Pathologic and Oncologic Outcomes of Patients Undergoing Orchiectomy After Chemotherapy for Advanced Testicular Germ Cell Tumors.

Background And Objective: Delayed orchiectomy is generally recommended for patients who receive upfront chemotherapy for advanced testicular germ cell tumors (TGCTs). However, the risk of residual disease in the primary tumor and the relationship this has on oncologic outcomes are unclear. We aimed to understand the histopathologic and oncologic outcomes of patients undergoing delayed orchiectomy.

Methods: All patients who underwent orchiectomy after at least one line of standard chemotherapy at our institution between 2000 and 2024 were included. Clinicopathologic findings and presurgical ultrasound findings are reported. Our primary outcome was the presence of residual viable disease (RVD) at orchiectomy, defined as a composite outcome that included germ cell neoplasia in situ (GCNIS), teratoma, or viable invasive nonteratomatous germ cell tumor (viGCT, with or without concomitant teratoma/GCNIS). Histologic concordance between postchemotherapy retroperitoneal lymph node dissection (pcRPLND) and orchiectomy was assessed. Disease-free survival (DFS) and overall survival (OS) were assessed using the Kaplan-Meier method.

Key Findings And Limitations: A total of 193 patients, 60 (31%) with pure seminoma and 133 (69%) with nonseminomatous germ cell tumors, met the inclusion criteria. Orchiectomy pathology showed no RVD in 131 (68%); among the 62 (32%) patients with RVD, nine (5%) had GCNIS only, 46 (24%) had teratoma only, and seven (4%) had viGCTs. Six of these seven viGCT cases had residual seminoma. Of the cohort, 126 patients underwent pcRPLND; histologic concordance between orchiectomy and pcRPLND was 58%. The unadjusted odds of RVD at orchiectomy was positively associated with a solid/cystic mass on postchemotherapy testicular ultrasound and negatively associated with age. During follow-up, 26 DFS and 22 OS events occurred. The median 5-yr DFS rates were 89% (95% confidence interval [CI]: 82-94) and 77% (95% CI: 63-86) for no RVD and RVD at orchiectomy, respectively (log-rank  = 0.061).

Conclusions And Clinical Implications: Consolidative radical orchiectomy after chemotherapy remains necessary for patients with advanced TGCTs. There is poor histologic concordance with pcRPLND pathology. Post-treatment ultrasound findings may be suggestive of the presence of RVD.

Patient Summary: The standard of care for patients with advanced testicular cancer involves surgical removal of the testicle followed by chemotherapy; however, certain clinical scenarios necessitate delaying orchiectomy until after chemotherapy. We studied patients with testicular cancer who received chemotherapy before the removal of their testicle and found that nearly one-third of patients had remaining cancerous or precancerous elements in their testicle. These findings reaffirm the typical practice of removing the testicle after chemotherapy in these situations.