CLINICAL STAGE-B NONSEMINOMATOUS GERM-CELL TESTIS CANCER - THE INDIANA-UNIVERSITY EXPERIENCE (1965-1989) USING ROUTINE PRIMARY RETROPERITONEAL LYMPH-NODE DISSECTION

Between 1965 and 1989, 1180 patients at Indiana University, U.S.A., underwent retroperitoneal lymph node dissection (RPLND) for non-seminomatous germ cell (NSGC) testis cancer of whom 638 cases had primary RPLND. A subset of 174 cases were considered clinical stage B (or II) before surgery (retroperitoneal nodal metastases by clinical staging). Surgery revealed that 23%(n = 41) had pathological stage A disease (no cancerous nodes). This error rate in clinical staging has decreased somewhat with improved techniques, but remains approximately 20% over the last decade. The relapse rate in pathological stage A (n = 41) was 5% (n = 2), both of whom were cured by chemotherapy. The relapse rate in pathological stage B without postoperative adjuvant treatment (n = 54) was 35% (n = 19); 2 patients died. This indicates that 65% of pathological stage B cases were cured by RPLND alone. From 1979 to 1989, the 140 pathological stage B cases participated in a randomised prospective trial of post-RPLND adjuvant chemotherapy versus no postoperative treatment. Forty two per cent (n = 59) received postoperative platinum-based therapy (two cycles), and there has been no relapse after RPLND for stage B disease. While advances in chemotherapy for NSGC testis cancer have led to its application by several study groups to clinical stage B (or II) testis cancer (with surgery reserved only for those in partial remission), the equivalent cure rate with RPLND surgery with chemotherapy rescue reserved for those who relapse appears to have both cost and risk-benefit advantages.