Podium Session 4: Oncology-Bladder, Kidney, Other

Introduction: Most guidelines recommend chemotherapy as opposed to primary retroperitoneal lymph node dissection (pRPLND) for clinical stage (CS) II testicular germ cell tumors (TGCTs) with elevated serum tumor markers (STMs) because of the risk of systemic disease.Contrary to this, we have offered primary retroperitoneal lymph node dissection (pRPLND) to select patients with CS II disease with elevated STMs, believing a substantial portion can be cured with surgery alone.Methods: A retrospective analysis using data from our prospectively maintained eCancerCare Testis database was performed.Patients who underwent primary robotic and open pRPLND between 1983 and 2022 were included.The primary endpoint was relapse-free survival (RFS).Secondary endpoints were location of relapse, cancer-specific survival (CSS), and perioperative outcomes, including operative time, length of stay (LOS), estimated blood loss (EBL), and surgical complications.RFS and CSS were calculated using the Kaplan-Meier product-limit method, and log-rank test was used to assess the impact of marker-positive vs. marker-negative status at the time of surgery.Results: We identified 208 patients who underwent pRPLND at our institution, 173 (83.2%) open and 35 (16.8%) robotic, with median followup of 4.7 years.All patients had non-seminomatous germ cell tumors (NSGCT); 46.1% were diagnosed with CS I disease with relapse as CS II and 53.9% with initial CS II.A total of 66 (31.7%) patients had elevated STMs.STM elevation was associated with a higher risk of relapse; RFS at five years was 93% (95% CI 86.5-96.5) vs. 75.9%(95% CI 62.6-85) in patients with negative vs. positive STMs (p=0.0004).CSS at five years was 100% vs. 96.1% (95% CI 85.3-99) in patients with negative vs. positive STMs (p=0.0044).Of the five cancer-specific deaths observed, two were associated with somatic transformation, two were in patients who were advised to receive upfront chemotherapy but were non-compliant, and one due to febrile illness during salvage chemotherapy.Elevation in one and/or both STMs was associated with increased relapse risk, whereas only the degree of AFP elevation was associated with worse CSS.There were no differences observed in surgical complications.Conclusions: This is the largest, single-center study of patients with marker-positive testicular cancer undergoing pRPLND.Although elevated STMs are associated with an increased risk of relapse and cancer-specific mortality when compared with patients with negative STMs, pRPLND can be curative in up to 74% of patients, and the majority of those who relapse can be effectively salvaged if compliant with care.pRPLND in patients with marker-positive status should be discussed with patients in a multidisciplinary fashion, balancing the increased risk of relapse and morbidity of salvage chemotherapy against the long-term effects of primary chemotherapy.

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