Early studies showed a lower risk of relapse when fewer than six nodes were involved and no node was 2 cm; and higher when 6 nodes or more were involved, any node was larger than 2 cm, or extranodal extension was present.
Surveillance is a treatment choice for compliant patients with fewer than six involved nodes and none larger than 2 cm. Surveillance requires close monitoring, and chemotherapy is reserved for patients who relapse. Patient compliance, psychologic factors, age, or other issues may make adjuvant chemotherapy the preferred choice in rare patients. Three or four cycles of cisplatin-based therapy will be required at relapse according to disease status at that time.
Adjuvant chemotherapy remains a strong consideration in patients when six nodes or more are involved, any node is larger than 2 cm, or there is extranodal extension. In the late 1970s, treatment programs based on cisplatin, vinblastine, and bleomycin were given as adjuvant therapy following RPLND, and nearly 100% of patients survived relapse free. Considerable treatment-related morbidity was associated with these regimens, prompting efforts to reduce toxicity. Two cycles of cisplatin-based chemotherapy are nearly always effective in preventing relapse. A randomized trial showed that observation with standard treatment at relapse and two cycles of adjuvant chemotherapy had equivalent survival. Etoposide has replaced vinblastine in adjuvant regimens. A recent study suggests that etoposide plus cisplatin alone is adequate, and that bleomycin is unnecessary as part of adjuvant therapy.