Ep. 58 RPLND for Early Stage Testicular Cancer with Dr. Clint Cary and Dr. Timothy Masterson

In this episode of BackTable Urology, Dr. Aditya Bagrodia discusses retroperitoneal lymph node dissection (RPLND) for early stage testicular cancer with Dr. Clint Cary and Dr. Timothy Masterson from Indiana University School of Medicine.

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SHOW NOTES

First, the doctors discuss how to approach T1 testicular cancer, which does not show elevated markers or nodal metastases. All the doctors agree that the best approach is just surveillance of the tumor without RPLND, unless there is evidence of somatic transformation. Because some patients have anxiety about just doing surveillance, they assure them that only 10-15% of T1 tumors progress. However, there are different warning signs for different tumor histologies. It is important to get medical oncologists on board quickly in order to have a balanced presentation of treatment options for the patient. The doctors agree that surgeons must counsel patients on the possible complications of RPLND, such as retrograde ejaculation, hernias, and lymphatic leaks, but the probability of these events is low.

Next, the doctors discuss whether certain tumor markers can predict the relapse of an early stage testicular cancer. They agree that LDH is not an important marker to check, as it may be falsely elevated. An elevated AFP level can be concerning, but urologists should always put the value into context by comparing to the patient’s normal baseline levels and seeing if there is an upward trend. Finally, hCG levels can falsely be elevated by marijuana and hypogonadism. Then, the doctors share their imaging protocol. Standard chest, CT, and pelvic imaging is needed, and Dr. Bagrodia favors chest CT over CXR for better visualization. The doctors also note that more pre-operative imaging immediately before an orchiectomy is not always necessary if the surgeon already has recent imaging.

Additionally, the doctors explore approaching T2 testicular cancer, in which there are positive nodes confined to peritoneal nodes. Dr. Masterson and Dr. Cary agree that axial CT imaging is superior. More preoperative factors would be considered such as the focality of the lymph nodes involved, the duration of surveillance time, primary histology of the tumor, and the size of mass. Depending on which lymph nodes are positive (i.e. paraaortic, pelvic. etc.), a surgeon can choose the best RPLND template (modified, unilateral, bilateral). The doctors then explain their intraoperative and postoperative anesthesia protocol. They do not routinely administer DVT prophylaxis before surgery because of the risk of lymphatic leakage. Additionally, they are careful not to disseminate disease by disrupting tumor, which can cause abnormal patterns of metastases

Next, the doctors share their post-operative advice for patients. With regards to diets, a lower fat diet will lead to quicker recovery. Ejaculatory function remains normal for patients with unilateral surgery, but should recover within 8-12 months in patients with bilateral surgery. Surgical pathology can determine whether the patient should start adjuvant therapy. For N1 tumors, no adjuvant chemotherapy needed. For N2 tumors, the decision depends on histology and patient factors. Additionally, the doctors explain that extranodal extension does not always mean relapse is inevitable. For this reason, it is important to consider the histology of the tumor. The doctors end the episode by discussing new research on seminoma relapse.