MANAGEMENT OF CLINICAL STAGE II (LOW TUMOR BURDEN)
Low tumor burden stage II seminoma includes all patients with retroperitoneal metastases measuring 5 cm or smaller in maximum transverse diameter. This encompasses both clinical stages IIA and IIB. Radiation therapy is the treatment of choice for most patients with these stages of disease. The radiation portal is fundamentally the same as that of patients with clinical stage I disease. Fractionation is the same except that a boost of approximately 500 to 750 rad is administered to involved lymph nodes. Relapses occur in from 5% to 15%, and death from seminoma is rare. Prophylactic mediastinal radiation therapy is not indicated, because relapses solely in the anterior or posterior mediastinum are infrequent. The combination of supradiaphragmatic and infradiaphragmatic radiation therapy results in chemotherapy intolerance, a high rate of treatment-related mortality due to chemotherapy, and a greater than expected death rate from disease due to the inability to administer adequate doses of chemotherapy.
There are exceptions to the need for radiation therapy for clinical stage I and nonbulky clinical stage II seminoma:
A horseshoe kidney is a contraindication to retroperitoneal radiation therapy due to the high likelihood of radiation-induced renal failure. Observation is preferred in clinical stage I, and primary chemotherapy is the treatment of choice for clinical stage II.
Patients who develop a second metachronous testicular germ cell tumor and who have undergone a prior RPLND or received radiation therapy should be observed frequently if clinical stage I disease is present, and undergo primary chemotherapy in the unlikely event that the disease is confined to residual retroperitoneal lymph nodes.
Inflammatory bowel disease may also be a contraindication to radiation therapy. Discussions with an experienced radiation oncologist would be indicated under such circumstances. If the decision is not to administer radiation therapy, then the management policies noted earlier for patients with a horseshoe kidney should be followed.
NONSEMINOMATOUS GERM CELL TUMORS
Low tumor burden clinical stage II nonseminomatous GCT encompasses disease ipsilateral to the primary tumor, at or below the renal hilum, not associated with tumor-related back pain, and limited to the primary landing zone. The presence of suprahilar or retrocrural lymphadenopathy, bilateral retroperitoneal nodal metastases, back pain, or contralateral lymph nodes (even if the ipsilateral lymph nodes do not appear to be involved) generally implies unresectable disease (e.g., tumor-associated back pain) or a higher likelihood of metastatic disease (suprahilar and retrocrural adenopathy), and initial chemotherapy is preferred. Ipsilateral solitary lymph nodes smaller than 3 cm are best handled by RPLND. Lymph nodes between 3 and 5 cm, even if solitary, may be associated with more extensive disease than can be detected on abdominal CT scan.
Retroperitoneal Lymph Node Dissection
The standard approach to patients with clinical stage IIA and some IIB tumors has been RPLND. The priority is to perform a definitive therapeutic operation, following which there is a minimum likelihood of infield recurrence. Margins of resection should not be compromised in an attempt to maintain ejaculatory function. Nerve-sparing dissection may be possible, depending on the location of disease.