Role and indications of RPLND in Testicular Malignancy
• RATIONALE IN STAGE I NSGCT: Surveillance is preferred for low risk stage I NSGCT compliant patient. High risk features include lymphovascular invasion, predominant embryonal component (>40%) and/or higher T stage (T2-T4) [30,31]. Patients with these high risk features have options of either one or two cycles of single agent platin or primary RPLND. Concern regarding long-term morbidities of imaging related ionizing radiation exposure and long term morbidities of chemotherapy, have emphasized the importance of surgery [32,33]. Advantages of RPLND include 1) definitive pathologic staging. 30% of stage I patients have occult metastasis in the retroperitoneum and 35% of patients with stage …show more content…
Resection of residual tumors after first line chemotherapy remains essential in the treatment of metastatic testicular cancer. Undifferentiated tumor may still be found in 20%. Necrosis is found in only 50% of marker normalized patients after first-line and approximately 30% after second-line chemotherapy [38]. The histological outcomes of patients after induction chemotherapy followed by Postchemotherapy RPLND revealed 45% fibrosis, 40% teratoma, and 15% viable tumor and after seconding chemotherapy, specimens revealed approximately 50% malignant GCT, 40% teratoma, and 10% fibrosis [39]. Bilateral RPLND with nerve sparing if possible is the preferred management as it provide definitive diagnosis, eliminate possibility of growing teratoma syndrome and malignant transformation of teratoma which occur in 3-6% and increase to 12-18% in late relapses [40,41,42].
• RATIONALE FOR SEMINOMA: advanced stage residual masses greater than 3 cm should be evaluated further with FDG-PET andPET positive should undergo RPLND. Observation is justified in patients with a negative FDGPET scan after primary chemotherapy, particularly for those with residual masses less than 3 cm
• RATIONALE IN STAGE I NSGCT: Surveillance is preferred for low risk stage I NSGCT compliant patient. High risk features include lymphovascular invasion, predominant embryonal component (>40%) and/or higher T stage (T2-T4) [30,31]. Patients with these high risk features have options of either one or two cycles of single agent platin or primary RPLND. Concern regarding long-term morbidities of imaging related ionizing radiation exposure and long term morbidities of chemotherapy, have emphasized the importance of surgery [32,33]. Advantages of RPLND include 1) definitive pathologic staging. 30% of stage I patients have occult metastasis in the retroperitoneum and 35% of patients with stage …show more content…
Resection of residual tumors after first line chemotherapy remains essential in the treatment of metastatic testicular cancer. Undifferentiated tumor may still be found in 20%. Necrosis is found in only 50% of marker normalized patients after first-line and approximately 30% after second-line chemotherapy [38]. The histological outcomes of patients after induction chemotherapy followed by Postchemotherapy RPLND revealed 45% fibrosis, 40% teratoma, and 15% viable tumor and after seconding chemotherapy, specimens revealed approximately 50% malignant GCT, 40% teratoma, and 10% fibrosis [39]. Bilateral RPLND with nerve sparing if possible is the preferred management as it provide definitive diagnosis, eliminate possibility of growing teratoma syndrome and malignant transformation of teratoma which occur in 3-6% and increase to 12-18% in late relapses [40,41,42].
• RATIONALE FOR SEMINOMA: advanced stage residual masses greater than 3 cm should be evaluated further with FDG-PET andPET positive should undergo RPLND. Observation is justified in patients with a negative FDGPET scan after primary chemotherapy, particularly for those with residual masses less than 3 cm