ASCO GU 2020: Chemotherapy/Radiation-Sparing Management Strategies for Early-Stage Germ Cell Tumors - Urologists Perspective

San Francisco, CA ( Dr. Clint Cary presented on the chemotherapy/radiotherapy sparing management strategies for early-stage Germ cell tumors. The difference between stage IIa and stage IIb disease was that for stage IIa the lymph nodes are less than two centimeters, while for stage IIb they are between 2 to 5 centimeters (Figure 1). 

According to the NCCN guidelines, stage II disease can be treated with a nerve-sparing RPLND or primary chemotherapy.

Figure 1 – Stage II disease

stage II disease

The guidelines also support surgery in early-stage disease due to high cure rates in the surgery alone that have been reported to be approximately 80%, with long-term toxicity being exceedingly low. Studies examining the role of surgery in stage Ia and IIb disease have shown very promising oncological outcomes (Table 1).

Table 1 – Oncological outcomes of RPLND:

rplnd in cs I II and oncologic outcomes

Surgical complications of primary RPLND include short term issues such as scar formation, ileus at 3% and chylous ascites at 1%. The long-term issues include retrograde ejaculation in 1% of cases and small bowel obstruction in 1% of patients.

Dr. Cary continues to discuss why surgery has significant advantages when compared to chemotherapy or radiotherapy. Both chemotherapy and radiotherapy are associated with significant adverse effects later on in life as can be seen in figure 2.

Figure 2 – Survival and survivorship:

survivors of primary chemotherapy

RPLND has evolved significantly during recent years, from a long and complicated procedure to become a short surgical procedure with a very low complication rate (Figure 3). Surgery alone results in cure in approximately 80% of cases with survival rates exceeding 96%. Long-term toxicity is minimal and surgical mortality is close to 0%.

Figure 3 - Historic and contemporary RPLND:

historical rplnd

In summary, surgery for early-stage disease is curative in most patients when managed at high volume centers, and it also mitigates the risk of late toxicities.

Presented by: Clint Cary, MD, MPH, Indiana University School of Medicine, Indianapolis, Indiana

Written By: Hanan Goldberg, MD, Urology Department, SUNY Upstate Medical University, Syracuse, NY, USA @GoldbergHanan at the 2020 Genitourinary Cancers Symposium, ASCO GU #GU20, February 13-15, 2020, San Francisco, California
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