testicular tumors are rare and account for 1 - 1.5% of all the tumors affecting men but are the commonest tumors in 15 - 35 years of age .
ninety to ninety five percent of testicular tumors are germ cell tumors ( gcts ) , 52 - 56% of which are seminomas . with the current multimodality approach , gcts are considered as one of the most curable solid neoplasms with > 90% survival rates .
chemotherapy is the usual first - line treatment for stage iia - iib gcts with bulky disease or stage iic - iii disease after high inguinal orchidectomy .
postchemotherapy , 60 - 80% of seminomatous and 30% of nonseminomatous gcts ( nsgcts ) have residual masses , most commonly in the retroperitoneum .
postchemotherapy retroperitoneal lymph node dissection ( pc - rplnd ) is indicated in patients with normal serum markers with radiologically identifiable disease in the retroperitoneum [ especially in nsgct > 1 cm and seminoma > 3 cm with fluorodeoxyglucose ( fdg ) uptake ] .
various studies show that postchemotherapy residual masses comprise necrosis in 50% , viable tumor in 15% , and teratoma in 35% of cases with nsgct and viable tumor in 10% and necrosis in 90% of patients with seminoma .
thus , there is a significant rate of nontherapeutic exploration . in the absence of established imaging or nomogram parameters that can accurately predict the histology of residual masses
thus , pc - rplnd is both diagnostic by providing definite histology and therapeutic by achieving local control .
this is especially true for nsgct because a teratoma may be present in the retroperitoneal mass that is chemoresistant and has potential for local growth , invasion , and transformation .
further , postchemotherapy residual masses can be considered chemotherapy resistant and they are better served by surgery . with growing experience of such surgical procedures refinement in surgical technique and better understanding of the anatomy , the morbidity rates are decreasing , further supporting its widespread role and incorporation into a therapeutic protocol .
we present a tertiary care center experience of the role and postoperative outcomes of rplnd in patients with retroperitoneal residual masses after primary or salvage chemotherapy .
from june 2003 to july 2012 , a total of 70 patients underwent rplnd for gct , of whom 45 had received chemotherapy .
patients who had residual , resectable retroperitoneal masses after chemotherapy , normal postchemotherapy tumor markers [ alpha - fetoprotein and beta - human chorionic gonadotropin ( beta - hcg ) ] and no previous rplnd were included in this study .
patients who underwent primary rplnd , had inadequate follow - up or incomplete data were excluded .
all patients underwent detailed physical examination , contrast - enhanced computed tomography ( cect ) of the chest and abdomen , and tumor marker assessment preoperatively and clinical stage was assigned according to the american joint committee on cancer ( ajcc ) staging system and the international germ cell cancer collaborative group ( igcccg ) tumor risk categorization .
the mean age of our patient group was 26.8 years ( 16 - 50 years ) with primary testicular tumor on the right side in 18 ( 51.4% ) patients and bilateral tumor in three ( 8.5% ) patients .
mixed gct was the most prevalent histology of primary tumor present in 19 ( 54.5% ) patients .
thirteen ( 37.1% ) patients had teratoma in the primary tumor , either alone ( in 6 patients - 17.1% ) or as a component of mixed gct ( in 7 patients - 20% ) .
seminoma was present in four ( 11.4% ) patients , all of whom had undescended testes .
characteristics of primary testicular tumor the most common site of retroperitoneal mass was the paraaortic region ( 14 patients - 40% ) and the mean size of retroperitoneal mass was 8.8 cm ( range 2.2 cm-20.4 cm ) before chemotherapy and 5.4 cm ( range 1.2 cm-14.6 cm ) postchemotherapy .
characteristics of retroperitoneal mass all patients received cisplatin - based chemotherapy either as induction ( 29 patients ) or salvage therapy ( six patients ) .
twenty - two ( 62.8% ) patients received four cycles of bep ( bleomycin , etopside , cisplatin ) , five ( 14.2% ) patients received three cycles of bep , and two ( 5.7% ) patients received four cycles of ep ( etopside and cisplatin ) as induction therapy .
salvage chemotherapy was given to six patients , five ( 14.2% ) received four cycles of vip ( vinblastin , ifosfamide , cisplatin ) , and one ( 2.8% ) received four cycles of tip ( paclitaxel , ifosfamide , cisplatin ) .
two patients were given radiotherapy in addition to four cycles of bep as induction therapy .
