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Primary RPLND for stage 1b non-seminoma

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  • Primary RPLND for stage 1b non-seminoma

    Hey Guys,

    I've been messaged by a number of newcomers here regarding the choice of primary RPLND for stage 1b non-seminomas. It's something that a lot of people seem to consider. So, I had some time to put down some of the pros/cons of a primary RPLND and my thoughts about it. I think it's a good option for those that are uncomfortable with surveillance, but also uncomfortable with BEP x 1, and want to significantly decrease their relapse rates from the dreaded 50/50 situation they find themselves in. I've never had an RPLND, but I did strongly consider it. It would also be great to hear from those that had the primary RPLND for stage 1b non-seminoma and hear what their experience was like, their thoughts about it, etc.

    RPLND pros:
    - no toxic chemicals, thus no long-term health risk with respect to cardiovascular health or secondary malignancies
    - no peripheral neuropathy, no tinnitus, no hair loss, no effect on the blood count
    - allows for close look at the retroperitoneal lymph nodes and actually see what's going on, instead of relying on highly unreliable CT scans
    - gives the best chance to avoid unnecessary chemotherapy
    - if there's teratoma in the primary and it has spread, surgical resection is the only way to remove it as it is chemo-resistant

    RPLND cons:
    - approx 10% risk of retrograde ejaculation even with nerve-sparing techniques. This is likely a lower risk with high volume surgeons. My urologist stated it was 10% if he was going to do it but he was not a high volume surgeon.
    - 1% risk of small bowel obstruction
    - approx 5% risk of hernia
    - chylous ascites possible, but VERY unlikely
    - even if lymph nodes are negative there is about an 8-10% risk of relapse (NOT bad!!). Relapse is usually seen either by mets to the lungs or by tumor marker elevation. If there is low volume disease found in the lymph nodes then the relapse risk increases to 15-20%. These are approximate numbers I've seen quoted in journals but I would make sure you discuss these numbers with your urologist to ensure accuracy with the most up to date research.
    - if high volume disease is found in the lymph nodes, then 2 x BEP will be a strong consideration. I suspect some oncologists would be okay with 1 x BEP, but this is something that I would ask Einhorn about. So there's no guarantee that chemo will not be recommended after the RPLND.

    Overall, if I had to do a primary RPLND, I would do the full-open method. Most surgeons agree that this is the best way to fully visualize the retroperitoneum. The laparoscopic approach is generally not as good. There is the robotic method (da Vinci robot) which allows for significant magnification of the retroperitoneum and some surgeons suggest that it is equally as good as the open method, but I still prefer the open method. Both the titans of the RPLND (Foster and Sheinfeld) prefer the open way and it's tried and tested so I think it's the safest bet. I would also go for a bilateral nerve sparing technique. This is better than a "modified template" as more lymph nodes are removed and will decrease the relapse rate even further. I would also get a high volume surgeon to do it as this has shown to decrease relapse rates. Anyways, I hope this helps anyone in the difficult situation with various options to consider....
    Diagnosed at age 31. Treated in NYC. Now living in Ottawa, ON, Canada.

    7/1/2015: felt tiny lump on side of R testicle
    7/30/2015: Ultrasound shows 2 intra-testicular masses.
    7/31/2015: tumor markers normal, CXR clear
    8/5/2015: R orchiectomy
    8/11/2015: Pathology: 1.2 x 1.0 x 1.0 cm, embryonal 80%, seminoma 20%, with LVI and rete testis invasion
    8/14/2015: CT abdomen/pelvis clear, Stage 1b
    8/24/2015: started 1 x BEP

  • #2
    I agree with this 100%. I did a primary RPLND with Stage 1b. For me, it was a personal choice directed at avoiding the potential long term effects of chemo.

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    • #3
      Jfert, I know you had it done by Sheinfeld. The people at Sloan are big proponents of primary RPLND. This is one management approach that I tend to like about Sloan. With Sheinfeld, they are well equipped to advocate for the RPLND. I tend to lean away from Indiana's approach here (they lean towards surveillance). I just think that way too many people will then require the dreaded 3 x BEP. I think it's easy for doctors to say "surveillance until we see something" but they don't really seem to acknowledge how hard chemo is on the patient.
      Diagnosed at age 31. Treated in NYC. Now living in Ottawa, ON, Canada.

      7/1/2015: felt tiny lump on side of R testicle
      7/30/2015: Ultrasound shows 2 intra-testicular masses.
      7/31/2015: tumor markers normal, CXR clear
      8/5/2015: R orchiectomy
      8/11/2015: Pathology: 1.2 x 1.0 x 1.0 cm, embryonal 80%, seminoma 20%, with LVI and rete testis invasion
      8/14/2015: CT abdomen/pelvis clear, Stage 1b
      8/24/2015: started 1 x BEP

      Comment

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