Features and Management of Late Relapse of Nonseminomatous Germ Cell Tumour

Alexander P M Jay; Mohammed Aldiwani; Michael E O'Callaghan; Adam K Pearce; Robert A Huddart; Erik Mayer; Alison H Reid; David L Nicol

doi:10.1016/j.euros.2021.04.008

Features and Management of Late Relapse of Nonseminomatous Germ Cell Tumour

Eur Urol Open Sci. 2021 Jun 7:29:82-88. doi: 10.1016/j.euros.2021.04.008. eCollection 2021 Jul.

Authors

Alexander P M Jay^{1

2

3}, Mohammed Aldiwani¹, Michael E O'Callaghan^{2

3

4}, Adam K Pearce^{1

5}, Robert A Huddart^{1

6}, Erik Mayer^{1

7}, Alison H Reid^{1

6}, David L Nicol^{1

6}

Affiliations

¹ Department of Urology, Royal Marsden Hospital, London, UK.
² Urology Unit, Flinders Medical Centre, Adelaide, Australia.
³ Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, Australia.
⁴ Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, Australia.
⁵ Urology Dept, Royal Brisbane and Women's Hospital, Brisbane, Australia.
⁶ Institute of Cancer Research, London, UK.
⁷ Imperial College London, London, UK.

Abstract

Background: Late relapse (LR) of nonseminomatous germ cell tumour (NSGCT) is uncommon, with limited data published. LR is defined as relapse occurring after a disease-free interval of 2 yr.

Objective: To review features of NSGCT LR in a UK tertiary centre.

Design setting and participants: A total of 3064 patients were referred from January 2005 to December 2017. We identified patients who experienced LR after initial pathology demonstrated NSGCT and reviewed data for their original and LR presentation and management.

Outcome measurements and statistical analysis: Outcomes included time to LR measured from the date of diagnosis, and overall survival. This was assessed using Cox proportional Hazards modelling, with stratification or adjustment for potential confounders.

Results and limitations: We identified 101 patients with LR; the median time to LR was 96 mo. Forty-three patients (42.6%) experienced relapse after 10 yr. Univariable log-rank testing revealed that the median time to LR was significantly shorter for patients who had not received induction chemotherapy (iCTx; 54 mo, 95% confidence interval [CI] 48-108) than for those who did (112 mo, 95% CI 84-186; p = 0.04). Patients who had received iCTx were less likely to have elevated tumour markers (36% vs 46%) and more likely to undergo initial surgical resection at LR compared to CTx-naïve patients. Postpubertal teratoma (PPT), yolk sac, and dedifferentiated elements predominated for patients with iCTx exposure, whereas active GCT or fibrosis predominated in postchemotherapy resections for CTx-naïve patients at LR. Forty-one men underwent postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) as part of their initial treatment for metastatic disease. Of these, 20 experienced LR in the retroperitoneum, with 18 undergoing repeat RPLND as part of their LR management. Fifteen of the repeat RPLND histopathology specimens had a PPT component. There have been 23 deaths overall; survival was worse for patients presenting with symptoms (13/36, 33%) and those receiving CTx and no surgery (10/17, 59%) at LR.

Conclusions: When LR of NSGCT occurs, it is frequently after an extended interval and is later among patients with prior iCTx, with PPT predominating. The high frequency of LR within the retroperitoneum following PC-RPLND reinforces the need for good-quality PC-RPLND.

Patient summary: We reviewed data for patients who had a late relapse of testicular cancer. We found that patients who did not receive chemotherapy as the first treatment for their initial diagnosis had a shorter time to relapse. Our results highlight the importance of long-term follow-up for testicular cancer.

Keywords: Cancer; Germ cell; Nonseminoma; Relapse; Retroperitoneal lymph node dissection.