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Editorial Comment on: Laparoscopic Retroperitoneal Lymph Node Dissection: Does It Still Have a Role in the Management of Clinical Stage I Nonseminomatous Testis Cancer? A European Perspective
1016
european urology 54 (2008) 1004–1019
quality of life has been reported to be better in patients receiving L-RPLND [2,3]. As pointed out by Rassweiler et al [1], the current potential for L-RPLND as a diagnostic and/or therapeutic tool is in clinical stage I NSGCT for cases in which no surveillance or chemotherapy are favoured by the patients. Regarding the curative role of RPLND (open or laparoscopic) in clinical stage IIA disease with low volume and in postchemotherapy stage IIA and IIB, some data from small-sized trials are available [4,5]. To clarify this issue, multicentre randomised trials with larger patient groups and longer follow-up are necessary and strongly encouraged. The use of laparoscopy was one of the most important steps in the progress of medicine in the 20th century. Laparoscopic radical nephrectomy is now considered the new gold-standard surgical treatment for benign renal masses as well as for localised renal cell carcinoma [6,7]. For radical prostatectomy, the laparoscopic approach provides promising results, which makes it likely to become the method of choice in the management of organconfined prostate cancer in the near future [8]. Nevertheless, laparoscopic techniques are associated with a learning curve. Hence, whenever reporting on laparoscopic methods (ie, L-RPLND), the adequate experience of the performing surgeon as well as that of the institution should be considered. For this purpose, hospital and surgeon case-load calculations to achieve optimum clinical outcome, already known from other surgical procedures, should also be applied to urologic laparoscopic procedures. As long as a high level of clinical evidence is not given for L-RPLND, only centres with adequate minimum case-load volume should be legitimate to perform this procedure.
References
Editorial Comment on: Laparoscopic Retroperitoneal Lymph Node Dissection: Does It Still Have a Role in the Management of Clinical Stage I Nonseminomatous Testis Cancer? A European Perspective Peter Albers Du¨sseldorf University, Du¨sseldorf, Germany [email protected]
low-risk tumors (no vascular invasion) and chemotherapy for high-risk tumors [1]. In Canada, the options for this patient group include surveillance, even for patients with high-risk features, based on equal cancer-specific survival data of >98% [2]. In view of these management guidelines, the review of Rassweiler and colleagues [3] is important for this small subgroup of <10% of patients with NSGCT who (1) wish to be staged surgically; (2) have pure teratomatous tumors; and (3) are at high risk for recurrence, do not want to undergo surveillance, and have contraindications for chemotherapy. In these rare situations, the patient may choose between open and laparoscopic
Surgical staging in patients with clinical stage I nonseminomatous germ cell tumors (NSGCT) has become a rare recommendation. In Europe, the recommendation is for patients to undergo a risk-adapted treatment with surveillance for
[1] Rassweiler JJ, Scheitlin W, Heidenreich A, Laguna MP, Janetschek G. Laparoscopic retroperitoneal lymph node dissection: does it still have a role in the management of clinical stage I nonseminomatous testis cancer? A European perspective. Eur Urol 2008;54:1004–19. [2] Poulakis V, Skriapas K, De Vries R, et al. Quality of life after laparoscopic and open retroperitoneal lymph node dissection in clinical stage I nonseminomatous germ cell tumor: a comparison study. Urology 2006; 68:154–60. [3] Steiner H, Peschel R, Janetschek G, et al. Long-term results of laparoscopic retroperitoneal lymph node dissection: a single-center 10-year experience. Urology 2004;63:550–5. [4] Weissbach L, Bussar-Maatz R, Flechtner H, Pichlmeier U, Hartmann M, Keller L. RPLND or primary chemotherapy in clinical stage IIA/B nonseminomatous germ cell tumors? Results of a prospective multicenter trial including quality of life assessment. Eur Urol 2000;37:582–94. [5] Neyer M, Peschel R, Akkad T, et al. Long-term results of laparoscopic retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testicular cancer. J Endourol 2007;21:180–3. [6] Fornara P, Doehn C, Seyfarth M, Jocham D. Why is urological laparoscopy minimally invasive? Eur Urol 2000; 37:241–50. [7] Fornara P, Doehn C, Friedrich HJ, Jocham D. Nonrandomized comparison of open flank versus laparoscopic nephrectomy in 249 patients with benign renal disease. Eur Urol 2001;40:24–31. [8] Jurczok A, Zacharias M, Wagner S, Hamza A, Fornara P. Prospective non-randomized evaluation of four mediators of the systemic response after extraperitoneal laparoscopic and open retropubic radical prostatectomy. BJU Int 2007;99:1461–6.
