Heidenreich Julian, Gößmann Ruben, Seelemeyer Felix, Pfister David, Paffenholz Pia, Heidenreich Axel
Klinik für Urologie, Uro-Onkologie, roboter-assistierte und spezielle urologische Chirurgie, Uniklinik Köln, Kerpener Str. 62, 50927, Köln, Deutschland.
Klink für Urologie, Medizinische Universität Wien, Wien, Österreich.
Urologie. 2024 Nov;63(11):1129-1136. doi: 10.1007/s00120-024-02435-y. Epub 2024 Sep 13.
The guideline-recommended treatment of choice for clinical stage IIA/B testicular germ cell tumors is chemotherapy with three cycles of PEB/four cycles of PE or, alternatively, radiation for seminomas. Despite their high curative efficacy, both options are associated with significant long-term toxicities. We evaluated the functional and oncological outcomes of primary retroperitoneal lymph node dissection (RPLND) as a therapeutic alternative.
Between 2018 and 2022, 76 patients (n = 34 seminomas, n = 42 nonseminomas) underwent primary RPLND for marker-negative clinical stage IIA/B testicular germ cell cancer. All patients underwent nerve-sparing RPLND with a unilateral or bilateral template dissection and had a follow-up ≥ 3 months. None of the patients received adjuvant chemotherapy. In 24 patients, the serum concentration of miR371a-3p was evaluated preoperatively. Follow-up was performed according to EAU guidelines.
Median age and median follow-up were 30.1 (17-62) years and 29.3 (3-72) months, respectively. Mean operation time, blood loss, and duration of hospitalization were 131 (105-195) min, < 150 ml, and 4.5 (3-9) days, respectively. A Clavien-Dindo IIIa complication was experienced by 8 (10.9%) patients. Antegrade ejaculation was preserved in 90.8%. A mean number of 19 (7-68) lymph nodes were dissected. The mean number of positive lymph nodes was 1.1 (1-5), and the mean diameter of positive lymph nodes was 2.4 (0.8-4.6) cm. Eleven (14.5%) patients had stage pN0 (3/34 seminomas, 8/42 nonseminomas). In 24/27 patients (88.9%) miR371 was positive, and it was negative in 4/4 with pN0 and 3/3 (100%) with teratoma. An outfield relapse was experienced by 7 patients (9.2%), who then received salvage chemotherapy.
Primary RPLND for marker-negative clinical stage IIA/B germ cell tumors results in high cure rates without adjuvant chemotherapy and is associated with a low rate of complications if performed in experienced hands. Therefore, primary RPLND should be included in the management of these patients.
对于临床IIA/B期睾丸生殖细胞肿瘤，指南推荐的治疗选择是采用三个周期的PEB化疗/四个周期的PE化疗，或者对于精原细胞瘤采用放疗。尽管这两种选择都具有很高的疗效，但都伴有显著的长期毒性。我们评估了原发性腹膜后淋巴结清扫术（RPLND）作为一种治疗替代方案的功能和肿瘤学结局。
2018年至2022年期间，76例患者（n = 34例精原细胞瘤，n = 42例非精原细胞瘤）因标记物阴性的临床IIA/B期睾丸生殖细胞癌接受了原发性RPLND。所有患者均接受了保留神经的RPLND，采用单侧或双侧模板清扫，并进行了≥3个月的随访。所有患者均未接受辅助化疗。24例患者术前评估了血清miR371a - 3p浓度。根据欧洲泌尿外科学会（EAU）指南进行随访。
中位年龄和中位随访时间分别为30.1（17 - 62）岁和29.3（3 - 72）个月。平均手术时间、失血量和住院时间分别为131（105 - 195）分钟、<150毫升和4.5（3 - 9）天。8例（10.9%）患者发生Clavien - Dindo IIIa级并发症。90.8%的患者保留了顺行射精功能。平均清扫淋巴结数为19（7 - 68）个。阳性淋巴结的平均数量为1.1（1 - 5）个，阳性淋巴结的平均直径为2.4（0.8 - 4.6）厘米。11例（14.5%）患者为pN0期（3/34例精原细胞瘤，8/42例非精原细胞瘤）。24/27例（88.9%）患者miR371呈阳性，4例pN0患者中有4/4例miR371呈阴性，3例畸胎瘤患者中有3/3例miR371呈阴性。7例（9.2%）患者发生野外复发，随后接受了挽救性化疗。
对于标记物阴性的临床IIA/B期生殖细胞肿瘤，原发性RPLND在不进行辅助化疗的情况下可获得较高的治愈率，且由经验丰富的医生操作时并发症发生率较低。因此，原发性RPLND应纳入这些患者的治疗方案中。
