Is primary retroperitoneal lymph node dissection the way forward for patients with testicular seminoma and limited retroperitoneal metastases?

Testicular cancer represents 1% of adult neoplasms and is the most common solid malignancy in young men. Of men presenting with seminoma, approximately 20% will have clinical stage (CS) II disease, characterized by enlarged retroperitoneal lymph nodes without further metastasis. A further group of men will present with CS I disease but later experience relapse in the retroperitoneal lymph nodes. The standard treatment for many decades in these patients is either radiotherapy (30-36Gy) or chemotherapy (BEPx3, EPx4). Despite high cure rates with these modalities, concerns persist regarding short and long-term treatment-related toxicities. Survivors of testicular cancer treated with chemotherapy or radiotherapy face increased risks of cardiovascular disease (1.5-6-fold) and secondary malignancies (twice as likely for solid cancers and 5 times for leukemia). An alternative approach explored is primary Retroperitoneal Lymph Node Dissection (RPLND). Several institutional series along with 4 single-arm phase II trials have investigated primary RPLND in men with low-volume retroperitoneal metastases. Herein, we review the evidence, strengths and limitations of the current studies and future for primary RPLND for seminoma.