Oncology - Bladder, Renal, Test
Introduction & Objective :
For patients with early-stage (clinical stage I and IIA) non-seminomatous germ cell tumor (NSGCT), primary retroperitoneal lymph node dissection (RPLND) accurately stages the retroperitoneum and affords a therapeutic benefit in men with limited nodal disease offering complete resection of chemoresistant teratoma and minimizing the need for chemotherapy. Lymphovascular invasion (LVI) is the only well-established predictor of retroperitoneal malignancy; while a number of variables including pT-stage, presence of embryonal cancer and teratoma are suggested to predict retroperitoneal histology. We consequently evaluated pathologic findings from radical orchiectomy specimens and patient characteristics to predict retroperitoneal pathology.
A retrospective review from an institutional testicular cancer database was performed of patients with clinical stage I and II NSGTC following radical orchiectomy managed with primary RPLND for between 2003-2017. Open, laparoscopic, and robotic modalities were included. Clinicopathologic predictors of node-positive disease and teratoma following primary RPLND were assessed.
Results : Of 126 patients who underwent primary RPLND for early-stage NSGTC, 43 (34.1%) were found to have node-positive pathology, of which 6 (4.8%) had teratomatous elements, and 3 (2.3%) had teratoma only. On multivariable analysis, predictors of node-positive disease included the presence of LVI (OR 3.07, 95% CI 1.02-9.21, p=0.046) and rete testis invasion (OR 4.12, 95% CI 1.08-15.78, p=0.039); embryonal cancer was not predictive (P=0.09). For each percent of teratoma noted on the orchiectomy specimen, there was an OR 1.022 (per 1%, 95% CI 1.002-1.04, p=0.032) that RPLND would yield teratoma in the retroperitoneum. Clinical N-stage was also predictive of teratomatous elements following RPLND (OR 4.4, 95% CI 1.08-17.98, p = 0.039).
The presence of LVI and rete testis invasion was strongly predictive of node-positive disease for patients undergoing primary RPLND for early-stage NSGCT. Patient with clinical stage I NSGCT with these primary tumor findings may consequently benefit from treatment over active surveillance to minimize risk of relapse. Furthermore, patients with clinical node positive disease and increasing portions of teratomatous elements in their testis may derive greater benefit from primary RPLND, with adjuvant chemotherapy utilized as needed.