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Is There Still an Indication for Primary RPLND in Clinical Stage I Non-seminoma?

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Diagnosis and Management of Testicular Cancer

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Abstract

Retroperitoneal lymph node dissection (RPLND) represented the only effective treatment for non-seminomatous germ cell tumours (NSGCT) up to the 1970s. A significant proportion (about two thirds) of patients with ascertained small nodal metastases at RPLND, are cured by surgery with no need of further therapy.

The introduction of effective cisplatin-based chemotherapy has progressively reduced the role of primary RPLND in early stages NSGCT. This was also due to the technical complexity that renders RPLND hard to reproduce at the best performance on a large scale.

As a consequence, the vast majority of clinical stage I patients are now offered non-surgical options, including active surveillance or adjuvant short chemotherapy.

Nonetheless, three recent aspects may have renewed the interest toward primary RPLND in stage I NSGCT. The first is the acquirement of significant long-term toxicity of chemotherapy in young patients, leading to limit this option when possible. The second is the current trend towards a deliberative approach in treatment delivery, which implies the patient empowerment in the decisional process considering all the potential options in stage I disease, re-including RPLND when performed in experienced hands. The third is the documented reduced morbidity of RPLND, due to technical improvements that encompass preservation of ejaculation in almost all patients and the introduction of new mini-invasive approaches (basically laparoscopic RPLND) that have minimised early side effects of surgery.

These aspects cast new light on this issue and permit to consider RPLND still a viable option for some clinical stage I patients, with the imperative recommendation that this intervention must be performed by experienced surgeons in centres with expertise in testicular cancer management.

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Intellectual Acknowledgements

The history of retroperitoneal lymph node dissection has been changed in the past four to five decades due to very special physicians who dedicated their best efforts in the cure of patients with testis cancer and were able to leave a mark in those who came after them, by transmitting the enthusiasm and the sensibility needed to manage these patients. Among these distinguished people, a particular thought is due to John P. Donohue and a personal gratitude is due to Giorgio Pizzocaro.

We thank Dr. Mario Catanzaro and Dr. Davide Biasoni for their contribution.

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  1. Department of Urology/ Testis Surgery Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, 20133, Italy

    Nicola Nicolai & Alessandro Crestani

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  1. Nicola Nicolai
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  2. Alessandro Crestani
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Correspondence to Nicola Nicolai .

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  1. Kliniken Essen-Mitte, Klinik für Urologie, Essen, Germany

    Susanne Krege

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Nicolai, N., Crestani, A. (2015). Is There Still an Indication for Primary RPLND in Clinical Stage I Non-seminoma?. In: Krege, S. (eds) Diagnosis and Management of Testicular Cancer. Springer, Cham. https://doi.org/10.1007/978-3-319-17467-9_4

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  • DOI: https://doi.org/10.1007/978-3-319-17467-9_4

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