Guidelines on Testicular Cancer: 2015 Update

External validation of 2 models to predict necrosis/fibrosis in postchemotherapy residual retroperitoneal masses of patients with advanced testicular cancer

OBJECTIVES

Nonseminomatous testicular germ cell tumors with residual retroperitoneal lesions >1 cm are treated with postchemotherapy retroperitoneal lymph node dissection (pcRPLND). However, up to 50% of patients are overtreated since the histology shows only residual necrosis/fibrosis. We aim to validate the 2 currently best performing prediction models (Vergouwe and Leao) for postchemotherapy residual mass histology.

METHODS AND MATERIALS

We performed a retrospective analysis including 402 patients who underwent a pcRPLND from 2008 to 2015. The study cohort was used to validate the 2 prediction models by Vergouwe and Leao using the published formulas and thresholds.

RESULTS

Using our validation cohort, the Vergouwe model reached a significantly better area under the curve compared to the Leao model (0.760 (confidence interval 0.713-0.807) vs. 0.692 (0.640-0.744), P = 0.002) in the prediction of benign histology. At a threshold of >70% for the predicted probability of benign disease, the Leao model revealed that pcRPLND would be avoided in 10.2% of patients with benign disease with an error rate of 3.8% for viable tumor, while the Vergouwe model would avoid pcRPLND in 27.4% of all patients with benign disease with an error rate of 10.1% for viable tumor and 2.9% for teratoma. Adjusting the models to our data had no significant improvement. Limitations include the retrospective design.

CONCLUSIONS

The discriminatory accuracy of both models is not sufficient to safely select patients for surveillance strategy instead of pcRPLND. Therefore, further studies including new biomarkers are needed to optimize the accuracy of potential prediction models and to minimize pcRPLND overtreatment.

[Relapse surveillance of patients with testicular germ cell tumor]

Germ-cell tumors are the most common solid tumors in young men. The follow-up of these patients is very important in their management. In stage I testicular cancer, surveillance is the standard for low-risk disease. In addition to the early detection of relapse, follow-up should be directed towards prevention, detection and treatment of late toxicity, and secondary malignancies. Follow up consists in physical examination, laboratory analysis and radiological imaging. Recently, guidelines recommend risk-adapted surveillance strategy, with a reduction of CT scans numbers, due to the recognition of the risk of ionizing radiation exposure. However, efforts to maintain adequate compliance with follow up are required.

Surgical Complications in Postchemotherapy Retroperitoneal Lymph Node Dissection for Nonseminoma Germ Cell Tumour: A Population-based Study from the Swedish Norwegian Testicular Cancer Group

BACKGROUND

Reports on perioperative complications after postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for nonseminoma germ cell tumour (NSGCT) are from experienced single centres, with a lack of population-based studies.

OBJECTIVE

To assess the complications of bilateral and unilateral PC-RPLND.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, population-based, observational multicentre study included all patients with NSGCT who underwent PC-RPLND in Norway and Sweden during 2007-2014. Of a total of 318 patients, 87 underwent bilateral PC-RPLND and 231 underwent unilateral PC-RPLND. The median follow-up was 6 yr.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Bilateral and unilateral PC-RPLND were compared for the outcomes of intra- and postoperative complications (graded by Clavien-Dindo) and retrograde ejaculation (with or without nerve-sparing surgery). Complications were reported as absolute counts and percentages. The χ² test was used for comparisons.

RESULTS AND LIMITATIONS

The incidence of intraoperative complications was higher for bilateral PC-RPLND than for unilateral PC-RPLND (14% vs 4.3%, p = 0.003), with ureteral injury as the most frequent reported complication (2% of the patients). Postoperative complications were more common after bilateral than after unilateral PC-RPLND (45% vs 25%, p = 0.001) with Clavien ≥3b reported in 8.3% and 2.2%, respectively (p = 0.009). Lymphatic leakage was the most common complication occurring in 11% of the patients. Retrograde ejaculation occurred more frequently after bilateral than after unilateral surgery (59% vs 32%, p < 0.001). Limitations of the study include reporting of retrograde ejaculation, which was based on a chart review.

CONCLUSIONS

Intra- and postoperative complications including retrograde ejaculation are more frequent after bilateral PC-RPLND than after unilateral PC-RPLND.

PATIENT SUMMARY

Lymph node dissection in patients with testicular cancer puts them at risk of complications. In this study, we present the complications after lymph node dissection.

