Original article
General thoracic
Thoracic Metastasectomy in Germ Cell Tumor Patients Treated With First-line Versus Salvage Therapy

Presented at the Poster Session of the Sixty-sixth Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 6-9, 2019.
https://doi.org/10.1016/j.athoracsur.2020.06.072Get rights and content

Background

Outcomes after thoracic metastasectomy in patients with testicular germ cell tumors (GCTs) who received first-line chemotherapy alone versus salvage chemotherapy remain unexplored.

Methods

We conducted a retrospective review of patients who underwent thoracic metastasectomy for residual GCT between 1997 and 2019 at a single tertiary center. Factors associated with progression-free survival (PFS) and overall survival (OS) were assessed using multivariable Cox regression.

Results

Of 251 patients, 191 received only first-line chemotherapy (76%) and 60 received salvage chemotherapy (24%). Median follow-up was 3.45 years (interquartile range, 1-7.93 years). Among first-line patients without teratoma in the primary tumor, with necrosis in the retroperitoneal nodes and normalized or decreasing serum tumor markers, 17 of 20 had intrathoracic necrosis (85%). Among first-line and salvage patients, respectively, 5-year OS was 93% (95% confidence interval [CI], 89%-98%) versus 63% (95% CI, 51%-78%; P < .001), and 5-year PFS was 69% (95% CI, 62%-77%) versus 40% (95% CI, 29%-56%; P < .001). On multivariable analysis, multiple lung lesions (hazard ratio [HR] = 3.01; 95% CI, 1.50-6.05; P = .002) and brain metastasis (HR = 4.51; 95% CI, 2.34-8.73; P < .001) at diagnosis, salvage chemotherapy (HR = 1.85; 95% CI, 1.10-3.13; P = .021), teratoma (HR = 2.68; 95% CI, 1.50-4.78; P = .001), and viable malignancy (HR = 4.34; 95% CI, 2.44-7.71; P < .001) were associated with worse PFS.

Conclusions

Although GCT patients treated with salvage chemotherapy followed by thoracic metastasectomy have more aggressive disease and poorer PFS, they can achieve encouraging OS. Our findings highlight the integral role of aggressive thoracic metastasectomy in the treatment of GCT patients with residual thoracic disease after first line–only or salvage chemotherapy.

Section snippets

Patient Selection

We performed a retrospective review of a prospectively maintained database of patients with primary testicular GCT (seminoma and NSGCT) who underwent thoracic metastasectomy at Memorial Sloan Kettering (MSK) between 1997 and 2019. Data collected included patient demographic information, diagnostic approaches, International Germ Cell Cancer Collaborative Group (IGCCCG) risk classification at diagnosis,10 preoperative chemotherapy regimens, STM (before chemotherapy and before and after surgery),

Preoperative Patient and Disease Characteristics

We identified 251 patients with testicular GCTs (4% seminoma and 96% NSGCT) who underwent postchemotherapy thoracic metastasectomy (60 salvage versus 191 first-line alone) (Table 1). Intrathoracic metastasis was identified at initial diagnosis in 237 patients (94%): 65% pulmonary only (n = 153), 10% mediastinum only (n = 24), and 25% pulmonary and mediastinum (n = 60). The NSGCT pathologic findings commonly demonstrated a mixed tumor (n = 165; 66%) composed of multiple NSGCT subtypes (teratoma,

Comment

This large contemporary study examined thoracic metastasectomy in patients with primary testicular GCT by chemotherapy exposure. Salvage patients had a more aggressive disease profile, were more likely to have increasing preoperative STM, and were 3-fold more likely to have residual viable malignancy. Even with resection of disease, 5-year PFS among salvage patients was 40%, compared with 69% for first-line patients. Our findings suggest that aggressive thoracic metastasectomy is warranted,

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