| The Testicular Cancer Resource Center |
Testicular cancer usually spreads in a fairly predictable way, first to lymph nodes in the retroperitoneum and then, if it continues to spread, to places such as the lungs and other organs. The retroperitoneal lymph nodes are deep in the abdomen, roughly between the kidneys and along the major blood vessels called the aorta and vena cava.
RPLND stands for Retroperitoneal Lymph Node Dissection. It is an operation in which a surgeon removes some or all of these lymph nodes so they can be examined for cancer and, in many situations, so that any cancer or teratoma in those nodes is physically removed.
In certain situations it makes sense to remove these nodes. In other situations it does not. Before the 1980s, RPLND was commonly used for nonseminomatous testicular cancer because there were few other effective treatment options. As cisplatin-based chemotherapy became extraordinarily effective and surveillance became safer, RPLND was used much less often.
More recently, there has been renewed interest in RPLND because we understand more about the long-term side effects of chemotherapy and radiation, the problems caused by residual teratoma, and how much better the operation can be when modern nerve-sparing techniques are used by experienced surgeons.
If you have Stage I or Stage II testicular cancer, RPLND is one of the choices worth understanding and at least considering. That does not mean it will be the best choice for you, but it should not be dismissed simply because surveillance, chemotherapy or radiation are also available.
So, who might need an RPLND?
The surgery provides actual pathological staging of the retroperitoneal lymph nodes. If the nodes are negative, that is very reassuring. If a small amount of cancer is found, the RPLND itself may be all the treatment that is needed. Depending on how much cancer is found, some patients may also consider a short course of adjuvant chemotherapy.
Another advantage is that a successful RPLND can greatly reduce the amount of abdominal imaging needed afterward. Surveillance after orchiectomy still requires repeated CT or MRI scans for several years, while some patients with a negative RPLND need only a postoperative scan and then imaging if there is a reason to suspect a problem. That can be important to someone who wants to minimize repeated CT radiation, although MRI is increasingly used as an alternative in some centers.
There are several reasons to consider surgery. The enlarged nodes might not contain cancer at all. If only a small amount of cancer is found, the surgery alone may cure it. And if chemotherapy is recommended after the surgery, some patients can receive fewer cycles than they would have received if chemotherapy had been the first treatment.
Tumor markers matter. If AFP or hCG remain elevated or are rising, that suggests cancer may exist outside the area that RPLND can remove, so chemotherapy is usually the better first treatment. A patient with normal markers and disease limited to the retroperitoneum is much more likely to be a good candidate for primary RPLND.
For Stage II seminoma, radiation and chemotherapy work extremely well, but a man cured in his 20s or 30s may live another 50+ years with the late effects of that treatment. Modern nerve-sparing RPLND gives some men with a small amount of seminoma in the retroperitoneum a chance to remove the known disease without automatically receiving chemotherapy or radiation. The SEMS and PRIMETEST trials showed that this approach can work, although some men still relapse and need additional treatment later.
RPLND is not appropriate for every Stage II seminoma patient, but it is now a real treatment choice for carefully selected men with low-volume disease.
Teratoma is a strange animal. Mature teratoma can look almost like normal adult tissue under the microscope, but in an adult testicular germ cell tumor it is not treated as harmless. It does not respond to chemotherapy, it can continue to grow, and occasionally it can transform into a completely different type of cancer. That is why residual teratoma generally needs to be removed surgically.
For nonseminoma, a residual retroperitoneal mass of about 1 cm or larger after chemotherapy is generally considered for surgical removal when tumor markers have normalized. Post-chemotherapy RPLND can therefore be both diagnostic and curative.
Post-chemotherapy seminoma is a different situation. Surgery may occasionally be needed for a large or troublesome mass left behind after treatment, but these operations can be extremely difficult because treated seminoma can produce dense scar tissue that sticks to surrounding structures. This is another situation where an experienced referral center matters enormously.
Who is less likely to be a good candidate for a primary RPLND?
Other things to think about before choosing an RPLND:
Open, laparoscopic and robotic RPLND
An RPLND can be done as an open operation or, in selected patients, with a minimally invasive approach. "Minimally invasive" means that instead of one larger abdominal incision, the surgeon works through several small incisions using long instruments and a camera. With robotic surgery, the surgeon controls those instruments from a console.
