Retroperitoneal lymphadenectomy: the anterior approach including bilateral suprarenal-hilar dissection.

Abstract

SUMMARY In summary, several conclusions can be drawn from our experience. Chemotherapy is opening new avenues in the management of these patients. It allows us to leave patients with Stage A disease untreated, with close follow-up. Should Stage C disease develop, the patient can be salvaged with appropriate and aggressive combination chemotherapy, as our cases were. Patients with Stage A disease should have a 100 per cent survival rate if the retroperitoneum is dissected appropriately and the patient is followed closely postoperatively. Several options exist for the postoperative management of patients with Stage B disease. Three courses are under cooperative study: (a) no treatment, as in Stage A; (b) one-drug chemoprophylaxis with actinomycin D; and (c) combination chemotherapy from the outset. We have treated with actinomycin D therapy. Those patients who developed Stage C disease have been switched to combined chemotherapy with cis-platinum, Velban, and bleomycin. Since 1974, all our patients with Stage B disease who progressed to Stage C have achieved complete remission with this three-drug combination. Another new horizon is the potential for chemical cytoreduction of disseminated Stage C disease; persistent abdominal disease can then be resected. It is this author’s opinion that chemotherapy provides a safer, more extensive initial cytoreduction than the contrary approach of primary surgical cytoreduction and postoperative chemotherapy. Serotesting for the beta subunit of human chorionic gonadotropin and for alpha-fetoprotein has been a helpful means of following patients with Stage B disease and for detecting tumor before it can be seen by any of the conventional radiologic methods. Although the future of retroperitoneal lymphadenectomy is still unclear, and improvements in noninvasive staging will doubtless continue (serotesting for tumor-associated antigens, ultrasound, axial tomography, and lymphangiography), it would seem unlikely that completely accurate staging can be obtained without surgical dissection and histologic nodal examination. We have had recent experience with several patients in whom all these preoperative tests for metastases (including serotesting) were negative, yet they had evidence of multiple tumorous nodes on microscopic examination. This suggests that the role of surgical staging with histologic nodal study will remain central to the accurate definition of the disease status and direction of therapy. Furthermore, retroperitoneal surgery, completely done, seems to have positive influence on patient survival in this disease.