Retroperitoneal Lymph Node
The story is a lot more complicated for stage I non-seminomas where there are several choices involved in the treatment of these patients. And I just want to go through these briefly in some amount of detail. Surveillance, retroperitoneal lymph node dissection and chemotherapy are the three alternatives. The standard in the United States for many years, particularly before effective chemotherapy was developed for non-seminomas, was a so-called on-block peritoneal lymph node dissection. You can see the borders of this particular surgery, which involved a dissection of lymph nodes from above the renal hila to below the aortic bifurcation bilaterally. This was effective at staging patients and was also effective, in some cases, in actually curing patients. But it left all patients with retrograde ejaculation and infertility. So procedures were developed over the last 20 years to modify the procedures, to allow the contralateral nerve supply involved in ejaculation to be maintained. Ether a template procedure like this or a nerve identification procedure such that one can spare the nerves. With those procedures about 90% of patients with stage I testicular cancer will maintain antegrade ejaculation.
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Now how effective is the retroperitoneal lymph node dissection in curing patients with stage I testicular cancer? The largest study ever conducted was a multi-institution study called the Testicular Cancer Intergroup Study, conducted between 1979 and 1984 in which over 500 patients from multiple institutions underwent a retroperitoneal lymph node dissection. In that study 284 patients were found to have pathological stage I disease. That is, they were found to have no involvement of the lymph nodes. In those patients, about 10% of the patients ultimately recurred, generally with supradiaphragmatic recurrences, pulmonary metastases and most of those patients were ultimately cured with chemotherapy. For stage I pathological testicular cancer, the mortality rate is 2%. Similar results are seen for patients who undergo a lymph node dissection, who are found to have involved lymph nodes. Pathological stage II disease. These patients subsequently may need chemotherapy and the cure rates in these patients is similarly 98%. So the results of retroperitoneal lymph node dissection are outstanding, 98% of patients with stage I disease will be cured.
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But if we look at how effective retroperitoneal lymph node dissection is at actually curing disease, one has to look at the studies in a little more detail. Look at the studies in which a retroperitoneal lymph node dissection was performed, disease was found in the lymph nodes, and no subsequent therapy was undertaken. What was the cure rate in those patients? Overall, the retroperitoneal lymph node dissection with no subsequent chemotherapy is curative about 50-60% of the time. The remainder of the time the patients will require chemotherapy. So if you think about the patients coming into the clinic with stage I non-seminomas, this is sort of what it looks like. Order canadian levitra 20 mg visa at cheap online pharmacy. If 100 patients come in with stage I non-seminoma and undergo retroperitoneal lymph node dissection, 70 of those patients will be found to have no evidence of disease. When they are found not to have any evidence of disease they are observed. Most of those patients will remain NED and cured of their disease. Seven or 10% of the patients will relapse, usually in the lung and will be cured with chemotherapy. There will be 30 patients out of 100 in whom disease will be detected in the lymph nodes and half of them will be cured with surgery alone. The remainder of patients will be cured with subsequent or immediate chemotherapy. We think that the patients who are best suited for no further chemotherapy are those patients who have minimal metastatic disease. That is, less than 5 lymph nodes involved with cancer and less than 2 cm of disease in any one lymph node.