rplnd was performed by abdominal or thoracoabdominal approach in standard bilateral infrahilar template and nerve sparing was done whenever possible .
standard template extended from renal vessels superiorly to bifurcation of common iliac vessels inferiorly and up to ureters laterally and anterior spinal ligament and psoas muscle fascia posteriorly .
split and roll technique was used to dissect the lymph node packet . in patients with small volume residual disease and minimal desmoplastic reaction , nerve - sparing technique with preservation of sympathetic chains , postganglionic fibers , and hypogastric
postoperatively , all patients were scheduled for regular follow - up every 3 months with physical examination , serum tumor markers , chest x - ray , and cect of the abdomen and pelvis for the first 2 years and then every 6 months for the next 2 years and then annually .
the median follow - up was of 33 months ( range 9 months-60 months ) and data were censored on january 1 , 2014 .
all patients received cisplatin - based chemotherapy either as induction ( 29 patients ) or salvage therapy ( six patients ) .
twenty - two ( 62.8% ) patients received four cycles of bep ( bleomycin , etopside , cisplatin ) , five ( 14.2% ) patients received three cycles of bep , and two ( 5.7% ) patients received four cycles of ep ( etopside and cisplatin ) as induction therapy .
salvage chemotherapy was given to six patients , five ( 14.2% ) received four cycles of vip ( vinblastin , ifosfamide , cisplatin ) , and one ( 2.8% ) received four cycles of tip ( paclitaxel , ifosfamide , cisplatin ) .
two patients were given radiotherapy in addition to four cycles of bep as induction therapy .
rplnd was performed by abdominal or thoracoabdominal approach in standard bilateral infrahilar template and nerve sparing was done whenever possible .
standard template extended from renal vessels superiorly to bifurcation of common iliac vessels inferiorly and up to ureters laterally and anterior spinal ligament and psoas muscle fascia posteriorly .
split and roll technique was used to dissect the lymph node packet . in patients with small volume residual disease and minimal desmoplastic reaction , nerve - sparing technique with preservation of sympathetic chains , postganglionic fibers , and hypogastric
postoperatively , all patients were scheduled for regular follow - up every 3 months with physical examination , serum tumor markers , chest x - ray , and cect of the abdomen and pelvis for the first 2 years and then every 6 months for the next 2 years and then annually .
the median follow - up was of 33 months ( range 9 months-60 months ) and data were censored on january 1 , 2014 .
all patients received cisplatin - based chemotherapy either as induction ( 29 patients ) or salvage therapy ( six patients ) .
twenty - two ( 62.8% ) patients received four cycles of bep ( bleomycin , etopside , cisplatin ) , five ( 14.2% ) patients received three cycles of bep , and two ( 5.7% ) patients received four cycles of ep ( etopside and cisplatin ) as induction therapy .
salvage chemotherapy was given to six patients , five ( 14.2% ) received four cycles of vip ( vinblastin , ifosfamide , cisplatin ) , and one ( 2.8% ) received four cycles of tip ( paclitaxel , ifosfamide , cisplatin ) .
two patients were given radiotherapy in addition to four cycles of bep as induction therapy .
rplnd was performed by abdominal or thoracoabdominal approach in standard bilateral infrahilar template and nerve sparing was done whenever possible .
standard template extended from renal vessels superiorly to bifurcation of common iliac vessels inferiorly and up to ureters laterally and anterior spinal ligament and psoas muscle fascia posteriorly .
split and roll technique was used to dissect the lymph node packet . in patients with small volume residual disease and minimal desmoplastic reaction , nerve - sparing technique with preservation of sympathetic chains , postganglionic fibers , and hypogastric
postoperatively , all patients were scheduled for regular follow - up every 3 months with physical examination , serum tumor markers , chest x - ray , and cect of the abdomen and pelvis for the first 2 years and then every 6 months for the next 2 years and then annually .
the median follow - up was of 33 months ( range 9 months-60 months ) and data were censored on january 1 , 2014 .
all our patients underwent pc - rplnd by an open approach ; an abdominal incision was used in 32 ( 91.4% ) and thoracoabdominal incision in three ( 8.5% ) patients .
standard template rplnd ( as described ) was performed in all the patients with three patients requiring extension of template in suprahilar area for residual masses .
nerve sparing was possible in seven patients ( 20% ) ( unilateral sparing in five and bilateral sparing in two ) with low volume stage iia / b disease .
