THE ROLE OF RETROPERITONEAL LYMPHADENECTOMY IN CLINICAL STAGE-B TESTIS CANCER - THE INDIANA-UNIVERSITY EXPERIENCE (1965 TO 1989)

Between 1965 and 1989, 1,180 patients underwent retroperitoneal lymph node dissection for nonseminomatous germ cell testis cancer (638 under went primary dissection). Of these patients, 174 were considered to ha ve clinical stage B disease preoperatively (suspected retroperitoneal node metastases by clinical staging). Surgery revealed that 41 patient s (23%) actually had pathological stage A disease (no cancerous nodes) . This nonspecificity in clinical staging remains consistent despite a dvance in clinical staging methods during this 25-year period. Of the pathological stage B cancer patients 65% were cured by retroperitoneal lymph node dissection alone. These long-term data indicate that prima ry retroperitoneal lymph node dissection for low stage metastatic nons eminomatous germ cell testis cancer (pathological stage B) not only ha d diagnostic but also therapeutic impact. Furthermore, this cure rate with long-term followup is equivalent to that of current series of pri mary chemotherapy alone for stage B disease, which are still relativel y early reports. This cure rate with single modality therapy (retroper itoneal lymph node dissection alone) was accomplished within an averag e of 4 hours and, therefore, should be more time and cost-effective th an prior reports of 3 and 4 courses of primary chemotherapy. In the po st-cisplatin era (1979 to 1989), 140 patients with clinical stage B di sease were treated with primary retroperitoneal lymph node dissection: 32 (23%) had pathological stage A cancer and 2 of them (6%) had relap se. Both patients are currently disease-free with subsequent chemother apy. Of the remaining 108 patients with pathological stage B disease 4 9 received no adjuvant chemotherapy and 59 received cisplatin-based ad juvant chemotherapy. Among the former 49 patients 18 (37%) had relapse and 2 died. No patient receiving postoperative cisplatin-based adjuva nt chemotherapy had relapse. The overall survival rate in these 140 cl inical stage B cancer patients was 98%. There were 3 deaths, only 1 fr om cancer. The addition of cisplatin-based adjuvant chemotherapy posto peratively has rendered pathological stage B nonseminomatous germ cell testis cancer entirely free of subsequent relapse. Therefore, retrope ritoneal lymph node dissection as monotherapy is curative in two-third s of the patients with stage II disease, while the remaining one-third with progression to clinical relapse can be reliably saved by chemoth erapy. Future considerations in selecting therapy for clinical stage I I nonseminomatous germ cell testis cancer will be risk-benefit, cost-b enefit and quality of life issues. Several cooperative studies will ex amine these issues, involving European and United States groups. KEY W ORDS: retroperitoneal neoplasms, lymph node excision, testicular neopl asms, carcinoma