Adjuvant chemotherapy after retroperitoneal lymph node dissection.

At present there are no firm data for the routine use of adjuvant chemotherapy in stage II testicular cancer after retroperitoneal lymph node dissection. The possible advantage of adjuvant chemotherapy in terms of reduced relapse rate and continuously disease free survival have to be weighed against the increasing cure rates with modern chemotherapy regimen, applied at the time of advanced and recurrent disease. About 10-15% of stage I and 40-50% of stage II patients relapse after RPLND. Depending on risk factors such as total tumor burden, histology and disease sites and symptoms at the time of presentation, 30-90% of these patients are brought into complete remission with modern chemotherapy (overall between 50 and 70%). Based on these results, a subgroup of patients with a low risk of relapse and a more than 90% chance of cure with salvage chemotherapy may be defined. They do not need adjuvant chemotherapy with its associated toxicity. On the other hand, in a high risk group, which demonstrates poor results with salvage chemotherapy, adjuvant chemotherapy seems to have the potential to significantly improve the cure rate. A third group of patients, presenting with bulky abdominal disease may need immediate postdiagnostic intensive chemotherapy, with surgical exploration only at the time of maximum response. The question of definition of optimal treatment strategies in the various subgroups of patients with testicular cancer can only be solved by ongoing and future randomized clinical trials.