Adjunctive surgery after chemotherapy for nonseminomatous germ cell tumors: recommendations for patient selection.

TLDR

The study recommends that patients with normalized serum markers after chemotherapy for NSGCT undergo resection of all residual retroperitoneal, pulmonary, and mediastinal abnormalities, and that all patients with initial bulky retroperitoneal metastases (≥3 cm) receive retroperitoneal lymph node dissection regardless of post‑chemotherapy CT findings. A retrospective analysis of 185 NSGCT patients who had surgery within six months of completing cisplatin‑ or carboplatin‑based chemotherapy examined how residual mass size, shrinkage, and pre‑treatment teratomatous elements correlated with surgical pathology. Multivariable logistic regression showed that residual mass size, shrinkage, and pre‑chemotherapy LDH and AFP levels best predicted only necrotic debris, but no factors reliably excluded residual viable malignancy or teratoma, and even small residual masses (≤1.5 cm) contained malignancy or teratoma in several cases.

Abstract

One hundred eighty-five patients who underwent surgery within 6 months of completing chemotherapy were identified from 360 patients with nonseminomatous germ cell tumors (NSGCT) treated with Memorial Hospital front-line cisplatin- or carboplatin-based combination chemotherapy protocols between 1979 and 1988. Clinical, pathologic, and radiologic features were correlated with the pathologic findings at surgery. The size of a residual retroperitoneal mass, the degree of shrinkage that occurred with chemotherapy, and the presence of teratomatous elements in pretreatment pathology specimens were each correlated with the pathologic findings of retroperitoneal resections after chemotherapy. Multivariable logistic regression analysis of those undergoing retroperitoneal resections identified the size and shrinkage of the residual mass and the prechemotherapy lactate dehydrogenase (LDH) and alphafetoprotein (AFP) levels as the best predictors of finding only necrotic debris. No factors could be found, however, that could selectively exclude patients who had residual viable malignancy or teratoma in the retroperitoneum. Of 39 patients with residual retroperitoneal masses measuring less than or equal to 1.5 cm in maximal diameter, three had residual malignancy and five had teratoma resected. No factors were identified for residual lung or mediastinal masses that could be used to select a group of patients who could safely avoid surgery. If serum markers have normalized after chemotherapy for NSGCT, resection of all residual abnormalities on imaging studies of the retroperitoneum, lungs, and mediastinum is recommended. In addition, retroperitoneal lymph node dissection (RPLND) is recommended for all patients with initial bulky metastases (greater than or equal to 3 cm in diameter) in the retroperitoneum, irrespective of the findings of postchemotherapy computed tomography (CT).