The prognostic impact of different tumor marker levels in nonseminomatous germ cell tumor patients with intermediate prognosis: A registry of the International Global Germ Cell Tumor Collaborative Group (G3)

BACKGROUND

Germ cell tumor patients with intermediate prognosis (IPGCT) according to the International Germ Cell Cancer Collaborative Group (IGCCCG) classification represent a heterogeneous group with different clinical features. This analysis was performed to investigate the prognostic impact of different tumor marker levels prior to first line chemotherapy within IPGCT.

METHODS

For this study an international registry for IPGCT was established. Eligibility criteria were intermediate prognosis according to IGCCCG criteria, nonseminomatous histology, male sex, and age ≥ 16 years. Uni- and multivariate analysis were conducted to identify characteristics associated with survival outcomes. Receiver-Operating-Characteristic curve analysis was applied to find cut-off parameters. Five-year overall survival (OS) rate was the primary and 5-year progression-free survival rate the secondary endpoint.

RESULTS

This database included 634 IPGCT with a median follow-up of 9.0 years (interquartile range: 14.35). Patients received first line treatment with platinum based chemotherapy, associated with a 5-year OS rate of 87%. The stratification of patients according to AFP levels revealed a correlation between AFP levels and outcome, associated with 5-year OS rates of 88% for AFP levels <1,000 IU/ml (n = 303), 89% for 1,000 to 2,000 IU/ml (n = 82), 87% for >2,000 to 6,000 IU/ml (n = 121), and 82% for >6,000 IU/ml (n = 57) prior first course of chemotherapy, respectively (P= 0.013). LDH levels prior fist course of chemotherapy also correlated with outcome associated with 5-year OS rates of 92% for <2 UNL (n = 271), 89% for ≥2 to 3 UNL (n = 85), 78% for >3 to 4 UNL (n = 34), and 77% for >4 UNL (n = 79), respectively (P= 0.03). Different HCG levels prior chemotherapy were not associated with outcome. In multivariable analysis AFP levels >6,000 IU/ml (P= 0.023; hazard ratio HR 2.263) or >1,982 IU/ml (P= 0.031; HR 1.722), and LDH levels >3 UNL (P< 0.001; HR 2.616) were independent prognosticators for OS.

CONCLUSIONS

Prognostication according to LDH and AFP levels prior chemotherapy could offer a new approach to stratify patients within the intermediate prognosis cohort. According to our findings, patients with AFP values above 6,000 IU/ml or/and LDH > 3 UNL represent an independent high risk cohort. Our results need to be confirmed in the upcoming IGCCCG reclassification.

[Management of metastatic testicular germ cell tumors]

Metastatic testicular germ cell tumors are rare entities with a high cure rate owing to their major chemosensitivity. Current guidelines should be strictly followed to ensure maximal cure rate. Germ cell tumor treatment requires multidisciplinary skills and is based on cisplatin-based chemotherapy. The current challenge for these patients with favorable prognosis is to limit over- or under-treatment. Centralization of care for patients with these rare cancers is a key point to achieve the best chance of cure.

Contemporary North-American population-based validation of the International Germ Cell Consensus Classification for metastatic germ cell tumors of the testis

BACKGROUND

The International Germ Cell Consensus Classification (IGCCC) is the recommended stratification scheme for newly diagnosed metastatic seminoma (mSGCT) and non-seminoma germ cell tumor (mNSGCT) patients. However, a contemporary North-American population-based validation has never been completed and represented our focus.

MATERIALS AND METHODS

We identified mSGCT and mNSGCT patients within the SEER database (2004-2015). The IGCCC criteria were used for stratification into prognostic groups. Kaplan-Meier (KM) derived actuarial 5-year overall survival (OS) rates were calculated. In addition, cumulative incidence plots tested cancer-specific (CSM) and other-cause mortality (OCM) rates.

RESULTS

Of 321 mSGCT patients, 190 (59.2%) and 131 (40.8%), respectively, fulfilled good and intermediate prognosis criteria. Of 803 mNSGCT patients, 209 (26.1%), 100 (12.4%), and 494 (61.5%), respectively, fulfilled good, intermediate, and poor prognosis criteria. In mSGCT patients, actuarial KM derived 5-year OS was 87% and 78% for, respectively, good and intermediate prognosis groups (p = 0.02). In cumulative incidence analyses, statistically significant differences were recorded for CSM but not for OCM between good versus intermediate prognosis groups. In mNSGCT patients, actuarial KM derived 5-year OS was 89%, 75% and 60% for, respectively, good, intermediate, and poor prognosis groups (p < 0.001). In cumulative incidence analyses, statistically significant differences were recorded for both CSM and OCM between good, intermediate, and poor prognosis groups.

