Historically, management of low stage nonseminomatous germ cell tumors (NSGCT) of the testis included active surveillance (AS), chemotherapy, and primary retroperitoneal lymph node dissection (RPLND). However, in the contemporary setting, some have suggested that primary RPLND is a less favorable option for men with low stage NSGCT.
Kollmannsberger et al. have shown that men with stage I NSGCT who underwent AS have excellent oncologic outcomes . Of the 19% of men who relapsed, 90% of these occurred within the first two years. Furthermore, late and advanced stage relapses were extremely rare and patients were salvaged with additional treatment. Given these data and others, many providers advocate AS as the preferred treatment strategyfor low stage NSGCT . For some men with cT1a NSGCT, AS is certainly an excellent option – it requires intensive imaging and follow-up, but it avoids unnecessary morbidity associated with an extensive surgery or chemotherapy. Chemotherapy offersthe highest cure rate as a single-modality, but has significant long-term risks (secondary malignancies, early cardiovascular disease, etc.) that are not yet well elucidated [3-5]. Given the young age at diagnosis, excellent cure rate and long-term survival for these patients, long-term risks are a serious consideration. While a theoretical risk is associated with all interventions, the morbidity associated with primary RPLND in reality is very low when done at high-volume centers [6, 7].
Given the fact that testis cancer generally affects young, otherwise healthy men, primary RPLND has the potential to eliminate the need for a prolonged course of cancer surveillance or the long-term side effects of chemotherapy. In a disease that is 99% curable and of patients with little surgical risk, the argument could be made for aggressively treating men with low-stage NSGCT with primary RPLND. While RPLND may overtreat a number of patients, it also will avoid chemotherapy in many more. Minimally invasive RPLND may have the most promise in this circumstance – for the man with low stage NSGCT who wants to ensure the lowest risk of recurrence without the long-term side effects of BEP chemotherapy. When performed by expert surgeons at a high-volume center, laparoscopic RPLND has superior perioperative outcomes with comparable oncologic control when compared to open RPLND [8, 9]. Laparoscopic RPLND is technically challenging and concerns regarding oncologic efficacy prevent its widespread utility. However, our group has shown that robotic is comparable to laparoscopic, with the added benefits of better three-dimensional visualization and degrees of freedom to afford a better, minimally-invasive cancer operation . In experienced hands, this may eventually translate into complete preservation of ejaculatory function and superior oncologic control. Given the low morbidity associated with minimally invasive techniques and the fact that it is a more definitive treatment than AS, the era of primary RPLND is far from over for men with low grade NSGCT.
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2. Nichols CR, Roth B, Albers P, et al. Active surveillance is the preferred approach to clinical stage I testicular cancer. J Clin Oncol 2013: 31:3490-3.
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10. Harris KT, Gorin MA, Ball MW, Pierorazio PM, Allaf ME. A Comparative Analysis of Robotic versus Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular Cancer. BJU Int 2015. Epub ahead of print.