Redefining the refined retroperitoneal lymph node dissection in testis cancer: a SWOT analysis of nonrandomized data.

A SWOT analysis, generally used in a business sense, comprises of a strategic evaluation that includes strengths, weaknesses, opportunities and threats. Here, it is applied to a body of nonrandomized clinical and scientific data. The historical significance of using a multimodality treatment approach to metastatic cancer is best exemplified by nonseminomatous germ cell tumors of the testis (NSGCTT). The high, durable, and meaningful remission rates achieved in the cisplatin-based era in patients with both retroperitoneal disease and more distant metastases have improved continually with the evolution of combination programs. These include cisplatin with vinblastine and bleomycin; the evolution to etoposide replacement of vinblastine, with associated decrements in significant toxicities; elimination of bleomycin for certain risk categories; and lessening the duration of treatments. These advances have fuelled great optimism in developing strategic treatments that enhance cure and minimize toxicity. Accompanying the refinements of curative chemotherapy programs have been evolutionary developments in the surgical management of NSGCTT. Once the mainstay of treatment for NSGCTT that had metastasized to the retroperitoneum, the retroperitoneal lymph node dissection (RPLND) has also undergone extraordinary improvements in operative technique, patient selection, approach (open v laparoscopic), anatomic understanding of disease landing zones, and refinements to minimize ejaculatory disturbances (both retrograde ejaculation and failure to ejaculate) that have led to nerve-sparing approaches. These are all welcome advances to the teams of physicians who care for the young and otherwise healthy men with stage II NSGCTT. In this issue of the Journal of Clinical Oncology, Carver et al, representing the disciplines of Urologic Surgery and Medical Oncology from Memorial Sloan-Kettering Cancer Center (MSKCC; New York, NY), provide masterly analyses that redefine the already established refinements of RPLND. Such an analysis is especially appropriate to emanate from MSKCC, given that institution’s incredible contributions to the field that have been so important in providing advances embraced by physicians worldwide. The issue at hand relates to the appropriate extent of RPLND for patients with retroperitoneal NSGCTT after chemotherapy (postchemotherapy [PC] -RPLND). Given the correlation of greater ejaculatory morbidity associated with more extensive bilateral infrahilar RPLND for stage I NSGCTT and a more refined (but still incomplete) understanding of nodal landing sites for metastases, the concept of modified dissection templates emerged that limited surgical boundaries to the areas most likely to contain microscopic metastases or disease below the detection of radiographic tests, and thereby minimize postoperative ejaculatory dysfunction. Although no fewer than five modified dissection templates have been described, and are now often applied to the stage II patient, the authors point out that none have undergone rigorous follow-up when applied to stage II disease in the PC setting. In other words, is the performance of a template-modified RPLND correct in the setting of patients with stage II disease of varying tumor burdens? Such an analysis would provide the much-needed comfort that less (surgery) is better or equivalent (in oncologic efficacy). Unfortunately, the results of the current study cast serious doubt on this optimistic assumption. Short of performing a randomized study that compares both the safety and oncologic efficacy of a modified template to the more extensive bilateral infrahilar dissection in the PC setting, the authors analyzed (deduced and imputed) the nature and extent of retroperitoneal disease (teratoma or viable germ cell tumor GCT) PC. Their results include the nature of disease that would have persisted had a template RPLND been performed instead of a more extensive bilateral dissection. Given the poorer prognosis of late and uncontrolled retroperitoneal relapses, and the treacherous and wildly uncertain natural history of unresected teratoma, they argue further that the 7% to 32% of patients who would have had extratemplate disease would not have been well served by a more limited template RPLND. Can the informed reader arrive at the same conclusion? To answer that, let us evaluate the strengths, weaknesses, opportunities, and threats of the data interpretation presented by Carver et al. What are the strengths of the article? First, by any standard of NSGCTT patient experience, the database is huge. In a 14-year period at MSKCC, 532 stage II patients underwent a PC-RPLND, of whom 269 had evidence of either teratoma or viable GCT; of these, 7% to 32% (depending on the template selected) would have had evidence of extratemplate disease had a template RPLND been performed. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 25 NUMBER 28 OCTOBER 1 2007