The obvious attraction is a smaller incision. In experienced hands, robotic RPLND can also mean less blood loss, less pain, and a shorter hospital stay. The important question, however, is not whether the scar is smaller. It is whether the surgeon can remove the same lymph-node tissue, just as completely and safely, as with an open RPLND.
That is where the controversy comes in. RPLND is unusual surgery, and many of the doctors with the greatest experience treating testicular cancer still perform the operation open. Robotic RPLND has encouraging results in carefully selected patients, but it has less long-term follow-up and far fewer surgeons have extensive experience doing it. Post-chemotherapy surgery can be especially complicated and is generally a very different situation from a straightforward primary RPLND.
If someone recommends a laparoscopic or robotic RPLND, ask a LOT of questions. How many RPLNDs has that surgeon personally done using that approach? Do they also know how to do an open RPLND if they run into trouble? What are their relapse rates and complication rates? This is not the place to choose a surgeon simply because a robot is available.
Whatever approach is used, the goal is the same: a complete cancer operation performed by someone who really knows how to do an RPLND.
What is the operation like?
Make no mistake, we're talking about serious surgery here.
With a traditional open RPLND, the surgeon makes an incision down the middle of the abdomen and moves the intestines and other structures out of the way to reach the lymph nodes around the aorta, vena cava and kidneys. Some surgeons use an extraperitoneal approach that reaches the same area without going through the main abdominal cavity. As discussed above, selected patients may instead have the operation done laparoscopically or robotically.
The surgeon removes the lymph-node tissue in a defined area based on where testicular cancer is expected to spread. The exact extent of the operation depends on the stage, which side the original testicular tumor was on, whether chemotherapy has already been given, and what the surgeon finds during the operation. The operation can take several hours. A straightforward primary RPLND can be considerably easier than a post-chemotherapy RPLND, where scar tissue and residual masses may be stuck to major blood vessels, kidneys, bowel or other organs.
Once the lymph nodes are removed, the pathologist examines them to find out what was actually there. If no cancer is found, that is very reassuring, although follow-up is still required. If cancer is found, the amount and type of disease in the nodes help determine whether surveillance is reasonable or whether chemotherapy should be considered.
Is this surgery "risk free"? Absolutely not! It is a complicated and delicate operation, and surgical experience matters a lot. This is one time when you should be willing to hurt your urologist's feelings and ask how many RPLNDs the surgeon actually does. Most urologists perform very few of these operations, and current guidelines specifically recommend experienced surgeons at high-volume centers when possible. That becomes even more important for a post-chemotherapy RPLND, which can be a much more complicated operation. And if future fertility matters to you, bank sperm before RPLND and certainly before chemotherapy. Think of it as insurance.
What are some of the risks with RPLND surgery? Here's a good starter list of possible problems:
These risks should not scare you away from a sometimes necessary procedure, but you do need to be aware of them and discuss them, and any other concerns, with your doctor. This is serious surgery, so ask LOTS of questions.
RPLND versus adjuvant chemotherapy
Another choice for some patients with early nonseminoma is one or occasionally two cycles of adjuvant chemotherapy instead of RPLND. This is an effective way to reduce the risk of relapse, and in many places it is offered much more often than surgery.
I still think RPLND deserves serious consideration by anyone thinking about adjuvant chemotherapy. The tradeoff is fairly straightforward: RPLND is major surgery, but it may show that there was no cancer in the nodes and allow the patient to avoid chemotherapy entirely. Adjuvant chemotherapy is easier in the short term than a major abdominal operation, but even a small amount of cisplatin-based chemotherapy can cause lasting side effects.
There is no single answer that is right for everybody. Surveillance avoids both treatments unless the cancer comes back. RPLND reduces the chance of later needing chemotherapy while avoiding systemic treatment in many patients. Adjuvant chemotherapy produces a very low relapse rate without major surgery. The important point is that these are choices, and patients should understand the tradeoffs rather than being told that only one path exists.
For more information on the subject, please take a look at these links:
