Department of Urology, Indiana University School of Medicine, Indianapolis, IN.
Department of Statistics, Indiana University, Indianapolis, IN.
J Clin Oncol. 2022 Nov 10;40(32):3762-3769. doi: 10.1200/JCO.22.00118. Epub 2022 Jun 8.
According to National Comprehensive Cancer Network guidelines, adjuvant chemotherapy (AC) has been advocated after primary retroperitoneal lymph node dissection (RPLND) to reduce the risk of relapse in pathologic nodal (pN) stage pN2 or pN3, whereas surveillance is preferred for pN1. We sought to explore the oncologic efficacy of primary RPLND alone for pathologic stage II in nonseminomatous germ cell tumors (NSGCTs) to reduce overtreatment with chemotherapy.
Patients with pathologic stage II NSGCT after primary RPLND between 2007 and 2017 were identified. Patients were excluded for elevated preoperative serum tumor markers, receipt of AC, or if pure teratoma or primitive neuroectodermal tumor elements were found in the retroperitoneal pathology.
We identified 117 patients with active NSGCT in the retroperitoneum after primary RPLND. We excluded seven patients who lacked meaningful follow-up and 13 patients who received AC. There were 97 patients treated with RPLND alone: 41 pN1, 46 pN2, and 10 pN3. In total, 77 of 97 patients had not recurred after a median follow-up time of 52 months. The 2-year recurrence-free survival (RFS) was 80.3%, and the 5-year RFS was 79%. No differences in RFS were noted among nodal stage-pN1, pN2, and pN3-on Kaplan-Meier analysis. Lymphovascular invasion in the orchiectomy specimen, a high-risk pathologic feature, was also predictive of recurrence after primary RPLND. All 20 patients who recurred were treated with first-line chemotherapy and remained continuously disease free.
Most men with pathologic stage II disease treated with surgery alone in our series never experienced a recurrence. We did not observe a difference in recurrences between patients with pN1 and pN2. The recommendation for AC for pN2 disease may be overtreatment in most patients.
根据美国国家综合癌症网络指南，在原发性腹膜后淋巴结清扫术（RPLND）后主张辅助化疗（AC），以降低病理淋巴结（pN）分期 pN2 或 pN3 患者的复发风险，而对于 pN1 患者则首选监测。我们试图探讨单独进行原发性 RPLND 治疗病理分期 II 期非精原细胞瘤生殖细胞肿瘤（NSGCT）的肿瘤学疗效，以减少化疗的过度治疗。
我们确定了 2007 年至 2017 年间接受原发性 RPLND 后病理分期为 II 期的 NSGCT 患者。排除了术前血清肿瘤标志物升高、接受 AC 治疗或腹膜后病理发现纯畸胎瘤或原始神经外胚层肿瘤成分的患者。
我们在原发性 RPLND 后发现 117 例腹膜后活动性 NSGCT 患者。我们排除了 7 例随访无意义的患者和 13 例接受 AC 治疗的患者。97 例患者接受了单独的 RPLND 治疗：41 例 pN1、46 例 pN2 和 10 例 pN3。在中位随访时间 52 个月后，总共有 77 例患者未复发。2 年无复发生存率（RFS）为 80.3%，5 年 RFS 为 79%。Kaplan-Meier 分析显示，在淋巴结分期 pN1、pN2 和 pN3 之间，RFS 无差异。在睾丸切除术标本中发现的淋巴血管侵犯是一种高危病理特征，也可预测原发性 RPLND 后的复发。所有 20 例复发的患者均接受了一线化疗，且持续无疾病。
在我们的研究中，接受手术单独治疗的大多数病理分期 II 期疾病患者从未经历过复发。我们没有观察到 pN1 和 pN2 患者之间复发的差异。对于 pN2 疾病推荐 AC 治疗可能对大多数患者来说是过度治疗。
