From the Guidelines
Retroperitoneal lymphadenopathy in a patient with testicular cancer should be managed with a retroperitoneal lymph node dissection (RPLND) as indicated by the European Association of Urology guidelines, particularly in cases with high-risk features such as lymphovascular invasion (LVI) or extranodal tumor extension 1. In the context of testicular cancer, the presence of retroperitoneal lymphadenopathy suggests potential metastasis to the lymph nodes, which necessitates a thorough evaluation and appropriate management to prevent recurrence and improve outcomes. Key considerations in managing retroperitoneal lymphadenopathy include:
- The risk of recurrence, which is influenced by factors such as the presence of LVI, predominant embryonal carcinoma, primary pT stage, and extranodal tumor extension on histology, as reported in the European Association of Urology guidelines 1.
- The role of RPLND, which is indicated in select cases, including men with teratoma with somatic malignant component and patients unwilling or unsuitable to undergo chemotherapy in cases of recurrence, particularly in the presence of high-risk features.
- The importance of nerve-sparing RPLND and minimally invasive approaches to reduce morbidity, which should be performed by an experienced surgeon in a specialist center 1. Given the potential for significant morbidity and mortality associated with untreated retroperitoneal lymphadenopathy in testicular cancer, a prompt and comprehensive evaluation followed by appropriate management, including RPLND when indicated, is crucial to improve patient outcomes.
From the Research
Retroperitoneal Lymphadenopathy
- Retroperitoneal lymphadenopathy refers to the enlargement of lymph nodes in the retroperitoneum, which can be a challenging diagnosis due to its rarity and scarce symptoms 2, 3.
- Imaging methods such as magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography-computed tomography (PET-CT) can help characterize and locate the tumor, while endoscopic ultrasound fine needle aspiration (EUS-FNA) may provide pathological confirmation 2.
- A study found that MRI can detect retroperitoneal lymphadenopathy with a high degree of accuracy, and that sagittal and coronal images can add to the appreciation of the size of nodes and the extent of retroperitoneal lymphadenopathy 4.
Diagnosis and Treatment
- The diagnosis of retroperitoneal lymphadenopathy can be challenging, and patients may present with unusual symptoms such as abdominal pain, nausea, and vomiting 2, 3.
- Treatment for retroperitoneal lymphadenopathy depends on the underlying cause, and may include chemotherapy, radiation therapy, or surgery 2, 3.
- A study found that patients with metastatic renal cell carcinoma and no preoperative retroperitoneal lymphadenopathy had a longer survival rate than those with lymphadenopathy 5.
Imaging Characteristics
- Dilated retroperitoneal lymphatic channels can appear as a mass of confluent low-density lymph nodes on CT, or as a meshwork of multiple tubular, tortuous, fluid-filled structures on MR urography 6.
- On axial T1W images, these channels can appear as numerous, interconnected small, nodular and streaky intensities, and as a cloak of diffuse homogenous hyperintensity on T2W axial images 6.