Evaluation of a risk-adapted strategy in the primary surgical management of clinical stage IIA testicular cancer.
Authors: Gerald Thomas , Amini Armon , Howard Jeffrey , Meng Xiaosong , Lafin John T. , Savelyeva Anna , Konneh Bendu , Arafat Waddah , Courtney Kevin Dale , Diaz De Leon Alberto , Jia Liwei , Woldu Solomon L. , Margulis Vitaly , Bagrodia Aditya 
Published: February 2022

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Background: Patients with clinical stage IIA (CS IIA) testicular cancer often present a diagnostic and management dilemma. Clinical guidelines recommend primary retroperitoneal lymph node dissection (RPLND), chemotherapy, or radiotherapy with excellent recurrence- and disease-specific survival (RFS, DSS) rates. Given the favorable prognosis and young age of men with CS IIA disease, efforts should be made to limit treatment burden while maintaining favorable oncologic outcomes. Here we present a risk-adapted, multi-disciplinary model in the management of CS IIA testicular cancer. Methods: This was a retrospective study of men undergoing primary RPLND for CS IIA testicular cancer from 6/1/2015 to 2/28/2021. Each patient underwent radical orchiectomy with a histologic diagnosis of testicular cancer. Staging was performed with cross-sectional imaging and serum tumor markers. The case and management options were presented in a multi-disciplinary setting with the preference for re-imaging in 6-8 weeks and performance of RPLND so long as no involution of nodes or development of distant metastases. Node positivity at RPLND and clinical recurrence were evaluated. Pearson’s correlations and logistic regression were performed to evaluate the relationship between time from staging imaging to surgery and the outcomes of interest. Results: Nineteen men with CS IIA testicular cancer underwent primary RPLND. Median age at RPLND was 28 years. There were 7 (36.8%) men with pure seminoma, 11 (57.9%) with non-seminomatous germ tumor (NSGCT), and 1 (5.3%) with burnt-out primary on orchiectomy. Median largest node size was 1.2 cm (IQR 1.0-1.4 cm) on staging imaging. Final RPLND pathology revealed 2 benign (10.5%), 11 with pure seminoma (57.9%), and 6 with NSGCT elements (31.6%). The median number of positive lymph nodes on final pathology was 2 with median largest node size of 2.0 cm (IQR 1.25-3.00 cm). 9 patients (47.4%) upgraded to pN2. Median follow-up was 15 months. There were two clinical recurrences, yielding a median RFS of 9 months. Pearson correlation and univariate regression revealed no significant association between time from imaging to RPLND and upstaging from cN1 to pN2, recurrence, or recurrence-free survival. Conclusions: This study demonstrates a multidisciplinary approach selecting patients that are best managed with RPLND, supporting the oncologic safety of this risk-adapted model in the management of CS IIA testicular cancer. The pN0 rate of 10.5% is lower than historical rates in CS IIA disease and may be related to selecting out patients more appropriate for active surveillance. Similarly the 10% recurrence rate is lower than large surgical series. We are limited by lack of the denominator of patients that developed metastases at interval imaging that subsequently received systemic therapy.