Primary Surgery Stage II ab Non Seminoma

1
Primary Surgery Stage II a/b Non Seminoma

• M.P. Laguna
• Department of Urology
• AMC, University of Amsterdam
• The Netherlands

2
When Primary RPLND ?

• EAU
• Alternative to Chemotherapy or Surveillance in
  markers
• Not willing to undergo primary Chemotherapy
• NCCN
• In CS IIa/b choice of treatment depends on marker
  levels,
• And extension of abnormal radiographic findings
  in CS IIb (landing zone)
• IGCCCG
• In markers and lymph nodes 1 -2 cm (CS IIa) as
  alternative to Surveillance

3
Primary NS-RPLND

• Advantages RPLND
• True pathological stage
• Imaging 25 suprastaging /10 underestimation
• If PS I Follow-up (spare Chemotherapy)
• If PS II Follow-up or reduced Chemotherapy ( 2
  vs 3 cycle )
• If Teratoma in the primary (?)
• Disadvantages
• Morbidity (perioperative / retrograde
  ejaculation)
• Loco-regional treatment

4
Goals Primary NS- RPLND

• As a Staging procedure
• Very low morbidity !!
• As a Curative procedure
• No adjuvant chemotherapy
• Less cycles than primary chemotherapy
• As a Loco-regional procedure
• Avoid local relapse (landing zone)

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Goals Primary NS- RPLND

• As a Staging procedure
• Very low morbidity !!
• As a Curative procedure
• No adjuvant chemotherapy
• Less cycles than primary chemotherapy
• As a Loco-regional procedure
• Systemic relapse
• Relapse outside landing zone

6
Boundaries NS-RPLND

• Left side
• Lateral half of the abdominal Aorta
• Left crus of diafragma
• Left ureter
• Left common arteria iliaca

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Boundaries NS-RPLND

• Right side
• Medial aspect abdominal Aorta
• Right crus diafragma
• Rigth ureter
• Right common arteria iliaca

8
Morbidity

• Surgical complications
• 12 in Primary RPLND
• 27 in RPLND postchemotherapy
• Loss antegrade ejaculation
• 32 in Primary RPLND
• 16 in RPLND postchemotherapy
• No differences in QoL

Weissbach et al, 2000
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Morbidity
German Group (Stage I RPLND)
Open
Laparoscopic?
17.5
9.2
Major complications
10.4
Minor complications
16.7
? In a few experienced centers
10
Contemporary Morbidity

• MSKCC
• 73 pax (94 unilateral and 82 NS)
• Mean operative time 132 min (81 -246)
• Mean blood loss 207 ml (50 -500)
• Nasogastric tube in 2 cases
• Mean time to start clear liquids 1 day
• Mean hospital stay 2.8 days (2-4)

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Primary NS-RPLND
PS II A/B 87 88
PS I 12 - 13
Surveillance Relapse 30 50
Adjuvant ChT Relapse rate 0- 7
Primary ChT overtreatment in 50 - 70
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Primary NS-RPLND (100 pax)
PS II A/B 87 pax
PS I 13 No ChT
Surveillance No relapse 61- 43 pax
Adjuvant ChT 26 44 pax (2 cycles) 2 3 more
than 2 cycles
Primary ChT overtreatment in 56 74 pax
13
Curative without ChT

• Indiana (NS-RPLND alone, PS II)
• DFS 68, median FU of 43 months
• Number of positive nodes or nodes density no
  significant prognostic factors (Beck 2005)

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Risk factors occult systemic disease
Risk Factors analysis 1989 1998

• Elevated Markers after orchiectomy
• Clinical lymph nodes 2 cm
• Multiple nodes
• Nodes outside landing zone

Choice based on Risk factors 1999 2002 Shift to
ChT in presence of adverse factors
Stephenson et al, 2007
15

• Improvement relapse free survival from 84 to
  98
• At the expenses of Primary RPLND group ( size of
  nodes, number nodes, elevated markers, nodes
  outside)
• No relapses in Primary RPLND without adverse risk
  factors
• Only 32 adjuvant chemotherapy
• Reduce number of ChT cycles (RPLND 1.4 cycles vs
  4.2 PC)

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Relapse

• Systemic / Local fifty / fifty
• Local relapse (outside landing zone)
• Insufficient surgery
• Different templates
• Imperative of NS

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Extra-template disease
Extra template disease ranged from 1 -11 in pN1
cases Extra-template without present in
template in 0-3
Eggener et al, 2007
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Pre A
PA
RCI
Extra template 2
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Pre A
IAC Pre C
IA
PA
PC
RCI
LCI
Extra template 2
Extra template 3
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In Stage II Non Seminoma

• Persistent disease after standard Chemotherapy
• 13 (Stephenson et al, 2007)
• 33 (Weissbach et al, 2000)
• RPLND of residual masses
• Complication rate higher than in primary
• Direct correlation with number of cycles

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Conclusions

• There is a role for NS-RPLND in CSIIa (b)
  patients, not in competition with ChT.
• Selection of candidates, based on clinical risk
  factors, reduces the need for adjuvant ChT.
• When indicated , to be performed in centers of
  reference following optimal templates.