Recurrence Pattern and Proposed Surveillance Protocol Following Post-Chemotherapy Retroperitoneal Lymph Node Dissection

Purpose

We evaluated the recurrence pattern in patients with nonseminomatous germ cell tumors treated with post-chemotherapy retroperitoneal lymph node dissection and determined the optimal surveillance strategy in these patients.

Materials and Methods

Between 1980 and 2003, 236 patients with clinical stage IIA-III nonseminomatous germ cell tumors underwent post-chemotherapy retroperitoneal lymph node dissection. Patients with increased preoperative tumor markers (α-fetoprotein greater than 15 ng/ml and/or β-human chorionic gonadotropin greater than 2.2 U/ml) were excluded from study resulting in 198 patients for analysis. We retrospectively reviewed medical records for pertinent clinical and treatment related outcomes. In our patient population recurrence developed in 45 (23%) patients and 22 (11%) died of disease at a median followup of 41 months (range 6 to 250) after retroperitoneal lymph node dissection.

Results

The clinical stage of testis cancer was IIA in 17, IIB in 49, IIC in 83 and III in 49 patients. Of the 45 patients with postoperative recurrence, 16 had concomitant multiple sites of recurrence with a total of 64 sites reported. Of the cases of recurrence 21 (46.7%) were in those of clinical stage III, 18 (40%) stage IIC and 6 (11.8%) stage IIB disease. The most frequent site of recurrence was the chest (32, 49%), followed by the abdomen (14, 22%), supraclavicular lymph nodes (8, 13%), brain (5, 8%) and other sites (5, 8%).

Conclusions

Based on the recurrence pattern we propose stage specific surveillance guidelines for the followup of patients after post-chemotherapy retroperitoneal lymph node dissection. These guidelines help identify patients at high risk for disease progression and, thus, requiring more stringent postoperative followup.

Key Words: recurrence, chemotherapy, adjuvant, retroperitoneal space, lymph node excision, testicular neoplasms

Abbreviations and Acronyms: AFP, α-fetoprotein, β-HCG, β-human chorionic gonadotropin, CT, computerized tomography, DSS, disease specific survival, LDH, lactate dehydrogenase, NSGCT, nonseminomatous germ cell tumors, PC-RPLND, post-chemotherapy retroperitoneal lymph node dissection, RFS, recurrence-free survival, RPLND, retroperitoneal lymph node dissection