Retroperitoneal Lymph Node Dissection Workup

Updated: Sep 21, 2015
  • Author: Jared M Whitson, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Workup

Laboratory Studies

See the list below:

  • Serum tumor markers: Prior to performing retroperitoneal lymph node dissection (RPLND) for nonseminomatous germ cell tumors (NSGCTs), levels of serum tumor markers (alpha-fetoprotein [AFP], human chorionic gonadotropin [hCG], lactate dehydrogenase [LDH]) should be within reference ranges after orchiectomy or after chemotherapy for more advanced disease.

  • CBC count: Patients with advanced testicular cancer may have anemia.

  • Basic metabolic panel: The serum creatinine level may be elevated in patients with ureteral obstruction due to sizable retroperitoneal disease. Renal function tests are mandatory in patients who require chemotherapy (eg, platinum) for advanced disease.

  • Liver panel: Liver function test results may be elevated in patients who present with hepatic metastasis.

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Imaging Studies

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  • Scrotal ultrasonography: This is the definitive diagnostic test for testicular tumors. Its sensitivity for revealing a solid mass within the parenchyma of the testis is greater than 90%. Scrotal ultrasonography is useful and may be required if physical examination findings of the testis are equivocal or cannot be adequately assessed because of a hydrocele.

  • Chest radiography: Obtain anteroposterior and lateral chest radiographs to stage the disease. Chest radiography carries a sensitivity of 85-90% in detecting pulmonary metastasis. Although chest CT scanning is more sensitive, it is thought to be of limited prognostic value because of decreased specificity. Reports indicate that approximately 70% of the lesions detected with chest CT scanning turn out to be benign. Individual disease characteristics and findings on abdominal imaging should dictate whether to obtain chest radiography or chest CT scanning.

  • CT scanning: This is the most effective method of detecting retroperitoneal lymph node involvement. This imaging modality has replaced intravenous pyelography and lymphangiography as the diagnostic study of the retroperitoneum. Abdominal CT scanning can help identify retroperitoneal lymphadenopathy smaller than 2 cm in diameter. However, CT scans cannot differentiate malignancy, fibrosis, or the presence of teratoma based on these size criteria alone. MRI: This modality is useful in evaluating the brain or spine for evidence of metastasis in patients with localizing symptoms.

  • Positron emission tomography (PET) scanning: Currently experimental and expensive, PET scanning may have a role in evaluating persistent retroperitoneal adenopathy in patients with seminoma who have undergone chemotherapy.

  • Pedal lymphangiography: This imaging modality is of historical importance, particularly in mapping testicular lymphatics and landing sites for metastases. For diagnostic purposes, it has an error rate of 25%.

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Staging

Many systems for staging testicular cancer exist. Almost all systems in use today are variations of the original staging criteria established by Boden and Gibb (1951). In their original system, stage A (or I) testicular cancer was located within the testis, stage B (or II) included regional lymph node spread, and stage C (or III) indicated spread beyond the retroperitoneal lymph nodes (eg, pulmonary, visceral, brain, bone).

A system devised by the Memorial Sloan-Kettering Cancer Center further delineates stage B into the following:

  • Stage B1 - Retroperitoneal lymph node involvement smaller than 5 cm in diameter

  • Stage B2 - Retroperitoneal nodes measuring 5-10 cm in diameter

  • Stage B3 - Retroperitoneal nodes larger than 10 cm in maximum diameter

M.D. Anderson has also modified this system, as follows:

  • Stage I - Lesion confined to the testes

  • Stage IIA - Retroperitoneal node involvement smaller than 10 cm in diameter

  • Stage IIB - Retroperitoneal node involvement larger than 10 cm in diameter

  • Stage III - Supradiaphragmatic nodal involvement and/or visceral involvement

Low-stage disease refers to stages I and IIA (A and B1), and high-stage disease includes stages IIB and III (B2, B3, C) of testicular cancer.

The TNM classification system devised by the American Joint Committee on Cancer (AJCC) has standardized staging of testicular cancer. This staging system is depicted below.

  • Primary tumor (T)

    • pTX - Primary tumor cannot be assessed (ie, no radical orchiectomy has been performed)

    • pT0 - No evidence of primary tumor (eg, histologic scar in testis)

    • pTis - Intratubular germ cell neoplasia (carcinoma in situ)

    • pT1 - Tumor limited to testis and epididymis without lymphatic/vascular invasion

    • pT2 - Tumor limited to testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis

    • pT3 - Tumor invades the spermatic cord with or without vascular/lymphatic invasion

    • pT4 - Tumor invades the scrotum with or without vascular/lymphatic invasion

  • Regional lymph nodes (N)

    • NX - Regional lymph nodes cannot be assessed

    • N0 - No regional lymph node metastasis

    • N1 - Metastasis in a single lymph node, 2 cm or smaller in greatest dimension

    • N2 - Metastasis in a single lymph node, larger than 2 cm but 5 cm or smaller in greatest dimension; or multiple lymph nodes, none larger than 5 cm in greatest dimension

    • N3 - Metastasis in a lymph node larger than 5 cm in greatest dimension

  • Distant metastasis (M)

    • MX - Presence of distant metastasis cannot be assessed

    • M0 - No distant metastasis

    • M1 - Distant metastasis

    • M1a - Nonregional nodal or pulmonary metastasis

    • M1b - Distant metastasis other than to nonregional nodes and lungs

  • Serum tumor markers (S)

    • SX - Tumor marker studies not available or not performed

    • S0 - Tumor marker levels within the reference range

    • S1 - LDH level less than 1.5 times the reference range AND HCG level less than 5000 mIU/mL AND AFP level less than 1000 ng/mL

    • S2 - LDH level 1.5-10 times the reference range OR HCG level 5000-50,000 mIU/mL OR AFP level 1000-10,000 ng/mL

    • S3 - LDH level more than 10 times the reference range OR HCG level greater than 50,000 mIU/mL OR AFP level greater than 10,000 ng/mL

The AJCC staging system is as follows:

  • Stage 0 - [pTis, N0, M0, S0]

  • Stage I - [pT1-4, N0, M0, SX]

  • Stage IA - [pT1, N0, M0, S0]

  • Stage IB - [pT2, N0, M0, S0]; [pT3, N0, M0, S0]; [pT4, N0, M0, S0]

  • Stage IS - [Any pT/Tx, N0, M0, S1-3]

  • Stage II - [Any pT/Tx, N1-3, M0, SX]

  • Stage IIA - [Any pT/Tx, N1, M0, S0]; [Any pT/Tx, N1, M0, S1]

  • Stage IIB - [Any pT/Tx, N2, M0, S0]; [Any pT/Tx, N2, M0, S1]

  • Stage IIC - [Any pT/Tx, N3, M0, S0]; [Any pT/Tx, N3, M0, S1]

  • Stage III – [Any pT/Tx, Any N, M1, SX]

  • Stage IIIA – [Any pT/Tx, Any N, M1a, S0]; [Any pT/Tx, Any N, M1a, S1]

  • Stage IIIB – [Any pT/Tx, N1-3, M0, S2]; [Any pT/Tx, Any N, M1a, S2]

  • Stage IIIC – [Any pT/Tx, N1-3, M0, S3]; [Any pT/Tx, Any N, M1a, S3]; [Any pT/Tx, Any N, M1b, Any S]

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