DOI: 10.1016/j.eururo.2008.08.023 DOI of original article: 10.1016/j.eururo.2008.08.022
european urology 54 (2008) 1004–1019
1017
surgery; however, in both cases, he will ask about the experience of the surgeon and the complication rates of the procedure. In a multicenter randomized trial, the relatively high in-field recurrence rate after open retroperitoneal lymph node dissection (RPLND) was not an expected result [4]. This finding contradicts RPLND data from single centers with high operative volume and further diminishes the role of RPLND in a community setting. In their review, the authors stress the importance of experienced centers for laparoscopy and compare operative data from high-volume laparoscopic centers to multicenter data on open surgery [3]. A well-accepted definition of an ‘‘experienced laparoscopic RPLND center,’’ however, is not available. In summary, this review [3] focuses on a minority of patients for whom laparascopic RPLND (L-RPLND) may be an option; however, not even high-risk patients would benefit from a double procedure of laparoscopic staging and chemotherapy for metastatic disease, as opposed to surveillance and chemotherapy for treatment of metastases. The clinical problem of overtreatment of curable patients is not solved with laparoscopy.
References
Editorial Comment on: Laparoscopic Retroperitoneal Lymph Node Dissection: Does It Still Have a Role in the Management of Clinical Stage I Nonseminomatous Testis Cancer? A European Perspective Giorgio Pizzocaro Urology Clinic 2nd, University of Milan, San Giuseppe Hospital, Milan, Italy [email protected]
the testis by comparing large, recent series of L-RPLND and O-RPLND. Risk factors were not considered. Table 2 in their paper demonstrates a minimal difference in operative time; a smaller number of removed nodes in L-RPLND (14 vs 19 in O-RPLND); and a shorter hospital stay (3.3 vs 6.6 d) for L-RPLND, even if the same short hospital stay has been recently reported in O-RPLND [3]. Interestingly, approximately 30% of patients in both groups received postoperative chemotherapy (Table 4 in the paper): This means that nearly all patients with positive nodes in both groups received adjuvant chemotherapy! Surgery followed by adjuvant chemotherapy can be considered overtreatment compared to surveillance in lowrisk patients and adjuvant chemotherapy in highrisk patients. It has been reported that after O-RPLND alone [4], relapses do occur in approximately 10% of pathological stage I patients and in 30% of pathological stage IIA (pN1) patients. To compare L-RPLND versus O-RPLND today, we need to stratify clinical stage I patients into good- and poor-risk categories. Good-risk patients could be randomised to O-RPLND versus L-RPLND without postoperative
Postorchiectomy treatment of clinical stage I nonseminomatous germ cell tumours (NSGCT) of the testis is controversial. The European Germ Cell Cancer Cooperative Group (EGCCCG) recommends surveillance for low-risk patients (no peritumoral vascular invasion; expected relapse rate of 14–22%) and two courses of regular bleomycin, etoposide, and cisplatin (BEP) in poor-risk patients (peritumoral vascular invasion present; expected relapse rate of 48%). Retroperitoneal lymph node dissection (RPLND) is considered an alternative option in both cases [1]. Rassweiler et al [2] try to demonstrate the equivalence of open RPLND (O-RPLND) and laparoscopic RPLND (L-RPLND) in clinical stage I NSGCT of
[1] Albers P, Albrecht W, Algaba F, et al. EAU guidelines on testicular cancer. Arnhem, the Netherlands: European Association of Urology; 2008 http://www.uroweb.org/ fileadmin/tx_eauguidelines/09%20Testicular%20Cancer. pdf. [2] Duran I, Sturgeon JF, Jewett MA, et al. Initial versus recent outcomes with a non–risk adapted surveillance policy in stage I non-seminomatous germ cell tumors (NSGCT). J Clin Oncol 2007;25(Suppl June 20), abstract 5021. [3] Rassweiler JJ, Scheitlin W, Heidenreich A, Laguna MP, Janetschek G. Laparoscopic retroperitoneal lymph node dissection: does it still have a role in the management of clinical stage I nonseminomatous testis cancer? A European perspective. Eur Urol 2008;54:1004–19. [4] Albers P, Siener R, Krege S, et al. One course of adjuvant PEB chemotherapy versus retroperitoneal lymph node dissection in patients with stage I non-seminomatous germ-cell tumors (NSGCT): results of the German Prospective Multicenter Trial (Association of Urological Oncology (AUO)/German Testicular Cancer Study Group). J Clin Oncol 2008;26(Suppl June 20):2966–72.