CONCLUSIONS

Our findings represent the first population-based validation of the IGCCC in contemporary North-American mSGCT and mNSGCT patients. The recorded OM rates closely replicate those of the original publication, except for better survival of poor prognosis mNSGCT patients.

Robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy for metastatic mixed testicular germ cell cancer: a case report

BACKGROUND

The robot-assisted laparoscopic management of post-chemotherapy retroperitoneal metastasis and inferior vena cava tumor thrombus secondary to testicular cancer is a challenging task for urologists.

CASE PRESENTATION

A pathological examination of a 36-year-old Caucasian man who had undergone a right radical orchiectomy showed mixed testicular germ cell cancer (70% embryonal cancer and 30% seminoma); he had undergone four prior courses of cisplatin, etoposide, and bleomycin chemotherapy and was found to have residual retroperitoneal enlarged lymph nodes close to the right renal hilum and a 9.8 cm inferior vena cava tumor thrombus (pT1, N2, M1, S2). Pre-surgical three-dimensional image reconstruction was performed based on contrast computed tomography data. The inferior vena cava tumor thrombus was found in the vena cava at the level of the celiac trunk and the inferior mesenteric artery. Our patient accepted treatment with robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and cava reconstruction on September 12, 2018. During the procedure, a drop-in robotic ultrasound probe was used to define the thrombus. Vena cavoscopy using a flexible ureteroscope found that the tumor thrombus adhered to the cava wall in all directions. The tumor thrombus was dissected free from the inferior vena cava lumen, and vena cava reconstruction was achieved using the da Vinci™ Si HD surgical system. The operative time was 550 minutes. The intraoperative estimated blood loss was 2300 ml. Intraoperative blood transfusions consisted of 10 units of red blood cells (Clavien-Dindo grade II). No Clavien-Dindo grade III or above perioperative complications occurred. The length of hospital stay was 7 days. Pathology revealed no viable cancer cells in any of the residual lymph node tissues or in the vena cava tumor thrombus.

CONCLUSION

This is the first case of robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and reconstruction for metastatic mixed testicular germ cell cancer published to date. This complicated surgical procedure was facilitated by the innovative usage of three-dimensional image reconstruction for defining the vena cava tumor thrombus, a robotic ultrasound probe for intraoperatively defining the vena cava tumor thrombus, and vena cavoscopy using a flexible ureteroscope.

Contemporary Assessment of Long-Term Survival Rates in Patients With Stage I Nonseminoma Germ-Cell Tumor of the Testis: Population-Based Comparison Between Surveillance and Active Treatment After Initial Orchiectomy

BACKGROUND

Historical data demonstrated similar survival outcomes in patients with stage I nonseminoma germ-cell tumor of the testis (NSGCTT) subjected to either surveillance or active treatment (AT) after orchiectomy. However, data with long-term follow-up are unavailable. We tested contemporary treatment rates and their effect on cancer-specific mortality (CSM) and other-cause mortality (OCM) relative to surveillance, as well as after stratification between chemotherapy (CHT) versus retroperitoneal lymph node dissection (RPLND).

PATIENTS AND METHODS

We identified patients with stage I NSGCTT with initial orchiectomy within the Surveillance, Epidemiology, and End Results (SEER) database (1988-2015). Subsequent surveillance versus CHT versus RPLND use rates were reported. Cumulative incidence plots and multivariable competing-risks regression (CRR) models were used after propensity score (PS) matching. These tests first compared surveillance versus AT (CHT vs. RPLND) and subsequently CHT versus RPLND.

RESULTS

Of 5034 patients with stage I NSGCTT, 61.2%, 24.9%, and 13.9%, respectively, underwent surveillance, CHT, and RPLND. Between 1988 and 2015, surveillance (estimated annual percentage change [EAPC]: +1.1%, P < .001) and CHT (EAPC: +2.3%, P < .001) rates increased. RPLND rates decreased (EAPC: -5.7%; P < .001). After PS matching, CRR models failed to identify AT as an independent predictor of lower mortality relative to surveillance. However, after PS matching, CRR models identified RPLND as an independent predictor of lower CSM (hazard ratio, 0.26; P = .002) relative to CHT. No difference in OCM rates was recorded (hazard ratio, 1.25; P = .2).

CONCLUSION

Surveillance and CHT use rates increased while RPLND decreased in the last two decades. Virtually the same outcomes were recorded between surveillance and AT. However, within AT, RPLND was associated with lower CSM than CHT.

CXCL12 expression is an adverse predictor for disease recurrence in patients with metastatic non-seminomatous testicular germ cell tumors

Background

To validate the utility of the chemokine ligand 12 (CXCL12) as prognostic marker in patients with localized and metastatic germ cell tumors (GCT).

