CUA 2017: The Role of Delayed Orchiectomy Following Chemotherapy in Metastatic Germ Cell Tumors, The Princess Margaret Cancer Centre Experience

Toronto, Ontario ( Rarely, testicular germ cell tumors (TGCT) present with high-burden metastases and chemotherapy is initiated prior to removal of the clinically diagnosed testicular primary.  The standard of care has been orchiectomy post-chemotherapy, as the testicle is considered a sanctuary site at risk for residual disease. However, several small studies have observed complete response in the testicle. 

James Hayes, a medical student from the University of Toronto, presented an interesting study analyzing the predictors of post-chemotherapy primary pathology to define patients in whom orchiectomy could safely be avoided. 

Using a prospectively maintained testicular cancer database, eTestis, from 1981‒2016, the authors identified TGCT men who received first-line chemotherapy followed by orchiectomy. Demographic and clinical parameters, including tumour markers, scrotal ultrasound (US), and testicular and retroperitoneal pathology were analyzed. Logistic regression was used to identify factors associated with disease (teratoma or viable GCT) in the testicle.  

Of 35 patients, 15 (43%) had necrosis or fibrosis only, 20 (57%) had teratoma/ITGCN, and 0 had viable GCT. In patients that underwent post-chemotherapy retroperitoneal lymph node dissection (RPLND), pathology was concordant in 75%. Factors that were associated with residual teratoma/ITGCN in the testis following chemotherapy include age, testicular mass identified on US or physical examination, and elevated tumor markers. 27/35 (77%) patients underwent a retroperitoneal lymph node dissection. 

These findings corroborate previous reports that complete responses can be achieved in the testicular primary tumor and that the majority of residual disease represents teratoma. Validating these findings in additional larger series, may lead to a carful recommendation to observe the post-chemotherapy testis, particularly in marker-negative, older (i.e., ≥35) population, and those with negative US.

Presented By: James Hayes, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre  Twitter: @GoldbergHanan at the  72nd Canadian Urological Association Annual Meeting - June 24 - 27, 2017 - Toronto, Ontario, Canada