Outcomes in patients with clinical stage III NSGCT who achieve complete clinical response to chemotherapy at extraretroperitoneal disease site.

OBJECTIVE

To compare the survival outcomes of patients with advanced nonseminoma and extraretroperitoneal (ERP) disease observed for a clinical complete response (CCR) with those demonstrating a pathologic complete response (PCR).

METHODS

From 1989 to 2003, 237 patients with clinical Stage III nonseminoma underwent induction chemotherapy followed by retroperitoneal lymph node dissection. After chemotherapy, 107 demonstrated a CCR to treatment at the ERP disease site. Of the remaining 130 patients with radiographic evidence of residual ERP disease, 86 (66%) had fibrosis only on pathologic review (ie, PCR). The probability of progression-free and disease-specific survival was estimated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to determine the prognostic significance of risk factors for progression and survival.

RESULTS

The median follow-up was similar for both CCR and PCR patients (44.5 and 50.7 months, respectively). Overall, the 5-year probability of freedom from progression (93% vs 72%, respectively; P = .0005) and disease-specific survival (96% vs 87%, respectively; P = .08) rates were far better for men with a PCR. The predictors of disease progression included residual retroperitoneal nodal size after chemotherapy (P = .05), and resection of the residual disease at the ERP site was protective (P = .02).

CONCLUSION

A CCR at the ERP disease site is associated with a greater likelihood of relapse compared with a PCR, underscoring the limitations of radiographic imaging after chemotherapy in detecting microscopic residual disease and need for rigorous monitoring of patients observed after a CCR. Furthermore, until more accurate clinical predictors of ERP histologic features are identified, we advocate for complete surgical resection of all sites of residual disease, when feasible.