San Francisco, CA (UroToday.com) Current guidelines from the National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) agree that either nerve-sparing (to limit the risk of retrograde ejaculation) retroperitoneal lymph node dissection or chemotherapy (BEP x 3 or EP x 4) are reasonable approaches to take for patients with clinical stage IIA non-seminoma (normal tumor markers, lymph nodes < 2 cm). Either approach may also be considered for tumor marker negative clinical stage IIB non-seminoma (lymph nodes between 2 and 5 cm).
In this discussion, Clint Cary MD, MPH, discussed the case for using surgical management for early stage non-seminoma (including Stage IIB with normal tumor markers) centered around two main points: (1) high cure rates approaching 80% and (2) very low long-term toxicity. The available studies looking at RPLND in CS1-2 (all tumor marker negative) tumors, including one currently in press (Douglawi et all) are summarized below. Additionally, these series suggest that a non-trivial rate of clinical stage II cases are down-staged at the time of surgery, which has important patient care implications for minimizing additional therapy.
Additionally, the surgical complications of primary RPLND (not done post-chemotherapy) are quite low. This in part is due to markedly improved technique and peri-operative care that have moved RPLND from a long surgical procedure involving a week post-operative stay in the hospital and significant morbidity to a 2-3-hour surgery followed by three days in the hospital and low complication rates.
This is in contrast to the long-term side effects of primary chemotherapy or radiation, shown in the picture below. This is illustrated further by a study from Fung et al surveying adverse health effects after cisplatin-based chemotherapy in 952 patients.1 This data showed that up to 40% of patients were experiencing at least one adverse health outcome over four years after platinum chemotherapy. 
In summary, Dr. Cary suggests that primary RPLND may be preferable for adjuvant management of clinical 1 and clinical stage 2 non-seminomatous germ cell tumors (including tumor marker negative stage IIB) based on a curative rate of approximately 80%, good long-term survival, and minimal short- and long-term toxicity.
Importantly, surgical management of isolated retroperitoneal spread of seminoma is NOT standard of care. However, two trials are ongoing to assess the efficacy of RPLND along for seminoma with isolated an isolated retroperitoneal lesion < 3 cm.
Presented by: Clint Cary MD, MPH, Associate Professor of Urology, Indiana University School of Medicine
Written by: Alok Tewari, MD, PhD, Medical Oncology Fellow at the Dana-Farber Cancer Institute, at the 2020 ASCO Genitourinary Cancers Symposium (#GU20), February 13th-February 15th, San Francisco, CA, at the 2020 Genitourinary Cancers Symposium, ASCO GU #GU20, February 13-15, 2020, San Francisco, California.
References
1. Fung C, Sesso H, Williams A, et al: Multi-Institutional Assessment of Adverse Health Outcomes Among North American Testicular Cancer Survivors After Modern Cisplatin-Based Chemotherapy. J Clin Oncol 35:1211-1222, 2017