#SUO14 - Session Highlights: Choice of templates for low-stage testis cancer

BETHESDA, MD USA (UroToday.com) - In this session, Dr. Joel Sheinfeld set out to argue the case against the use of modified templates in retroperitoneal lymph node dissection (RPLND). He argued that modified templates always understage the retroperitoneum, increase the risk of un-resected disease, and result in worse clinical outcomes in a subset of patients.

suoModified templates were developed in an attempt to minimize morbidity in low-risk patients, specifically with regards to preserving ejaculatory function. These modified templates were developed initially in the 1980s, based on mapping studies performed at that time, and excluded areas thought to be at low risk of harboring disease (< 10%). He pointed out the flaws of this approach, including the fact that mapping studies underestimate disease as they do not account for any disease that is un-resected. He further discussed that 2 of the 3 mapping studies used to create the modified templates did not have any follow-up, one had limited follow-up, and one study included patients who received postoperative chemotherapy. Dr. Sheinfeld then presented data on late relapse in stage I testis cancer which found that 61% occurred within the retroperitoneum, pointing potentially to un-resected disease at time of RPLND. He noted that several studies have shown that the most common location for late relapse is the para-aortic region which is not included in right-sided modified RPLND templates. The most common histology in late relapse is teratoma, which in this setting demonstrates an increased rate of malignant transformation.

At MSKCC, they utilized modified templates up until 1999 before changing to a full-template in all patients due to inferior clinical outcomes seen with the modified templates. He concluded by arguing that it is not possible to reliably predict the pathological status of normal-appearing lymph nodes, and that the reduction of surgical boundaries can never be oncologically better. He noted that nerve-sparing techniques in bilateral templates allow for preservation of ejaculatory function without compromising oncologic outcomes, and thus modified templates should not be utilized.

Presented by:
Joel Sheinfeld, MD
Memorial Sloan-Kettering Cancer Center, New York, NY USA

Reported by:
Timothy Ito, MD
* from the 2014 Winter Meeting of the Society of Urologic Oncology (SUO) "Defining Excellence in Urologic Oncology" - December 3 - 5, 2014 - Bethesda, MD USA

*Fox Chase Cancer Center, Philadelphia, PA USA