ASCO GU 2020: Evaluation of the Oncologic Benefit of Adjunctive Surgery at Time of Postchemotherapy Retroperitoneal Lymph Node Dissection (PC-RPLND)

San Francisco, California (UroToday.com) The treatment of advanced testicular cancer is a model modern medicine, with patients originally facing dismal fates, now with the majority of patients thriving. Within this framework, the burden of that intense therapy is currently being evaluated and Dr. Tim Nestler presented this morning on the possible over treatment from traditional surgical therapy.

Following chemotherapeutic management, PC-RPLND for advanced nonseminomatous germ cell tumors, surgery aims to resect all remaining metastatic tissue. Guidelines recommend the resection of all adjacent visceral or vascular organs to ensure complete removal of the residual mass. However, not all of these lesions will harbor residual disease or teratoma with the frequency of necrosis/fibrosis in adjacent metastatic involvement of those organs with teratoma or vital cancer is currently unknown.

To that end, the authors reviewed a cohort of 1181 patients who underwent PC-RPLND between 2008 and 2018 as a 2-center study with 20% of patients undergoing adjunctive surgery at the time of PC-RPLND. They analyzed the pathohistological elements in the resected organ and measured associated complications according to the Clavien-Dindo classification.

Nearly 40% of patients harbored no viable GCT or teratoma in the resected organs. Overall, nephrectomy was the most frequent additional procedure, with resection of the vena cava or liver following thereafter. Interestingly, the rates of fibrosis were similar in all these tissue types. These resections, were not without complication, with 21% of the cohort experiencing adverse events.

Given the advanced nature of their disease, not surprisingly over a quarter of patients suffered from relapse during a median follow-up of 22 months [0-180]. AS anticipated patients without fibrosis in the resected specimens had a significantly reduced 5-year RFS compared to patients.

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In the end, Dr. Nestler finished his talk by concluding that 40% of all resections of adjunct organs are oncologically unnecessary, exposing these young men to unnecessary harm. In closing, he proposed that this arena is ripe for the development of pre-operative tools to better risk stratify patients and provide a more accurate presurgical workup to spare patients from PC-RPLND.

Presented by: Tim Nestler, MD, Department of Urology, University Hospital of Cologne, Cologne, Germany

Written by: Adrien Bernstein, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Fox Chase Cancer Center, Philadelphia, PA at the 2020 Genitourinary Cancers Symposium, ASCO GU #GU20, February 13-15, 2020, San Francisco, California

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