While cisplatin-based induction chemotherapy is effective in treating metastatic testicular cancer, approximately 30% of patients will require salvage chemotherapy or surgery. Patients with platinum-refractory disease who can potentially be cured with salvage retroperitoneal lymph node dissection (RPLND) are difficult to identify. Metastatic testis cancer is potentially curable if localized to the retroperitoneum after failure of chemotherapy.  We sought to describe the clinical characteristics and outcomes in patients with salvage RPLND for relapsed or refractory disease after induction or salvage chemotherapy in an effort to better identify patients who may be cured with surgery.

Patients with rising serum tumor markers (STMs) and residual disease after induction chemotherapy or salvage chemotherapy who underwent salvage retroperitoneal lymph node dissection at Indiana University from 2005-2019 were identified.

Of 81 patients (median age 33 years), salvage surgery was performed in 31 (38.3%) patients after induction chemotherapy and 50 (61.7%) patients after salvage chemotherapy (SC).  Patients classified as IGCCCG poor risk were more likely to receive SC prior to surgery (p= 0.042).  Thirty one patients had an elevated HCG (median 79, IQR 16.5-542.4), fifty eight had an elevated AFP (median 433.2, IQR 105-1230) (8 patients with both). Pathology revealed viable germ cell tumor in all patients.  Thirty four (42%) patients normalized their STMs after salvage surgery, 9 additional patients normalized after subsequent SC.  Median time from surgery to follow-up/death was 13.5 months (IQR 4-197), 43(53.1%) patients had no evidence of disease, 32 (39.5%) died of disease, 5 (6.2%) alive with disease, and 1 patient died of other causes.  RFS was significantly reduced in patients who required SC prior to RPLND (p< 0.001)(Fig 1).  Median overall survival was 60 months.

Salvage RPLND in the setting of elevated tumor markers and anatomically confined disease after induction or salvage conventional or high-dose chemotherapy should be considered in the treatment paradigm.  This option has the potential to achieve a durable response and potential cure in properly selected patients.