Salvage post-chemotherapy retroperitoneal lymph-node dissection: evolving paradigm for marker-positive non-seminomatous germ-cell tumors management

Background: The role of post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) in non-seminomatous germ cell tumour (NSGCT) patients with persistently elevated serum tumour markers remains controversial, although traditional management favours salvage chemotherapy. This study aimed to re-define the surgical and oncologic outcomes of salvage PC-RPLND. Methods: We select 107 (2008–2023) consecutive NSGCT patients undergoing PC-RPLND with elevated markers after ≥1 chemotherapy line. Multivariable linear regression models (MLRM), and Cox proportional hazards models recurrence-free survival (RFS) and overall survival (OS) were used. Results: Definitive histology revealed viable GCT (47.7%), post-pubertal teratoma (32.7%), fibro-necrotic tissue (FNT) (11.4%), and somatic malignancy (8.4%). After a median follow-up of 45 months, overall 5-year RFS was 54% and OS was 68%. Outcomes varied significantly by histology: post-pubertal teratoma had superior 5-year OS (96%) and RFS (77%), while somatic malignancy and FNT predicted worse RFS (MCRM HRs 23.11 and 28.77, respectively). Larger residual mass size correlated with higher relapse risk and increased probability of somatic malignancy. Advanced stage and increasing chemotherapy lines also associated with poorer outcomes. Conclusions: Salvage PC-RPLND for marker-positive NSGCT achieved meaningful survival, particularly for patients with post-pubertal teratoma. These findings support surgery, even as first-line salvage, when teratoma or somatic malignancy is suspected.