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JU INSIGHT Oncological Benefit of Adjunctive Surgery Within Postchemotherapy Retroperitoneal Lymph Node Dissection

By: Tim Nestler, MD, Hospital of Cologne, Germany, Federal Armed Services Hospital Koblenz, Germany; Pia Paffenholz, MD, Hospital of Cologne, Germany; David Pfister, MD, Hospital of Cologne, Germany; Justine Schoch, MD, Federal Armed Services Hospital Koblenz, Germany; Alessandro Nini, MD, Azienda ULSS 7 Pedemontana, Bassano del Grappa, Italy; Andreas Hiester, MD, Heinrich-Heine-University Duesseldorf, Germany; Peter Albers, MD, Heinrich-Heine-University Duesseldorf, Germany; Axel Heidenreich, MD, Hospital of Cologne, Germany, Medical University, Vienna, Austria | Posted on: 20 Mar 2024

Nestler T, Paffenholz P, Pfister D, et al. Adjunctive surgery is often without oncological benefit at time of postchemotherapy retroperitoneal lymph node dissection. J Urol. 2024;211(3):426-435.

Study Need and Importance

Metastatic nonseminomatous germ cell tumor (GCT) patients often need postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). This study analyzes the frequency of variable adjunctive surgeries in PC-RPLND and their correlation with pathohistological findings such as necrosis vs teratoma and viable GCT, aiming to reduce overtreatment and associated long-term morbidity.

What We Found

Among 1204 GCT patients undergoing PC-RPLND in 2 high-volume centers, 242 (20%) received adjunctive surgery. Viable GCT was present in 54 (22%), teratoma in 94 (39%), and necrosis/fibrosis in 94 (39%) of specimens. Vascular resections or reconstructions (n = 112; viable GCT: 23%, teratoma: 41%, necrosis: 36%) were performed most frequently, followed by nephrectomies (n = 77; viable GCT: 29%, teratoma: 39%, necrosis: 33%). Patients with viable GCT or teratoma had a significantly higher risk of recurrence in 5 years compared to necrosis-only cases (19% vs 59% vs 81%, P < .001; Figure).

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Figure. Kaplan-Meier curves depicting recurrence-free survival after stratification for necrosis/fibrosis (blue), teratoma (green), and viable germ cell tumor (GCT; red) with a significant difference between the groups (P < .001). PC-RPLND indicates postchemotherapy retroperitoneal lymph node dissection.

Limitations

The retrospective nature and reliance on pathohistological reports pose limitations. The study might underestimate cases with minimal viable GCT surrounded by necrosis. A second evaluation of organ surfaces was not feasible, potentially impacting the accuracy of histological classification of resected organs.

Interpretation for Patient Care

The findings underscore the importance of precise preoperative patient selection to minimize overtreatment in patients harboring only necrosis. Overall, 33% to 40% of adjunctive surgeries might be avoided, which would reduce long-term morbidity. Further research on biomarkers and imaging techniques is needed to enhance preoperative predictions for viable tumor or teratoma in order to optimize PC-RPLND outcomes.

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