Primary retroperitoneal lymph node dissection (RPLND) for non-seminomatous germ-cell tumor (NSGCT): Impact of trends in patient selection on retroperitoneal pathology and outcome

Abstract

4523 Background: Elevated pre-RPLND serum tumor markers (STM) is prognostic for relapse for clinical stage (CS) IS and pathologic stage (PS) N1 patients, and for persistence of disease for PS N2–3 patients. Since 1999, we have recommended that patients with elevated STM and/or CS IIB receive induction chemotherapy. We examined the impact of these selection criteria on outcome after primary RPLND. Methods: Since 1989, 453 patients with NSGCT have undergone primary RPLND (345 pre-1999, 108 post-1999). Data was obtained from a prospective database. A level of AFP or BhCG that was elevated and not declining according to half-life pre-RPLND was considered elevated. The median follow-up was 68 and 25 months for patients treated pre- and post-1999, respectively. Results: Pre-1999, 28 (8%) patients had elevated STM and 23 (7%) had CS IIB. Post-1999, all patients had normal STM and 1 (1%) had CS IIB. Patients treated since 1999 trended toward a lower rate of PS II (44% pre- vs. 33% post-1999, P=0.06). Among patients with PS II, those treated since 1999 were more likely to have low-volume (PN1) retroperitoneal disease at RPLND (64% vs. 40%, P=0.01), even when excluding patients with elevated STM and CS IIB (63% vs. 52%, P=0.02). Patients treated since 1999 have had lower rates of relapse after RPLND (4-year relapse-free survival 97% vs. 90%, P=0.04), even when excluding those receiving adjuvant chemotherapy (96% vs. 88%, P=0.049). In multivariate analysis, elevated STM (P=0.001) was the only significant pre-RPLND predictor of relapse when accounting for the use of adjuvant chemotherapy. Although not statistically significant, embryonal carcinoma predominance (P=0.06), treatment year (P=0.07) and clinical stage (P=0.09) may also be important predictors of relapse. Conclusions: As a result of excluding patients with elevated STM and/or CS IIB, proportionately more PS II patients have low-volume retroperitoneal disease and are likely to be cured by RPLND alone. Patients treated since 1999 may have a favorable prognosis independent of STM status and clinical stage. No significant financial relationships to disclose.