Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: Impact of patient selection factors on outcome

Purpose To investigate the impact of patient selection criteria on the outcome of patients with nonseminomatous germ cell testicular cancer (NSGCT) treated by primary retroperitoneal lymph node dissection (RPLND). Since 1999, our criteria have excluded patients with persistent postorchiectomy elevation of serum tumor markers (STM) or clinical stage (CS) IIB disease from RPLND. Patients and Methods Between 1989 and 2002, 453 patients underwent primary RPLND at our institution for CS I to IIB NSGCT. Patient information was obtained from a prospective database. Retroperitoneal pathology and relapse rates were compared for patients treated before and after application of the current selection criteria in 1999. Results By excluding patients with elevated STM or CS IIB disease after 1999, the proportion of pathologic stage II patients with low-volume (pN1) retroperitoneal disease increased significantly (40 % before 1999 v64 % after 1999; P = .01), without significantly affecting the rate of retroperitoneal teratoma (21 % v 22 %, respectively; P = .89) or pathologic stage I disease (56 % v 67 %, respectively; P = .06). For patients who did not receive adjuvant chemotherapy, the 4-year progression-free probability improved significantly from 83 % before 1999 (95 % Cl, 79 % to 88 %) to 96 % after 1999 (95 % Cl, 91 % to 100 %; P = .005). Elevated postorchiectomy STM (P < .0001), clinical stage (P = .0002), and pre-1999 RPLND (P = .05) were independent pretreatment predictors of progression. Conclusion Excluding patients with CS IIB disease or elevated postorchiectomy STM from primary RPLND has had a favorable impact on the extent of retroperitoneal disease and has significantly reduced the risk of relapse after RPLND. For patients with normal STM and CS I to IIA disease, the low rate of systemic progression and 22 % incidence of retroperitoneal teratoma supports RPLND as the preferred primary intervention.