Retroperitoneal lymph node dissection after chemotherapy

Abstract

Retroperitoneal lymph node dissection after chemotherapy (PC‐RPLND) plays a crucial role in managing patients with advanced germ cell tumours (GCTs). In the last few years improvements in radiographic staging, a better understanding of the role of serum tumour markers, and the introduction of cisplatin‐based chemotherapy have all contributed to this surgical therapy. PC‐RPLND is necessary when residual radiographic abnormalities are present after chemotherapy. The need for a PC‐RPLND in the face of normal findings from computed tomography (CT) is controversial. CT criteria alone are not sufficiently reliable to distinguish viable tumour or teratoma from necrosis. No combination of variables can predict negative retroperitoneal pathology with sufficient accuracy after induction chemotherapy. Unresected teratoma or viable GCT are at least partly chemorefractory and, if untreated, will progress. So completeness of resection is an independent and consistent predictive variable of clinical outcome. In PC‐RPLND surgical margins should not be compromised in an attempt to preserve ejaculation, although nerve‐sparing dissections are possible in patients with marker normalization after chemotherapy and necrotic tissue in frozen‐section histology. In these patients nerve‐sparing techniques and the reduction of surgical field to the left‐ or right‐sided template are applicable to preserve antegrade ejaculation and consecutive fertility. The size and location of residual masses coupled with the retroperitoneal desmoplastic reaction make PC‐RPLND a technically demanding procedure that should be performed by experienced surgeons in dedicated referral centres.

Post-chemotherapy retroperitoneal lymph node dissection in the management of metastatic testis cancer: the 16-year experience in an Irish setting

“…The incidence of viable malignant tissue, teratoma and fibrosis/necrosis reported by histopathology following RPLND is similar in our series to the ranges reported by Winter et al [20]. Most recent studies have shown the percentage of patients with residual malignant disease decreasing to between 2 and 15 %.…”

Retroperitoneal lymph node dissection for residual masses after chemotherapyin nonseminomatous germ cell testicular tumor

“…Although some authors suggest the possibility of performing less extensive templates for selected residual masses after chemotherapy[19], this approach has not been accepted as standard of care and we could not demonstrate a reliable pattern of dissemination to allow safe modified dissections in this setting. The presence of viable cancer post-chemotherapy varies from 4 to 20% among tertiary centers.…”

Management of residual mass in nonseminomatous germ cell tumors following chemotherapy

“…Fortunately, the complication rate appears to have decreased with time due to improved surgical technique and perioperative management [Winter et al 2009]. We have recently adopted an extraperitoneal approach using a midline incision in select patients undergoing PC-RPLND with a significant reduction in complications rate and hospital stay (unpublished data).…”