Figure. CT scans after first-line chemotherapy with seminoma and before salvage treatment. A and C, Patients were felt to be surgically resectable with minimal morbidity and were cured. B, Patient was expected to tolerate salvage chemotherapy poorly so elected to pursue surgery and was cured. D, Patient who was felt to require additional procedures during surgery and had high-dose chemotherapy.

Metastatic testicular seminoma that has metastasized to the retroperitoneum and beyond will principally be managed with cisplatin-based combination chemotherapy. Despite high treatment response, residual retroperitoneal disease will often be seen. The role of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for residual seminoma remains uncertain. Based on National Comprehensive Cancer Network guidelines, resection of a residual mass concerning for persistent seminomatous disease may be attempted.¹ However, previous studies have demonstrated high rates of necrosis in the final pathology among these series.² Based on prior experience, surgical management can have worse efficacy and increased morbidity compared to nonseminomatous germ cell tumor, and the decision between further chemotherapy and PC-RPLND as second-line therapy can be challenging. Salvage chemotherapy is effective but is associated with short- and long-term morbidity.³ Surgical efficacy in this setting seems to be limited, and in our previously described experience 9 patients out of 36 patients (25%) experienced no evidence of disease without postoperative salvage therapy.⁴ However, the study included patients who had multiple lines of preoperative chemotherapy. We sought to study the efficacy of PC-RPLND after first line chemotherapy to determine if careful selection of patients could lead to surgical success without affecting the ability to receive any systemic salvage therapies if necessary or causing life-threatening morbidity.

Out of 889 patients who underwent PC-RPLND at Indiana University between January 2011 and December 2021, only 14 patients were operated on for seminoma. One patient was excluded for lack of follow-up. Out of 13 patients, only 3 patients were disease-free with surgery only (23.1%). Median follow-up time was 29.9 months (IQR: 22.6-53.7). Two patients died of disease. The remaining 8 patients were treated successfully with salvage chemotherapy.

All surgical candidates were first carefully selected to ensure that patients had active disease demonstrated by either clear progression of disease on standard CT imaging, elevated serum tumor markers, or progression of fluorodeoxyglucose (FDG) avidity on positron emission tomography (PET) imaging. Several prior studies by Decoene⁵ and Cathomas⁶ et al have shown a high false-positive rate when only using FDG PET acidity to select patients for PC-RPLND.

Of the included patients, 8 patients had confirmed disease recurrence by increasing growth on standard imaging. Two patients were followed with sequential use of FDG PET scan and demonstrated growth and increasing standardized uptake value positivity. Two patients had a CT scan with increasing growth, then had a FDG PET scan to show that the mass was positive. One patient was followed with serial FDG PET scans and had a shrinking mass but developed new avidity in that lesion and elected to undergo surgery.

Additionally, patients were selected if they were felt to be poor candidates for salvage chemotherapy or based on the feasibility of surgery without having to perform adjunctive procedures (nephrectomy or vascular grafting) that may add significant morbidity. Preoperative CT scans of cured patients are listed in the Figure, and a patient with recurrent seminoma who was felt to require significant additional procedures with PC-RPLND who went on to receive high-dose chemotherapy (HDCT) only is also included in the Figure. Despite the careful selection of patients for surgery, 4 patients required a concurrent nephrectomy, 1 patient required an aortic graft replacement, 2 patients required a partial ureterectomy with ureteroureterostomy, and 3 patients required some form of caval resection. Two patients had partial resection of the cava without grafting, and 1 patient required caval graft replacement. Even with careful consideration for surgical candidate to minimize morbidity, these cases remain challenging due to the desmoplastic reaction associated with seminoma.

Management of residual masses after chemotherapy for seminoma differs significantly from nonseminoma germ cell tumors. Limitations of diagnostic imaging with high rates of false positivity mean that the chance for overtreatment with a salvage chemotherapy or surgery is possible. With the toxicities of HDCT and the desmoplastic reaction of seminoma associated with surgical treatment, the decision to treat residual masses needs careful consideration.

PC-RPLNDs for active seminoma after first-line chemotherapy occur far less frequently than nonseminoma. At Indiana University, 23.1% of patients (3 out of 13) were disease-free after surgery despite careful selection, and even then, many required additional procedures such as nephrectomy or vascular grafting. With HDCT having success rates with 2-year progression-free survival of 90%, surgery should be reserved for select scenarios.³ PC-RPLND for seminoma should only be utilized in rare scenarios such as a patient with concerns for life-threatening toxicity from HDCT. This decision is complicated and should involve a multidisciplinary effort from high-volume centers.