Is there still a place for retroperitoneal lymph node dissection in clinical stage 1 nonseminomatous testicular germ-cell tumours? A retrospective clinical study.

BACKGROUND: Primary retroperitoneal lymph node dissection (RPLND) ultimately lost its role as the standard management of clinical stage (CS) 1 nonseminomatous (NS) testicular germ cell tumours (GCTs) in Europe when the European Germ Cell Cancer Consensus Group released their recommendations in 2008. Current guide-lines recommend surgery only for selected patients but reasons for selection remain rather ill-defined. We evaluated the practice patterns of the management of CS1 patients and looked specifically to the role of RPLND among other standard treatment options. METHODS: We retrospectively evaluated the treatment modalities of 75 consecutive patients treated for CS1 NS at one centre during 2008-2017. The patients undergoing RPLND were selected for a closer review. Particular reasons for surgery, clinical features of patients, and therapeutic outcome were analyzed using descriptive statistical methods. RESULTS: Twelve patients (16%) underwent nerve-sparing RPLND, nine surveillance, 54 had various regimens of adjuvant chemotherapy. Particular reasons for surgery involved illnesses precluding chemotherapy (n = 2), patients´ choice (n = 4), and teratomatous histology of the primary associated with equivocal radiologic findings (n = 6). Five patients had lymph node metastases, two received additional chemotherapy. Antegrade ejaculation was preserved in all cases. One patient had a grade 2 complication that was managed conservatively. All RPLND-patients remained disease-free. CONCLUSIONS: Primary RPLND is a useful option in distinct CS1 patients, notably those with concurrent health problems precluding chemotherapy, and those with high proportions of teratoma in the primary associated with equivocal radiological findings. Informed patient's preference represents another acceptable reason for the procedure. RPLND properly suits the needs of well-selected patients with CS1 nonseminoma and deserves consideration upon clinical decision-making.

Testicular biopsy for early cancer detection--objectives, technique and controversies.

This review highlights the usefulness of testicular biopsy for early detection of testicular germ cell tumour (GCT). GCT develops through a precursor stage, called testicular intraepithelial neoplasia (TIN; also called intratubular germ cell neoplasia or carcinoma in situ, CIS), which is present many years before invasive malignancy occurs. TIN/CIS is safely detected histologically. TIN is usually widely but non-randomly distributed within the testicle, thus, a biopsy of 3 mm size usually indicates the presence of TIN. Surgically, testicular biopsy should be performed at the cranial pole. Two-site biopsies provide an 18% diagnostic yield over single biopsy. Surgical complications occur in about 2.8%, most of which are managed conservatively. Serial scrotal imaging studies after biopsies revealed significant early changes. Eighteen months thereafter, less than 5% of cases have changes detectable. False-negative biopsies are extremely rare. Biopsy also provides information regarding spermatogenesis. In case of diagnosis of TIN, orchiectomy is rarely required. Low-dose radiotherapy eradicates TIN. In conclusion, testicular biopsy is useful in patients with unilateral GCT to explore the opposite testis, and in patients with retroperitoneal GCT to look for occult testicular primary. Further candidates for biopsy are selected patients with sonographic testicular microlithiasis. Despite its usefulness, the procedure has been implemented in clinical routine only in few countries thus far.