fourteen patients ( 40% ) required 15 adjunctive procedures , the most common being nephrectomy in nine ( 25.7% ) patients , which was more common on the left side ( six patients ) .
adjunctive procedures were more common in patients with larger retroperitoneal masses ( > 5 cm ) ( 9 out of 12 patients with > 5 cm residual mass ) , patients who presented with stage iii disease ( six out of 10 patients ) or have received salvage chemotherapy ( four out of six patients ) or had fibrosis as the final histology ( six out of six patients ) .
most of the surgical complications were of clavien grade i or ii ( the most common being blood transfusion in 28.5% patients ) and required conservative management . only two ( 5.7% ) patients required surgical intervention for clavien grade iii complications .
one patient who developed adhesive intestinal obstruction in the immediate postoperative period was re - explored on postoperative day 12 after a failed trial of conservative management .
intraoperatively , there was a band at terminal ileum with twisting of the small bowel requiring adhesiolysis and detorsion .
another patient developed paralytic ileus after drain removal on postoperative day 5 and ultrasonography of the patient revealed a 19 cm  10 cm localized collection in the right paracolic gutter extending into the pelvis that turned out to be of serous nature on diagnostic tapping .
ultrasound - guided percutaneous drain was placed under local anesthesia and the ileus resolved after 2 days .
the drain was removed after 5 days when serial abdominal ultrasounds documented no residual collection .
complications were more common in patients with larger postchemotherapy masses ( > 5 cm ) and fibrosis as the final histology .
characteristics of surgical procedures surgical complications the histopathology of rplnd specimen was fibrosis or necrosis in 17 ( 48.5% ) patients , teratoma in 12 ( 34.2% ) patients , and viable tumor in six ( 17.1% ) patients .
on retrospect , among these six cases with viable tumor , two had lung metastasis and three were at high risk according to the igcccg risk classification , and the clinical stage was of either stage iic ( three cases ) or stage iii ( three cases ) .
four of these patients had received salvage chemotherapy and the retroperitoneal mass size was > 5 cm in three patients .
the median follow - up was of 33 months ( ranging 9 - 60 months ) .
antegrade ejaculation was preserved in five out of 28 ( 17.8% ) patients with standard rplnd and in five out of seven ( 71.4% ) patients with nerve - sparing procedure .
seven ( 20% ) patients had recurrence over a median follow - up of 33 months .
three patients had recurrence in the retroperitoneum ; bilateral complete rplnd was performed in two patients and extended rplnd in one .
three patients had distant recurrence , one had bony recurrence , and the other two had pulmonary recurrence .
out of these four patients with retroperitoneal recurrence , the histopathology of the resected residual mass was viable tumor in two , teratoma in one , and necrosis in one patient .
five of these seven patients with recurrences succumbed to their disease and two were alive with stable disease at the last follow - up .
surgical resection of residual retroperitoneal lymph node mass represents an integral part of the multimodality treatment for patients with advanced testicular cancer undergoing systemic chemotherapy .
the objective is to remove persistent retroperitoneal lymph nodes that may have mature teratoma in about 40 - 50% or viable tumor in 10 - 20% of cases . in our series , out of 35 patients , 26 presented with advanced disease ( stage iic in 16 and stage iii in 10 ) and 11 patients were in the poor risk category according to the igccc tumor risk categorization .
the postchemotherapy mean retroperitoneal tumor size was 5.4 cm ( range 1.2 cm-14.6 cm ) .
bulky retroperitoneal mass necessitated bilateral classical rplnd in 32 patients with extended dissection in three cases .
fourteen patients required adjunctive procedures and the complication rate was 37.1% . at a median follow - up of 33 months
nerve sparing may be used in pc - rplnd although the rates of antegrade ejaculation are lower than that for primary rplnd as complete resection of the often large , adherent mass supersedes ejaculatory concerns . in our series ,
nerve - sparing procedure was possible in seven patients with low volume iia / iib disease with preservation of antegrade ejaculation in five ( 71.4% ) patients without any disease recurrence with a median follow - up of 42 months . in 28 patients who had undergone bilateral standard template rplnd ,
this compares favorably with 79 - 89% antegrade ejaculation rates and 98% 5-year relapse free survival rates reported in the literature .
