Treatment outcomes for men with stage 2 non-seminoma undergoing primary RetroPeritoneal Lymph Node Dissection (RPLND): A systematic review

Abstract

Introduction & Objectives: Current guidelines recommend primary RPLND as a treatment option for tumour marker negative stage 2 non seminoma. RPLND offers several potential advantages compared to cisplatin-based first-line chemotherapy, including: 1) clarification of ambiguous cN+ on imaging; 2) resection of potentially chemo-resistant histologies, which reduces the risk of late recurrence and the need for post chemotherapy RPLND; and 3) limited long-term morbidity. The aim of this review is to examine the oncological outcomes of RPLND for men with clinical stage 2 disease with or without elevated tumour markers. Materials & Methods: A systematic review was conducted to summarize treatment options and outcomes in the published literature, using the electronic databases MEDLINE, EMBASE and Cochrane Database of Systematic Reviews. Results: Of 4,386 total records, 448 full texts were screened and 13 studies were selected for the review, of which 12 were retrospective in nature. The studies included in the review contributed data from 892 men. Studies used different inclusion criteria (e.g., amount of teratoma in orchiectomy specimen, level of preoperative tumour markers, nodal size, synchronous or metachronous disease). Among men with enlarged retroperitoneal lymph nodes (cN+), 13–53% had false positive findings in imaging; in other words, no cancer was found in the RPLND specimen (pN0). Six of the studies used a bilateral or modified template. A bilateral or modified unilateral template was used in one study each. No template description was available for the remaining five studies. Nerve sparing was mentioned in three studies. In the case of pN+ disease, additive systemic treatment was given to most men in five studies, whereas in six studies, additive chemotherapy was only used for participants who had large or several affected lymph nodes or had persistently elevated tumour markers. One study did not mention the indication for chemotherapy, and in the last study, no additive chemotherapy was prescribed. Recurrence after RPLND without additive systemic chemotherapy was observed in 19–37% of participants, and recurrence after RPLND with additive systemic chemotherapy was observed in 0–7% of participants. Overall, survival rates ranged from 88–100% of participants, and disease-specific survival rates ranged from 97–100% of participants. Conclusions: The literature describing surgery among men with enlarged retroperitoneal lymph nodes on cross-sectional imaging is heterogenous in selection criteria, surgical templates, additive therapy, and length of follow-up, which prevents a meta-analysis at the study level.