DOI: 10.1016/j.eururo.2008.08.024 DOI of original article: 10.1016/j.eururo.2008.08.022
european urology 54 (2008) 1004–1019
quality of life has been reported to be better in patients receiving L-RPLND [2,3]. As pointed out by Rassweiler et al [1], the current potential for L-RPLND as a diagnostic and/or therapeutic tool is in clinical stage I NSGCT for cases in which no surveillance or chemotherapy are favoured by the patients. Regarding the curative role of RPLND (open or laparoscopic) in clinical stage IIA disease with low volume and in postchemotherapy stage IIA and IIB, some data from small-sized trials are available [4,5]. To clarify this issue, multicentre randomised trials with larger patient groups and longer follow-up are necessary and strongly encouraged. The use of laparoscopy was one of the most important steps in the progress of medicine in the 20th century. Laparoscopic radical nephrectomy is now considered the new gold-standard surgical treatment for benign renal masses as well as for localised renal cell carcinoma [6,7]. For radical prostatectomy, the laparoscopic approach provides promising results, which makes it likely to become the method of choice in the management of organconfined prostate cancer in the near future [8]. Nevertheless, laparoscopic techniques are associated with a learning curve. Hence, whenever reporting on laparoscopic methods (ie, L-RPLND), the adequate experience of the performing surgeon as well as that of the institution should be considered. For this purpose, hospital and surgeon case-load calculations to achieve optimum clinical outcome, already known from other surgical procedures, should also be applied to urologic laparoscopic procedures. As long as a high level of clinical evidence is not given for L-RPLND, only centres with adequate minimum case-load volume should be legitimate to perform this procedure.
References
Editorial Comment on: Laparoscopic Retroperitoneal Lymph Node Dissection: Does It Still Have a Role in the Management of Clinical Stage I Nonseminomatous Testis Cancer? A European Perspective Peter Albers Du¨sseldorf University, Du¨sseldorf, Germany [email protected]
low-risk tumors (no vascular invasion) and chemotherapy for high-risk tumors [1]. In Canada, the options for this patient group include surveillance, even for patients with high-risk features, based on equal cancer-specific survival data of >98% [2]. In view of these management guidelines, the review of Rassweiler and colleagues [3] is important for this small subgroup of <10% of patients with NSGCT who (1) wish to be staged surgically; (2) have pure teratomatous tumors; and (3) are at high risk for recurrence, do not want to undergo surveillance, and have contraindications for chemotherapy. In these rare situations, the patient may choose between open and laparoscopic
Surgical staging in patients with clinical stage I nonseminomatous germ cell tumors (NSGCT) has become a rare recommendation. In Europe, the recommendation is for patients to undergo a risk-adapted treatment with surveillance for
[1] Rassweiler JJ, Scheitlin W, Heidenreich A, Laguna MP, Janetschek G. Laparoscopic retroperitoneal lymph node dissection: does it still have a role in the management of clinical stage I nonseminomatous testis cancer? A European perspective. Eur Urol 2008;54:1004–19. [2] Poulakis V, Skriapas K, De Vries R, et al. Quality of life after laparoscopic and open retroperitoneal lymph node dissection in clinical stage I nonseminomatous germ cell tumor: a comparison study. Urology 2006; 68:154–60. [3] Steiner H, Peschel R, Janetschek G, et al. Long-term results of laparoscopic retroperitoneal lymph node dissection: a single-center 10-year experience. Urology 2004;63:550–5. [4] Weissbach L, Bussar-Maatz R, Flechtner H, Pichlmeier U, Hartmann M, Keller L. RPLND or primary chemotherapy in clinical stage IIA/B nonseminomatous germ cell tumors? Results of a prospective multicenter trial including quality of life assessment. Eur Urol 2000;37:582–94. [5] Neyer M, Peschel R, Akkad T, et al. Long-term results of laparoscopic retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testicular cancer. J Endourol 2007;21:180–3. [6] Fornara P, Doehn C, Seyfarth M, Jocham D. Why is urological laparoscopy minimally invasive? Eur Urol 2000; 37:241–50. [7] Fornara P, Doehn C, Friedrich HJ, Jocham D. Nonrandomized comparison of open flank versus laparoscopic nephrectomy in 249 patients with benign renal disease. Eur Urol 2001;40:24–31. [8] Jurczok A, Zacharias M, Wagner S, Hamza A, Fornara P. Prospective non-randomized evaluation of four mediators of the systemic response after extraperitoneal laparoscopic and open retropubic radical prostatectomy. BJU Int 2007;99:1461–6.
