What are the indications for postchemotherapy retroperitoneal lymph node dissection?

Platinum combination chemotherapy has dramatically altered the survival curves for all stages of testicular cancer. We entered our first patient in August 1974 on our phase II trial of the then experimental drug, cisplatin, combined with vinblastine + bleomycin (PVB) [1]. This study immediately transformed metastatic testicular cancer from a highly fatal disease to a model for a curable neoplasm, as over 50% of our 47 patients on our first PVB trial achieved durable complete remission with chemotherapy alone or with postchemotherapy retroperitoneal lymph node dissection (RPLND) (5 patients). This single-institution phase II trial led to the approval by regulatory agencies of cisplatin as a component of combination chemotherapy, despite never having been subjected to the rigors of a phase III trial. Subsequent PVB studies, carried out mainly at Indiana University and through the American Cooperative Groups and in Europe, demonstrated the reduction of the vinblastine dose and elimination of 2 years of maintenance vinblastine would mitigate acute toxicity without compromising cure rates. A subsequent phase III trial determined that the substitution of etopo-side (BEP) for vinblastine ameliorated the neuromuscular toxicity and improved the cure rate. PVB became a historical footnote with the completion of this randomized trial in 1984. Further reduction in acute morbidity was accomplished in patients with good risk metastatic germ-cell tumors with the demonstration that equivalent durable remission were achieved with BEP×3 over 9 weeks compared with the control arm of BEP×4 administered over 12 weeks. The high cure rate of meta-static testicular cancer represented one of the landmark achievements in oncology [2]. Testicular cancer is uniquely chemosensitive and chemocura-tive. Perhaps, less well appreciated is the high success rate of RPLND in this patient population. There is a higher cure rate with presence of nodal metastases with RPLND as initial therapy or following cisplatin combination chemotherapy than any other epithelial cancer. What is the role of RPLND in the modern cisplatin era? In this issue of the Annals of Oncology, Ravi et al. interrogate the literature as well as their own data from Dana Farber addressing the role of postchemotherapy RPLND in patients with normal size (<1 cm) nodes on CT scan [3]. This editorial will also expand the query as to the value of RPLND for patients presenting with clinical stage I–II disease and for situations with >1 cm nodes remaining postchemotherapy. The majority of patients with clinical stage I non-seminomatous germ-cell tumors (NSGCT) will …