EAU 2018: The Role of Lymphadenectomy in Urological Cancers - Testicular Cancer

Copenhagen, Denmark (UroToday.com) Dr. Alvaraz provided a summary of the role of lymphadenectomy in testicular cancer, albeit in a slightly abbreviated format. While testicular cancer is a fairly guidelines-oriented malignancy with well-established pathways, there is still some controversy in management of early stage disease. 

He began by reviewing the TNM staging for testicular cancer and the International Germ Cell Cancer Collaborative Group (IGCCCG) risk stratification (good, intermediate and poor risk). These are important to understand to participate in the discussion of testicular cancer.

The drainage pattern of testicular cancer is well established and standard. Unlike other malignancies, the drainage of testicular cancer has been studied extensively, leading to significant improvement in cancer outcomes. Donohue (1982), Weissbach and Boedefeld (1987), and Ray (1974) established specific anatomic drainage areas within the retroperitoneum. 12 total areas identified.

  • Right sided tumors drain primarily to interaortocaval (primary landing zone) – followed by precaval and paracaval
  • Left sided tumors drain primarily to para-aortic (primary landing zone) – followed by pre-aortic
  • Right sided tumors are more likely to cross over (Sogani 1991, Richie 1992)
Some key points – though not all of which are accepted:

1. Recurrence rates for NSGCT Stage 1 on surveillance: 30%. 
2. He recommends risk stratified approach – though our experience at PMH would suggest that risk stratification is not needed. We recommend AS in all stage 1 patients as the 30% that relapse can be salvaged.

- Low risk (No LVI, pT1) – AS, but consider single-course BEP or primary RPLND
- High risk (+LVI, pT2) – single-course BEP, but consider primary RPLND

3. Stage 1 seminima – RPLND is not recommended!
4. Following first line BEP chemo, residual masses (>1 cm) are 10% residual tumors, 50% mature teratoma, 40% benign. Hence, as 60% are not benign, RPLND is recommended.
5. Desperation RPLND is from chemoresistant masses that are resectable, with rising tumor markers.
6. FDG-PET scan

- Not indicated in NSGCT
- In seminoma, it has a high negative predictive value in patients with residual masses. PET scan should be done with residual masses > 3 cm to assess for viable tumor.

Surgical treatment

He had some basic points regarding the RPLND approach.

-Initial description of a full-template RPLND (Whitmore 1962, Skinner 1971, Donahue 1977) – emphasis placed on extensive dissection and complete removal of all lymphatic tissue in the retroperitoneum.
-Suprahilar dissection was associated with complications (pancreatic injury, lymphatic injury, renal vessel injury) – subsequent studies (Donahue et al) demonstrated that its exclusion did not compromise oncologic outcomes.
-Most common long-term complication – infertility secondary to retrograde ejaculation
-Nerve sparing RPLND – sparing the sympathetic fibers is key to success. He emphasized sparing the nerves as they leave the lumbar sympathetic trunks and converge inferior to the IMA (hypogastric plexus). Oncologic outcome should never be compromised to provide fertility!

He then spent some time on laparoscopic approach to the RPLND. He showed one of his institutions videos. This can also be done robotically. However, oncologic standard is still open – if you can’t achieve the same results through MIS approach, don’t do it!

  • Best indication for laparoscopic RPLND – well selected patient with unilateral mass <5 cm
  • Main problem with MIS approach – long and steep learning curve

Presented by: M.E. Alvaraz, MD

Written by: Thenappan Chandrasekar, MD Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark
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