Retroperitoneal staging lymphadenectomy in stage II nonseminomatous germ cell tumours of the testis

Abstract

The standard primary therapeutic approach recommended in stage II nonseminomatous germ cell testicular tumours (NSGCTT) in current practice is specific, aggressive chemotherapy. Retroperitoneal lymphadenectomy (RPLA) is a second line therapy, being currently restricted to those patients who present with residual abdominal mass after chemo regimens. The authorsâ experience comprises 12 total RPLA for stage II NSGCTT in the last 4 years: 4 primary RPLA and 8 secondary RPLA (preceded by ВЕР cycles). The main sequence of the operative technique of primary total RPLA for stage II disease is presented. Access was gained through a midline abdominal incision. Teratoma was present in the primary pathologic specimen in half of the cases. In such cases we consider the primary total RPLA as the first option, being aware of the inefficacy of combination chemotherapy on teratoma and the risk of hazardous, seriated, even incomplete surgical resections in advancing abdominal disease. In two of three cases the operative pathologic staging corrected the preoperative CAT staging! There were no intra or postoperative complications. Adjuvant specific chemotherapy (2 ВЕР cycles) was delivered as a routine, this strategy granting curability in all cases. Conclusively, the authors propose a revaluation of the primary total RPLA in the therapeutic approach of NSGCTT stage II minimal or moderate abdominal disease, considering the operation as complete and easier to perform than in postchemo local conditions. This is especially valid in case of teratoma in the primary tumor, as teratomatous elements in the retroperitoneum will respond only to surgery. Moreover, the chemotherapeutic effort is reduced, more efficient, with lower toxic side effects. Under current conditions, this approach grants high cure rates with low medical and social costs.