NO USE OF RPLND AFTER COMPLETE REMISSION OF TESTICULAR CANCER

Your patient with testicular cancer received chemotherapy and had a complete response. What's next? Is a retroperitoneal lymph node dissection really necessary? Unfortunately, no level 1 evidence exists (or ever will) to answer this question, but this retrospective review from Indiana University -- where curative treatment for this disease was developed and where Lance Armstrong was treated -- gives us a wonderful long-term perspective. In fact, Lance's data could well be included in this report. The authors report on 141 patients -- 78 were reported previously and treated from 1987 to 1994 -- plus another 71 treated from 1994 to 2005.[1] All patients had nonseminomatous germ cell tumors, and all were treated primarily with chemotherapy, but none underwent retroperitoneal lymph node dissection. With a median of 15.5 years of follow-up, there was only a 9% relapse rate and two thirds of these cases were salvaged, remaining without evidence of disease (NED). Only 4 patients out of 141 patients died of the disease. At 15 years, the disease-free survival was 90% and cancer-specific survival was 97%. The only predictive variable was the International Germ Cell Cancer Collaborative Group (IGCCCG) risk classification: At 15 years, good-risk patients had 95% disease-free survival, as compared with 73% disease-free survival for intermediate- to poor-risk patients. Median time to relapse was 11 months and late relapses were rare. The Indiana group does not even recommend follow-up abdominal computerized tomographic (CT) scans for this patient population given the good outcome, except if teratoma is found in the primary (and then they recommend only 1 CT at 6-12 months). For the next nonseminomatous germ cell tumor patient who achieves complete remission with chemotherapy, the outcome is very good. Feel free to reassure your patients that retroperitoneal lymph node dissection will not change their outcome.