The Role of Retroperitoneal Lymphadenectomy in Clinical Stage B Testis Cancer: The Indiana University Experience (1965 to 1989)

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Abstract
Between 1965 and 1989, 1,180 patients underwent retroperitoneal lymph node dissection for nonseminomatous germ cell testis cancer (638 underwent primary dissection). Of these patients, 174 were considered to have clinical stage B disease preoperatively (suspected retroperitoneal node metastases by clinical staging). Surgery revealed that 41 patients (23%) actually had pathological stage A disease (no cancerous nodes). This nonspecificity in clinical staging remains consistent despite advance in clinical staging methods during this 25-year period. Of the pathological stage B cancer patients 65% were cured by retroperitoneal lymph node dissection alone. These long-term data indicate that primary retroperitoneal lymph node dissection for low stage metastatic nonseminomatous germ cell testis cancer (pathological stage B) not only had diagnostic but also therapeutic impact. Furthermore, this cure rate with long-term followup is equivalent to that of current series of primary chemotherapy alone for stage B disease, which are still relatively early reports. This cure rate with single modality therapy (retroperitoneal lymph node dissection alone) was accomplished within an average of 4 hours and, therefore, should be more time and cost-effective than prior reports of 3 and 4 courses of primary chemotherapy. In the post-cisplatin era (1979 to 1989), 140 patients with clinical stage B disease were treated with primary retroperitoneal lymph node dissection: 32 (23%) had pathological stage A cancer and 2 of them (6%) had relapse. Both patients are currently disease-free with subsequent chemotherapy. Of the remaining 108 patients with pathological stage B disease 49 received no adjuvant chemotherapy and 59 received cisplatin-based adjuvant chemotherapy. Among the former 49 patients 18 (37%) had relapse and 2 died. No patient receiving postoperative cisplatin-based adjuvant chemotherapy had relapse. The overall survival rate in these 140 clinical stage B cancer patients was 98%. There were 3 deaths, only 1 from cancer. The addition of cisplatin-based adjuvant chemotherapy postoperatively has rendered pathological stage B nonseminomatous germ cell testis cancer entirely free of subsequent relapse. Therefore, retroperitoneal lymph node dissection as monotherapy is curative in two-thirds of the patients with stage II disease, while the remaining one-third with progression to clinical relapse can be reliably saved by chemotherapy. Future considerations in selecting therapy for clinical stage II nonseminomatous germ cell testis cancer will be risk-benefit, cost-benefit and quality of life issues. Several cooperative studies will examine these issues, involving European and United States groups.