SUO 2020: Salvage Retroperitoneal Lymph Node Dissection in the Setting of Rising Tumor Markers in Relapsed Germ Cell Tumor

(UroToday.com) Standard or high dose chemotherapy has curative potential in relapsed patients with germ cell tumor but is associated with significant toxicity. Although cisplatin-based induction chemotherapy is effective in treating metastatic testicular cancer, approximately 30% of patients will require salvage chemotherapy or surgery. Patients with platinum-refractory disease who can potentially be cured with salvage retroperitoneal lymph node dissection (RPLND) are difficult to identify. Additionally, metastatic testis cancer is potentially curable if localized to the retroperitoneum after failure of chemotherapy. At the 2020 Society of Urologic Oncology (SUO) Annual Virtual Meeting's best of the testicular and penile cancer session, Dr. Sean Kern and colleagues presented their work describing the clinical characteristics and outcomes in patients with salvage RPLND for relapsed or refractory disease after induction or salvage chemotherapy in an effort to better identify patients who may be cured with surgery (those who do not need subsequent chemotherapy after RPLND).

In this study, patients with rising serum tumor markers and residual disease after induction chemotherapy or salvage chemotherapy who underwent salvage retroperitoneal lymph node dissection at Indiana University from 2005-2019 were identified and included in the cohort. The primary outcome was recurrence-free survival (RFS) and overall survival.

Among the 81 patients, the median age was 33 years (IQR 25-41). Salvage surgery was performed in 31 (38.3%) patients after induction chemotherapy and 50 (61.7%) patients after salvage chemotherapy. There were 31 patients that had an elevated human chorionic gonadotropin (hCG) (median 79, IQR 16.5-542.4), and 58 had an elevated alpha-fetoprotein (AFP) (median 433.2, IQR 105-1230); 8 patients had both elevated hCG and AFP. Patients classified as International Germ Cell Cancer Collaborative Group (IGCCCG) poor-risk were more likely to receive salvage chemotherapy prior to surgery (p = 0.042). Pathology revealed viable germ cell tumor in all patients. Thirty-four (42%) of patients normalized their serum tumor markers after salvage surgery and nine additional patients normalized after subsequent salvage chemotherapy. The median time from surgery to follow-up/death was 13.5 months (IQR 4-197), 43 (53.1%) of patients had no evidence of disease, 32 (39.5%) died of disease, five (6.2%) were alive with disease, and one patient died of other causes. RFS was significantly reduced in patients who required salvage chemotherapy prior to RPLND (p < 0.001):

reduction of recurrence free survival

Median overall survival was 60 months. Patients that had a late relapse had a significantly worse RFS after salvage RPLND (p=0.03).

Dr. Kern concluded his presentation with the following take-home messages:

Salvage RPLND in the setting of elevated tumor markers and anatomically confined disease after induction or salvage conventional or high-dose chemotherapy should be considered in the treatment paradigm
Initial favorable surgical response portends favorable long-term RFS
This option has the potential to achieve a durable response and potential cure in properly selected patients

Presented by: Sean Q. Kern, MD, Urology Fellow, University of Indiana, Indianapolis, Indiana

Written by: Zachary Klaassen, MD, MSc, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Augusta, Georgia, Twitter: @zklaassen_md at the 2020 Society of Urologic Oncology Annual Meeting – December 2-5, 2020 – Washington, DC

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