Stephenson Andrew J, Bosl George J, Motzer Robert J, Kattan Michael W, Stasi Jason, Bajorin Dean F, Sheinfeld Joel
Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA.
J Clin Oncol. 2005 Apr 20;23(12):2781-8. doi: 10.1200/JCO.2005.07.132.
To investigate the impact of patient selection criteria on the outcome of patients with nonseminomatous germ cell testicular cancer (NSGCT) treated by primary retroperitoneal lymph node dissection (RPLND). Since 1999, our criteria have excluded patients with persistent postorchiectomy elevation of serum tumor markers (STM) or clinical stage (CS) IIB disease from RPLND.
Between 1989 and 2002, 453 patients underwent primary RPLND at our institution for CS I to IIB NSGCT. Patient information was obtained from a prospective database. Retroperitoneal pathology and relapse rates were compared for patients treated before and after application of the current selection criteria in 1999.
By excluding patients with elevated STM or CS IIB disease after 1999, the proportion of pathologic stage II patients with low-volume (pN1) retroperitoneal disease increased significantly (40% before 1999 v 64% after 1999; P = .01), without significantly affecting the rate of retroperitoneal teratoma (21% v 22%, respectively; P = .89) or pathologic stage I disease (56% v 67%, respectively; P = .06). For patients who did not receive adjuvant chemotherapy, the 4-year progression-free probability improved significantly from 83% before 1999 (95% CI, 79% to 88%) to 96% after 1999 (95% CI, 91% to 100%; P = .005). Elevated postorchiectomy STM (P < .0001), clinical stage (P = .0002), and pre-1999 RPLND (P = .05) were independent pretreatment predictors of progression.
Excluding patients with CS IIB disease or elevated postorchiectomy STM from primary RPLND has had a favorable impact on the extent of retroperitoneal disease and has significantly reduced the risk of relapse after RPLND. For patients with normal STM and CS I to IIA disease, the low rate of systemic progression and 22% incidence of retroperitoneal teratoma supports RPLND as the preferred primary intervention.
探讨患者选择标准对经原发性腹膜后淋巴结清扫术（RPLND）治疗的非精原细胞性生殖细胞睾丸癌（NSGCT）患者预后的影响。自1999年以来，我们的标准将睾丸切除术后血清肿瘤标志物（STM）持续升高或临床分期（CS）为IIB期疾病的患者排除在RPLND之外。
1989年至2002年期间，453例患者在我院接受了针对CS I至IIB期NSGCT的原发性RPLND。患者信息来自前瞻性数据库。比较了1999年应用当前选择标准前后接受治疗患者的腹膜后病理及复发率。
通过排除1999年后STM升高或CS IIB期疾病的患者，低体积（pN1）腹膜后疾病的病理II期患者比例显著增加（1999年前为40%，1999年后为64%；P = 0.01），而对腹膜后畸胎瘤发生率（分别为21%和22%；P = 0.89）或病理I期疾病发生率（分别为56%和67%；P = 0.06）无显著影响。对于未接受辅助化疗的患者，4年无进展概率从1999年前的83%（95%CI，79%至88%）显著提高至1999年后的96%（95%CI，91%至100%；P = 0.005）。睾丸切除术后STM升高（P < 0.0001）、临床分期（P = 0.0002）以及1999年前的RPLND（P = 0.05）是进展的独立术前预测因素。
将CS IIB期疾病或睾丸切除术后STM升高的患者排除在原发性RPLND之外，对腹膜后疾病范围产生了有利影响，并显著降低了RPLND后的复发风险。对于STM正常且CS I至IIA期疾病的患者，全身进展率低且腹膜后畸胎瘤发生率为22%，支持将RPLND作为首选的原发性干预措施。
