Clinical stage IIA/B embryonal carcinoma predominant nonseminomatous germ cell tumor: Minimizing treatment burden

Embryonal carcinoma predominance (ECP) in the orchiectomy specimen is linked to a higher risk of retroperitoneal and systemic relapse. Both chemotherapy and primary retroperitoneal lymph node dissection (RPLND) are recommended options. This study aims to investigate which approach minimizes treatment burden.

We queried the Indiana University Testicular Cancer Database to identify patients with nonseminomatous germ cell tumors (NSGCT) and ECP >50% in the orchiectomy specimen, stage II with retroperitoneal adenopathy <3 cm, and normal serum tumor markers. Patients with malignant transformation (n = 3) or bilateral cancer (n = 3) or receiving 1 to 2 cycles of BEP after orchiectomy were excluded (n = 14). Treatment courses and outcomes were compared.

Between 2005 and 2022, 126 patients met the criteria. Of 67 patients who underwent primary RPLND, 62 had active EC in final pathology. Adjuvant chemotherapy (2 cycles of EP or BEP) was given to 5 patients. After a median follow-up of 37.7 months, 10 recurred, with a 3-year recurrence-free survival (RFS) of 85.1%. After induction chemotherapy, 9 patients were disease-free, with 1 disease-related death. The overall survival (OS) after RPLND plus/minus chemotherapy was 98.5%. Of the 59 patients who received upfront chemotherapy, 13 required postchemotherapy (PC) RPLND, and 1 recurred and needed chest surgery. Among the 46 patients (78%) who had complete remission after chemotherapy, 5 recurred, requiring second-line chemotherapy in 1 and high-dose chemotherapy in 4. The 3-year RFS was 89.8%. The OS after chemotherapy plus/minus salvage therapy was 98.3%.

Primary RPLND achieved complete remission as a single treatment modality in 85% of patients, compared to 78% for chemotherapy. Recurrence after primary RPLND could be effectively treated by chemotherapy. Primary RPLND may reduce treatment burden in early-stage II ECP NSGCT.