Distribution of Nodal Metastases in Nonseminomatous Testis Cancer

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Abstract
The distribution of 104 consecutive stage II (or B) nonseminomatous germinal cell testis tumor deposits in the retroperitoneal space was analyzed and segregated into 11 anatomic zones of spread: right para-caval, right pre-caval, inter-aortocaval, left pre-aortic, left para-aortic, right (renal) suprahilar, left suprahilar, right iliac, left iliac, inter-iliac (pre-lumbosacral) and gonadal vein. Each patient had no treatment after orchiectomy and before retroperitoneal lymph node dissection, that is no preoperative radiotherapy or chemotherapy, which may have influenced histologic analysis. Each patient had an extended bilateral retroperitoneal lymph node dissection, including both suprahilar zones. Tumor deposits in these 11 nodal zones were correlated with the side of the primary lesion (right vs. left side) and the extent of metastatic disease (B1, N.A. B2 or B3). The inter-aortocaval zone, just below the left renal vein, is the most common site of tumor deposition (93%) of right testis tumors (primary right side). The pre-aortic (88%) and left para-aortic (86%) areas are the most common sites of left testis tumor nodal spread (primary left side). The right and left suprahilar zones are rarely involved in low stage (B1) disease. No suprahilar nodes were positive in stage B1 disease if the primary was on the right side and only 3 of 14 were positive with B1 disease on the left side. In stage B2 disease the suprahilar zones were involved more often with tumor (13-33% if the primary was on the right side and 16-42% if the primary was on the left side). There is a positive correlation between extent of disease and involvement of suprahilar nodes. A significant number of gonadal veins and their lymphatics are involved with tumor (14-17%), even in low stage disease (8-14%). The ipsilateral iliac areas rarely are involved with tumor in low stage disease (0-14%), and contralateral iliac involvement is a rarity (1 of 40). Contralateral (right para-caval if the primary is on the left side or left para-aortic if the primary is on the right side) nodes were negative in low stage disease but commonly positive in B2 disease, especially when the primary was on the right side. Lymphatic drainage of the testis follows predictable and preferential pathways. This clinical study confirms earlier lymphangiographic studies, suggesting abundant crossover and subsequent suprahilar drainage. Suprahilar nodes are so rarely involved in low stage (B1) disease that dissection in this area is unnecessary in routine staging retroperitoneal lymphadenectomy.