542

Practical Urology: EssEntial PrinciPlEs and PracticE

The strategies are discussed in greater detail

initial orchidectomy, while those with lower­risk

below but in brief, these are subdivided into

characteristics are entered into standard surveil­

patients who are clinically stage 1 and those who

lance schedules. In this way, the toxicities of treat­

have cT2 or greater staging. Those with clinical

ment are avoided in low­risk patients, while the

stage 1 seminoma or NSGCT have traditionally

potential for undertreatment of high­risk cases is

been managed by very different strategies, with

minimized. Active treatment schedules involve

options for radiation, low dose chemotherapy or

the use of low dose adjuvant chemotherapy.

surveillance and salvage therapy emerging for

Retroperitoneal lymph node dissection (RPLND)

seminoma, and observation, low dose chemo­

is still used in some centers (particularly in the

therapy, or, in specific circumstances, primary

USA), but its use is decreasing for the reasons set

RPLND for non­seminoma, depending on risk

out below. The schemes of management are set

characteristics. If the disease is stage 2 or more,

out in the flow diagrams in Figs. 39.2 and 39.3.

the standard treatment for most tumors is

by combination platinum­based chemotherapy

Surveillance Versus Primary RPLND

using bleomycin, etoposide, and cisplatinum

Treatment strategies for clinical stage 1 disease

(BEP) with subsequent surgical removal of post­

chemotherapy residual masses. This is under­

have varied in different countries: for example,

taken for most NSGCT, while chemotherapy is

primary surgery has prevailed in the USA, while

used alone for most seminomas, with post­

surveillance has been most commonly used in

chemotherapy surgery being indicated only for

Europe. The rationale for primary RPLND is

highly selected cases.8

that up to 30% of patients will have microscopic

evidence of disease in the retroperitoneal nodes.

However, using risk stratification profiles based

Management of Clinical

on histology, it is possible to predict with accu­

racy of approximately 80% that low­risk cases

Stage 1 Disease

will not relapse9 and furthermore, if they do,

they can then undergo systemic treatment with

Non-Seminomatous Germ Cell

chemotherapy with excellent results. Patients

relapsing on surveillance are successfully treated

Tumor (NSGCT)

with standard chemotherapy and have long­

term cure rates of 98%, which is the same as that

Risk Stratification

for primary surgery.11 In addition, over 95% of

patients who are going to relapse will do so

Data from large multicenter studies correlating

within the first 2 years of diagnosis of their

tumor­related factors with disease outcome has

original cancer. Prolonged and intensive follow­

enabled stratification of clinical stage 1 NSGCT

up over many years is therefore not required

for risk.9 The rationale for this is to identify men

although a degree of follow­up is needed because

who truly have stage 1 disease and to separate

of the risk of late relapse. Surveillance is now

these from those who are clinically stage 1 but

the standard of care in most high volume

have risk characteristics associated with the pres­

centers.7

ence of occult microscopic metastases (pathologi­

calstage2+).Inthisway,aggressiveandpotentially

Primary RPLND

toxic treatments can be reserved only for those

men who truly need them. Defined pathological

Existing noninvasive staging techniques fail to

findings in the primary are known to be associ­

identify up to 30% of patients with positive

ated with a high risk of occult metastatic spread

nodes. This fact has provided a rationale for a

in clinical stage 1 disease.9,10 They are:

surgical approach in clinical stage 1 testicular

• Vascular and/or lymphatic invasion

cancer. The procedure is usually carried out

• Absence of the yoke sac elements

through a midline abdominal incision although

an increasing number of reports have emerged

• Presence of embryonal carcinoma

relating to the use of laparoscopic techniques.

Patients with these primary characteristics are

The traditional approach of standard bilateral

usually treated with a more aggressive therapeutic

lymphadenectomy is associated with loss of ejac­

regimen or more intensive surveillance following

ulatory function in most patients. By contrast,