Primary Retroperitoneal Lymph Node Dissection in Marker-Positive Clinical Stage II Nonseminomatous Germ Cell Tumors

Guidelines usually recommend chemotherapy rather than primary retroperitoneal lymph node dissection (pRPLND) for clinical stage II nonseminomatous germ cell tumors (NSGCTs) with elevated serum tumor markers (STMs). This study evaluated oncologic and perioperative outcomes of pRPLND in patients with marker-positive vs marker-negative clinical stage II NSGCTs.

A retrospective review from our prospectively maintained database identified patients undergoing pRPLND (1983-2022). The primary end point was relapse-free survival. Secondary end points included cancer-specific survival (CSS), relapse location, and perioperative outcomes. Outcomes were compared using Kaplan-Meier analysis, log-rank testing, and multivariable COX regression.

Among 207 patients with NSGCTs, 65 (31%) had elevated STMs (alpha fetoprotein: 12-376 µg/L; human chorionic gonadotropin: 3-354 IU/L). Marker elevation was associated with higher relapse risk, with 5-year relapse-free survival of 75% vs 93% for marker-negative patients (P < .001). Five-year CSS was 96% vs 100% (P = .009). Of 4 cancer-specific deaths, 2 involved somatic transformation, 1 patient declined chemotherapy at relapse, and 1 death occurred during chemotherapy. Elevated alpha fetoprotein correlated with worse CSS, and dual marker elevation predicted greater relapse risk. Surgical complication rates did not differ between groups.

Although elevated STMs are associated with increased relapse and mortality risk, pRPLND is associated with long-term disease control in approximately 75% of patients. Most relapses can be successfully treated in compliant individuals. Multidisciplinary decision-making should weigh relapse risk and potential salvage chemotherapy needs against the long-term morbidity of primary chemotherapy.