the small number of nerve - sparing procedures in our series was attributed to the advanced stage of presentation and bulky retroperitoneal disease . in pc - rplnd ,
20 - 25% of the patients require adjunctive procedures for completeness of the resection , nephrectomy being the most common amongst them .
in our series , 14 ( 40% ) patients underwent adjunctive procedure and among them , nine ( 25.7% ) underwent nephrectomy .
four patients required resection of adjacent structures and two required separation of the ureter from the desmoplastic mass ( ureterolysis ) . of those who underwent adjunctive nephrectomy ,
four patients received salvage chemotherapy , three had advanced stage ( iii ) disease , and two had bulky retroperitoneal disease ( retroperitoneal tumor size > 10 cm ) .
the higher proportion of patients with adverse features in our pc - rplnd series may explain the higher rate of adjunctive nephrectomy unlike the usual 25% reported in the literature .
in our series , histopathological analysis of the nephrectomy specimen revealed residual disease in six ( 66.6% ) patients , justifying the need for adjunctive nephrectomy in these patients .
the complication rates for postchemotherapy surgery are higher than that for primary rplnd . in our series ,
the complication rate was 37.1% that compares well with the reported rates of 20 - 35% in various series .
most of the complications were of clavien grade i and ii , which included blood transfusion , postoperative fever , superficial wound infection , and paralytic ileus .
the higher complication rate in our series is attributed to the advanced stage of presentation , bulky retroperitoneal disease , and high number of patients with salvage chemotherapy with severe desmoplastic reaction , all of which are known risk factors .
luz et al . observed that patients with fibrosis in the residual mass had more complications and ended up undergoing nonnerve - sparing procedures .
these findings pose a dilemma when offering pc - rplnd in residual masses as almost half of the patients will have necrosis and nontherapeutic resections with higher complications .
we observed seven recurrences including three retroperitoneal , three distant , and one combined . among these 7 patients with recurrence
all belonged to the igccc high risk category and 4 patients had a viable tumor in residual mass and received postoperative chemotherapy .
fox et al . noted that if viable gct was present in the retroperitoneal mass and is entirely resected , two additional cycles of adjuvant chemotherapy confer a disease - free survival of 70% . in our series among the seven patients with recurrences ( local or distant ) , five died due to disseminated neoplasia and
the estimated 5-year overall survival of pc - rplnd after induction and salvage chemotherapy has been reported as 85 - 95% and 44 - 61% , respectively . in our series ,
the estimated 5-year overall survival rate after pc - rplnd in our series was 83.75% and approaches the results of previously reported series .
pc - rplnd is a relatively safe procedure in experienced hands with an acceptable morbidity rate .
half of the residual masses have teratoma or viable tumor , thereby , justifying surgical resection .
complete removal of post - chemotherapy residual mass remains the standard of care and allows improved oncologic and functional outcomes .
 introduction : we aimed to study the outcomes of retroperitoneal lymph node dissection ( rplnd ) in postchemotherapy residual masses in advanced testicular germ cell tumor ( gct ) in the indian population.patients and methods : we retrospectively analyzed 35 patients who underwent postchemotherapy rplnd at our institute after primary ( 29 patients ) or salvage ( 6 patients ) chemotherapy over a period of 9 years ( june 2003 to july 2012).results : the mean age of our patients was 26.8 years . 18 ( 51.42% ) presented with primary tumor in the right testis and 3 ( 8.51% ) had bilateral tumors . 
 mixed gct was the most common histology among 19 ( 54.3% ) patients . 
 14 ( 40% ) patients had the residual mass in para - aortic location , which was the most common site . 
 14 ( 40% ) patients required an adjunctive procedure , most commonly nephrectomy which was required in 9 out of 14 ( 25.7% ) . 
 we recorded 25 complications , mostly clavien - dindo grade ii . 
 histopathology of residual mass was necrosis in 17 ( 48.57% ) , teratoma in 12 ( 34.28% ) , and viable tumor in 6 ( 17.14% ) patients.conclusion:nearly half of the patients had either teratoma or viable tumor , thus justifying the surgical resection of postchemotherapy residual mass . 
 although nearly half of the patients had complications , they were adequately managed and there was no mortality . 
 thus , postchemotherapy rplnd can be a useful procedure in multimodality approach to gct in carefully selected patients . 
INTRODUCTION
PATIENTS AND METHODS
None
Chemotherapy
RPLND template
Follow-up
RESULTS
DISCUSSION
CONCLUSION
None
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Conflicts of interest