DOI: 10.1016/j.eururo.2008.08.023 DOI of original article: 10.1016/j.eururo.2008.08.022
european urology 54 (2008) 1004–1019
1017
surgery; however, in both cases, he will ask about the experience of the surgeon and the complication rates of the procedure. In a multicenter randomized trial, the relatively high in-field recurrence rate after open retroperitoneal lymph node dissection (RPLND) was not an expected result [4]. This finding contradicts RPLND data from single centers with high operative volume and further diminishes the role of RPLND in a community setting. In their review, the authors stress the importance of experienced centers for laparoscopy and compare operative data from high-volume laparoscopic centers to multicenter data on open surgery [3]. A well-accepted definition of an ‘‘experienced laparoscopic RPLND center,’’ however, is not available. In summary, this review [3] focuses on a minority of patients for whom laparascopic RPLND (L-RPLND) may be an option; however, not even high-risk patients would benefit from a double procedure of laparoscopic staging and chemotherapy for metastatic disease, as opposed to surveillance and chemotherapy for treatment of metastases. The clinical problem of overtreatment of curable patients is not solved with laparoscopy.
References
Editorial Comment on: Laparoscopic Retroperitoneal Lymph Node Dissection: Does It Still Have a Role in the Management of Clinical Stage I Nonseminomatous Testis Cancer? A European Perspective Giorgio Pizzocaro Urology Clinic 2nd, University of Milan, San Giuseppe Hospital, Milan, Italy [email protected]
the testis by comparing large, recent series of L-RPLND and O-RPLND. Risk factors were not considered. Table 2 in their paper demonstrates a minimal difference in operative time; a smaller number of removed nodes in L-RPLND (14 vs 19 in O-RPLND); and a shorter hospital stay (3.3 vs 6.6 d) for L-RPLND, even if the same short hospital stay has been recently reported in O-RPLND [3]. Interestingly, approximately 30% of patients in both groups received postoperative chemotherapy (Table 4 in the paper): This means that nearly all patients with positive nodes in both groups received adjuvant chemotherapy! Surgery followed by adjuvant chemotherapy can be considered overtreatment compared to surveillance in lowrisk patients and adjuvant chemotherapy in highrisk patients. It has been reported that after O-RPLND alone [4], relapses do occur in approximately 10% of pathological stage I patients and in 30% of pathological stage IIA (pN1) patients. To compare L-RPLND versus O-RPLND today, we need to stratify clinical stage I patients into good- and poor-risk categories. Good-risk patients could be randomised to O-RPLND versus L-RPLND without postoperative
Postorchiectomy treatment of clinical stage I nonseminomatous germ cell tumours (NSGCT) of the testis is controversial. The European Germ Cell Cancer Cooperative Group (EGCCCG) recommends surveillance for low-risk patients (no peritumoral vascular invasion; expected relapse rate of 14–22%) and two courses of regular bleomycin, etoposide, and cisplatin (BEP) in poor-risk patients (peritumoral vascular invasion present; expected relapse rate of 48%). Retroperitoneal lymph node dissection (RPLND) is considered an alternative option in both cases [1]. Rassweiler et al [2] try to demonstrate the equivalence of open RPLND (O-RPLND) and laparoscopic RPLND (L-RPLND) in clinical stage I NSGCT of
[1] Albers P, Albrecht W, Algaba F, et al. EAU guidelines on testicular cancer. Arnhem, the Netherlands: European Association of Urology; 2008 http://www.uroweb.org/ fileadmin/tx_eauguidelines/09%20Testicular%20Cancer. pdf. [2] Duran I, Sturgeon JF, Jewett MA, et al. Initial versus recent outcomes with a non–risk adapted surveillance policy in stage I non-seminomatous germ cell tumors (NSGCT). J Clin Oncol 2007;25(Suppl June 20), abstract 5021. [3] Rassweiler JJ, Scheitlin W, Heidenreich A, Laguna MP, Janetschek G. Laparoscopic retroperitoneal lymph node dissection: does it still have a role in the management of clinical stage I nonseminomatous testis cancer? A European perspective. Eur Urol 2008;54:1004–19. [4] Albers P, Siener R, Krege S, et al. One course of adjuvant PEB chemotherapy versus retroperitoneal lymph node dissection in patients with stage I non-seminomatous germ-cell tumors (NSGCT): results of the German Prospective Multicenter Trial (Association of Urological Oncology (AUO)/German Testicular Cancer Study Group). J Clin Oncol 2008;26(Suppl June 20):2966–72.
DOI: 10.1016/j.eururo.2008.08.024 DOI of original article: 10.1016/j.eururo.2008.08.022