Stage I nonseminomatous germ-cell testicular cancer — management options and risk-benefit considerations

Summary

The results obtained with primary retroperitoneal lymph-node dissection (RPLND) in 464 patients with clinical stage A nonseminomatous germ-cell (NSGC) testicular cancer over a period of 25 years (1965–1989) were reviewed. Results were analyzed in clinical terms and subdivided into early (1965–1978) and contemporary (1979–1989) findings so as to be comparable with series using radiotherapy or surveillance. Between 1965 and 1978 (86 clinical stage A patients), the overall relapse rate of 15% (n=13) was similar to that obtained in radiotherapy series but the survival (98.8% after RPLND) was superior to that achieved with irradiation (87%). From 1979 to 1989, 378 clinical stage A cases had primary RPLND, of whom 29% (n=111) had cancerous nodes. The relapse rate for pathological stage A patients (n=267) was 11% and two patients died. The rate of relapse for pathological stage B patients who did not receive adjuvant chemotherapy was 32%. No relapse was seen among 46 pathological stage B patients given postoperative adjuvant chemotherapy. The mortality of 0.7% observed among 378 clinical stage A RPLND cases was lower than the 2% value reported in surveillance series. Although not statistically significant, these consistent results reported for two eras (pre- and postplatinum) spanning a period of 25 years suggest a sound basis for the surgical approach. The anatomic and medical principles in oncology, which have supported this approach, remain cogent today. They are discussed herein. Now that nerve-sparing techniques have been developed, the one long-term morbidity of RPLND (i.e., anejaculation) can be avoided. It would seem appropriate to have nerve-sparing RPLND techniques in any armamentarium dealing with clinical stage A disease.