cancer usually spreads via a very predictable route through the lymph
nodes upwards to the lungs, and then outward to the liver, brain, and
elsewhere. The affected lymph nodes are call the "retroperitoneal lymph
nodes" and they are located behind all of the major organs in the
belly, basically between the kidneys and along the vena cava and aorta.
certain situations it makes sense to remove these nodes. In other
situations the RPLND is simply not done. So, who might need an RPLND? WE
SUGGEST CONTACTING AN EXPERT IN THE FIELD OF TESTICULAR CANCER TO FIND
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a patient has Stage I nonseminoma, it may make sense to remove the
lymph nodes to determine whether, in fact, the cancer really is gone.
If it isn't, the surgery alone may cure them or they can proactively
receive a short course of chemotherapy that will essentially cure them.
patient with Stage II nonseminoma, meaning that the doctors think the
cancer has spread to these lymph nodes, may also choose to have the
surgery if the nodes are small enough. The motivation here is either 1)
it might not be cancer, 2) if only a small amount of cancer is found,
the surgery alone might cure it or 3) removing the lymph nodes first
may reduce the amount of chemo required to cure the cancer.
a number of people may need this surgery after chemotherapy. The chemo
may kill the cancer, but one of the things left behind, teratoma, must
be removed. Teratoma is a benign tumor with a tendency to grow or
degenerate back into another cancer. If the stuff left after chemo is
large enough (perhaps more than 1-2cm), it is likely that the doctors
will want to remove it. In a few cases it is possible that the chemo
did not completely kill all the cancer. In these cases, removing the
lymph nodes might also be therapeutic and cure the cancer.
who does not need an RPLND or is not likely to be offered an RPLND? In
general, if you don't fall into one of the categories mentioned above,
you should not be thinking about the RPLND. However, things may be a
little more complicated, so I will try to specifically list those
situations where you do not want or will not be offered an RPLND.
RPLND is almost never done for seminoma. It is more difficult to do and
radiation is a preferable treatment. The most common reason to perform
the surgery on a seminoma patient is to remove large, bulky masses left
over after radiation or chemo that are somehow getting in the way of
the normal operation of the internal organs around it.
who do not have any visible spread of their cancer, but who DO have
positive and rising tumor markers after their orchiectomy should not
have an RPLND. A number of studies have shown that this surgery will
not cure them, and they should go directly to chemotherapy.
patients whose lymph nodes are larger than 3 cm usually are not offered
an RPLND. They almost definitely have cancer and should go directly to
chemotherapy. However, there are exceptions. A patient with teratoma in
his testicular tumor and a 4cm lymph node stands a greater than average
chance that his lymph nodes also have teratoma in them. In such a case,
the RPLND alone could cure him about half the time.
with clinical stage I cancer who had their orchiectomy more
than 6 weeks before the scheduled RPLND date should consider canceling
the surgery. The RPLND is most beneficial if it is done soon after the
orchiectomy. If you wait long enough before having an RPLND, you are
essentially on surveillance and/or if they do find cancer during the
surgery, it is less likely that they will have caught it before it
spread outside of the surgical boundary. This is not a hard and fast
rule, but unless there is a very good reason for delay, try to have the
surgery done quickly.
for good or bad, if you live in the UK or parts of Europe or Australia,
you may not be offered an RPLND except possibly in the post-chemo
situation. The reason for this is less medical than you think. I will
attempt to explain this issue later in the article.
about who should and should not have the operation. What is the
operation like? Make no mistake, we're talking some serious surgery
here, folks. In a nut shell, the RPLND involves an incision from just
below your sternum to below the belly button (but they do go around
it!). Your intestines and associated organs are literally lifted out of
the way, nerves are identified and hopefully moved out of the way, and
then the surgeons remove all the lymph nodes that were connected to the
testicle containing the tumor.
operation itself can take 4-6 hours, but I have spoken with doctors who
have had advanced cases lasting 20+ hours! They usually check the lymph
nodes on the same side as the affected testicle first, and if they find
anything suspicious, they may check the other side as well for
additional spreading. If you would like to see more details about the
actual surgical procedure, take a look at some of the links at the
bottom of this page.
is a very well studied surgical procedure: if you come out clean, odds
are pretty good that you are TC free! (not good enough to never go back
to the doctor, but very good nonetheless.) If they find cancer, you've
most likely got a longer (but still survivable!) path of surveillance
or chemo in your future.
this surgery "risk free"? Absolutely not! It is a complicated and
delicate procedure that is rarely done. There are far more urologists
in the US than there are RPLND's in a single year. Few doctors do more
than a couple of these surgeries a year. This is one time when you
should be willing to hurt your urologist's feelings and look for
someone who has some experience. If you need a post-chemo RPLND, I
strongly suggest that you find someone who has done the procedure many
times before. (I also suggest banking sperm before the surgery if you
are interested in having children in the future. It is good insurance
and worth the expense.)
are some of the risks with RPLND surgery? Here's a good starter list of
due to retrograde ejaculation. If the doctor cuts a nerve during the
surgery, and it is very easy to do this, you will lose the ability to
ejaculate normally. You'll still ejaculate, but your sperm will end up
in your bladder!!
bowel inactivity (also called "ileus")
scar and possible infection
management issues - You will definitely be feeling the effects of the
operation for 2-3 months.
damage to surrounding organs, blood vessels, etc.
from blood transfusions
- lymphatic fluid continues to collect in the removal area
these risks should not scare you away from this sometimes necessary
procedure, but you do need to be aware of them and discuss them, and
any other concerns with your doctor. As we have pointed out, this is
serious surgery, so ask LOTS of questions.
developments in the field include the laparoscopic RPLND. This is an
infrequently available, very new, very difficult, time consuming
operation. It does substantially reduce morbidity and recovery time.
However, we do not recommend it because we do not feel that it is a
curative operation. In other words, since it won't cure you, it will
not eliminate the need for chemotherapy. If it doesn't do this, then
why bother doing it at all? See the articles listed below for more
information on this topic.
an increasing number of doctors in Europe and a few in the United
States are offering their patients 2 cycles of chemotherapy instead of
an RPLND. This is popular in Europe because they appear to avoid the
RPLND like the plague - basically, they simply do not have enough
urologists around to do the surgery, and the surgeons they do have do
not have any experience with the operation. It is becoming more popular
here because there is the belief that the surgery is not valuable and
can be avoided with a little chemo. I strongly disagree with this
approach. The RPLND is serious surgery, but it is a proven treatment
for this cancer. If there is no cancer, and the nerve sparing approach
is used, then there should be no long term side effects of the surgery.
You cannot say that with chemo - even two cycles of chemo can cause
some lasting side effects, and it would be unfortunate to go through
chemo and not even need it. Finally, the chemo is not a proven
treatment and there is no long term data to support its effectiveness.
Two cycles done after a properly done RPLND can virtually ensure a
cure. Two cycles done without an RPLND might be too much treatment,
just enough, or not enough at all.
out Dr. Fosters article: Current Status of Retroperitoneal Lymph Node
Dissection and Testicular Cancer: When to Operate