Postchemotherapy Residual Tumor Resection in Patients with Elevated Tumor Markers

Abstract

Purpose:The oncologic benefit of postchemotherapy (PC) residual tumor resection (RTR) in patients with germ cell tumors and elevated serum tumor markers (STMs) remains unclear. This analysis was performed to better define patients who benefit from surgery in this setting.Materials and Methods:Of 575 PC-RTR procedures (July 2008–July 2019) 153 were performed in patients with elevated STMs (human chorionic gonadotropin [HCG] >2.0 mIU/ml, alpha-fetoprotein [AFP] >7.0 µg/l), including 55 after first line and 98 after second or later line chemotherapy.Results:Viable cancer in the resected specimen was significantly more common in the salvage group than in the first line group (48.98% vs 16.36%, p=0.0001988) and was a predictor of survival in both groups. A preoperative serum level of AFP ≥30 µg/l was a significant predictor of viable cancer in the first line and salvage groups (55.56% [p=0.0157] and 66.67% [p=0.0017], respectively). The overall relapse-free survival rate (22.7% and 50%, p=0.00032) and overall survival rate (37.8% and 65%, p=0.0059) were significantly worse in the salvage group than in the first line group. A preoperative serum level of AFP ≥30 µg/l and viable cancer/teratoma found in the histological examination of the RTR specimens were significant predictors of relapse after first line chemotherapy. Serum AFP ≥30 µg/l and HCG ≥20 mIU/ml were significant factors affecting survival in the first line group.Conclusions:Patients with AFP serum levels >30 µg/l and HCG ≥20 mIU/ml after first line chemotherapy should receive salvage chemotherapy instead of surgery. After second or later line therapy, the prognosis of patients with elevated markers and surgery is poor regardless of the tumor marker levels. However, 38% of these patients are long-term survivors, which justifies PC-RTR in this setting.

Resection of Residual Masses After Chemotherapy for Metastatic Nonseminomatous Germ Cell Tumors in Adolescents and Adults

“…Patients with persistent elevations of AFP or BHCG after chemotherapy are at high risk of relapse after resection of residual disease. 17,21,55 A German study reported the outcomes of 153 patients who underwent PC-RPLND in the setting of elevated AFP and/or BHCG, including 55 who had received first-line chemotherapy and 98 who had received salvage chemotherapy. 55 Of the first-line chemotherapy patients, 50% relapsed, including 78% of those with an AFP > 30 ng/mL.…”

“…17,21,55 A German study reported the outcomes of 153 patients who underwent PC-RPLND in the setting of elevated AFP and/or BHCG, including 55 who had received first-line chemotherapy and 98 who had received salvage chemotherapy. 55 Of the first-line chemotherapy patients, 50% relapsed, including 78% of those with an AFP > 30 ng/mL. The OS for the first-line group was 65%, and it was 22% for those with an AFP > 30 ng/mL and 0% for those with a BHCG > 20 μg/L.…”

“…Mildly elevated AFP levels (between the upper limit of normal and 30 ng/mL) are not as concerning as levels above 30 ng/mL. 55,56 Elevation of AFP has also been associated with worse survival after resection of residual thoracic disease. 17 As a result, salvage chemotherapy is generally preferred to resection of residual disease in men with testicular NSGCT rising serum AFP or BHCG after first-line chemotherapy.…”