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Surgery may be a better first-line option for some men with stage II testicular cancer, allowing them to avoid the toxicity of chemotherapy or radiotherapy, said authors of a recent study in the .

Isamu Tachibana, MD, of Indiana University School of Medicine in Indianapolis, and colleagues reported a 2-year recurrence-free survival (RFS) rate of 80% in 67 stage II patients treated with first-line surgery. In men with a longer progression time from stage I to stage II disease (more than 12 months), the 2-year RFS after surgery was 92%.

"This largely retrospective study demonstrated that many clinical stage II seminomas can be cured with retroperitoneal lymph node dissection [RPLND] alone," Tachibana and colleagues wrote. "Further optimizing patient selection and surgical technique may improve RFS."

Tachibana offered further details in the following interview:

This was both an observational study and a clinical trial. Can you briefly explain that?

Tachibana: Of all the included patients, only 19 patients were part of the SEMS [Surgery in Metastatic Seminoma] trial. There were a number of patients outside of the study who underwent surgery for various reasons -- older age, felt to be poor candidates for chemotherapy, or patient preference. A similar inclusion category was used to identify candidates for surgery. By including patients on trial and off trial, we had a much more robust database for study.

What did your study suggest about using tumor size and number of positive nodes as a guideline for considering surgery?

Tachibana: We typically chose patients based on a guideline of 3 cm in largest dimension with fewer than three lymph nodes positive. However, some patients who were poor chemotherapy candidates had a higher burden of disease.

Patients with equivocal nodes on standard imaging were carefully selected. Often, these patients were actively observed with short-term interval imaging to make sure that retroperitoneal lymph nodes were growing in size. As result, only one patient had pathologic N0 disease. This is important in that with careful close surveillance, we were able to decrease overtreatment and still maintain 2-year RFS of 80%.

With the SEMS trial, nine out of 55 patients (16%) had pN0 disease; the historical chemotherapy and radiation studies may also have included overtreatment of patients who did not necessarily have pathologic retroperitoneal disease. This may inflate the RFS rates of chemotherapy or radiotherapy compared to surgery.

What did your study find about bilateral versus unilateral template dissection?

Tachibana: We noticed that patients undergoing RPLND for seminoma had different distribution of disease compared to non-seminoma. More patients had contralateral nodal disease and had a higher frequency of contralateral retroperitoneal recurrence compared to non-seminoma. Currently, we advocate for the use of bilateral templates with seminoma due to the pattern of spread.

Is there anything else you want to make sure oncologists understand about this study?

Tachibana: There may be potential long-term complications such as secondary malignancy with treatment using chemotherapy or radiotherapy. Surgical resection in patients with stage II seminoma should be a consideration to minimize these long-term risks.

Do you have any additional research planned or ongoing in this area?

Tachibana: With the early data, patients seem to have a higher prevalence of contralateral disease. Dr. Clint Cary [senior author of the study, also of Indiana University School of Medicine] is heading efforts to optimize surgical templates for primary RPLND with seminoma.

Read the study here.