.”

Sparing patients from unnecessary chemotherapy is another advantage of primary RPLND. Long-term complications linked to cisplatin-based treatment include cardiovascular disease and metabolic syndrome. Secondary malignancy associated with radiation exposure during post-chemotherapy follow-up CT imaging would also be avoided by employing this management strategy.