Role of Retroperitoneal Lymph Node Dissection in Clinical Stage IIA/B Seminoma: Recommendations from the European Association of Urology Guidelines Panel on Testicular Cancer

Chemotherapy with 3 cycles PEB or 4 cycles PE is the standard treatment option for clinical stage IIA/B seminomas with a relapse rate of 0-8% and 8-14% in CS IIA and CS IIB, respectively. Radiation therapy with doses of 30 Gy and 36 Gy for CS IIA and CS IIB, respectively, has been used historically, and it results in relapse rates of 9-24%. Despite low relapse rates and high cure rates, both treatment options are associated with increased risks of long-term toxicities such as secondary malignancies and cardiovascular disease.

In an attempt to de-escalate treatment intensity while maintaining oncological efficacy, six institutions have explored the potential role of primary retroperitoneal lymph node dissection (RPLND) for 296 patients in 4 prospective and 2 retrospective clinical studies. All patients underwent RPLND for marker-negative seminomas with CS IIA or small volume CS IIB, and only 34/296 (11.5%) patients received adjuvant chemotherapy, which consisted of 1 cycle PEB in the majority of cases. The surgical approach was open trans- or extraperitoneal laparotomy and robotic-assisted surgery for 238 (80%) and 58 (20%) patients. Median follow-up is 23 to 58 months for prospective and 18 to 22 months for retrospective trials.

Frequency of surgery-related Clavien-Dindo complications >= 3a was low in all trials, with 5% to 12% and antegrade ejaculation could be preserved in 90% to 97%.

84% to 98% of patients did harbour lymph node metastases in the resected specimens; interestingly, up to 5% of patients exhibited nonseminomatous histology in the resected specimens. With regard to oncological outcome, 48 (16%) patients relapsed, with more than 90% of the recurrences developing within the first 2 years of follow-up. All patients could be saved by salvage chemotherapy. Only 10 (3.4%) patients demonstrated in-field relapses, which, in general, underlines the high surgical quality performed by high-volume surgeons of high-volume testis cancer centers. Relapse rates were 0-7.5% and 14-30% for patients undergoing surgery with or without adjuvant chemotherapy.

In summary, nsRPLND for marker-negative clinical stage IIA/B seminoma is associated with a low rate of treatment-associated morbidity, a chemotherapy-free survival of 80 to 85% if performed in expert hands. Both the AUA and the NCCN guidelines have included primary nsRPLND in their evidence-based recommendation concerning the management of low-volume CS IIA/B seminomas.

Written by: Axel Heidenreich, MD, PhD, Professor, Director of the Clinic for Urology, Uro-Oncology, Robot-Assisted and Special Urological Surgery, Department of Urology, University of Cologne, Cologne, Germany

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