Methods

CXCL12 expression was analyzed on a tissue microarray consisting of 750 tissue cores of different histological tumor components, Germ cell neoplasia in situ (GCNIS) and adjacent normal tissue of 263 testicular cancer patients using a semi-quantitative score. The association between CXCL12 expression and recurrence-free survival (RFS) as well as overall survival (OS) was assessed using Kaplan-Meier curves with log-rank tests.

Results

CXCL12 expression was absent in all seminomas but was found in 52 of 99 (52.5%) non-seminomas. Follow-up was available for 260 patients of which 36 (13.8%) recurred. In patients with stage 1 non-seminoma GCT, CXCL12 expression was not associated with higher risk of disease recurrence (p = 0.270). In contrast, post chemotherapy RFS of patients with metastatic non-seminoma and positive CXCL12 expression was significantly shorter compared to CXCL12 negative patients (p = 0.003). OS differences were not statistically different between patients with CXCL12 positive or negative tumors for either localized or metastatic disease.

Conclusions

CXCL12 is almost exclusively expressed in non-seminoma. Pure seminoma, GCNIS and adjacent normal testicular tissue are CXCL12 negative. Our analysis suggests that patients with metastatic disease and a CXCL12-positive non-seminoma are at higher risk for disease recurrence after first-line chemotherapy and might thus be candidates for more intensive treatment and/or closer follow-up.

Management of Stage II Germ Cell Tumors

There are several treatment approaches for stage II germ cell tumors (GCTs), and a thorough understanding of the staging classification and histologic differences in tumor biology and therapeutic responsiveness is critical to determine an effective, multimodal management strategy that involves urologists, medical oncologists, and radiation oncologists. This article discusses contemporary management strategies for stage II GCTs, including chemotherapy, radiotherapy, retroperitoneal lymph node dissection (RPLND), and surveillance. Patient selection, histology, and extent of lymphadenopathy drive management, and, as both treatment and detection strategies continue to emerge and be refined, the management of patients with stage II GCT continues to evolve.

[Awareness of clinical relevance of malignant testicular cancer among university students : The value of ​prevention campaigns]

BACKGROUND

Early detection of localized testicular cancer is associated with a significantly better prognosis compared to advanced tumor stages. Testicular cancer prevention campaigns like "Hodencheck.de" launched by the German Society of Urology or the international campaign "Movember Foundation" want to inform and raise awareness about testicular cancer and other male cancers. This study aimed to evaluate to which extent public prevention campaigns may influence the behavior of young men and women in Germany.

OBJECTIVES

Questionnaires were used to ask students at the University of Frankfurt, Germany, whether they are familiar with the currently most widespread testicular cancer prevention campaigns and whether testicular examinations for cancer screening were performed by themselves, a partner or a physician.

RESULTS

Only a minority of the students were aware of the testicular cancer prevention campaigns "Hodencheck.de" and/or "Movember Foundation"; 79.9% of the male and 83.6% of female students had not heard of the two mentioned prevention campaigns. Significantly more male (35.2%) compared to female students (28.9%) knew that testicular cancer is the most common cancer in young men. Of the men, 48.9% had already palpated their testicles, while only 12.4% of the women had already palpated the partner's testicles for cancer screening. Students knowing about the testicular cancer prevention campaigns performed significantly more testicular examinations for screening purposes.

CONCLUSIONS

Our study demonstrates that current testicular cancer prevention campaigns are little known amongst German university students. However, the knowledge of testicular cancer prevention campaigns resulted in an increased awareness and an increased willingness for testicular (self-) examinations.

Pure yolk sac tumour, post-pubertal type, arising from cryptorchid testes

Yolk sac tumour (YST), the most common germ cell tumour (GCT) in infants and children, accounts for 80% of GCTs in this age group. ¹ It is observed in only 2.4% of adult patients in their pure form since up to 42% of mixed GCTs have some component of the yolk sac. ² We present a 46-year-old cryptorchid man who presented with complaints of abdominal lump, pain and altered bowel habits since 1 month. CT scan of the abdomen revealed a mass arising from the pelvic cavity with feeders predominantly from the left gonadal vessel. Mass was excised via exploratory laparotomy and sent for histological examination. Microscopic examination was suggestive of pure YST. Immunohistochemistry stained positive for cytokeratin, placental-like alkaline phosphatase, Glypican 3 and alpha fetoprotein. The patient succumbed prior to commencing chemotherapy. Pure YSTs of post-pubertal origins are extremely rare and are more aggressive than their prepubertal counterparts.

Testicular cancer in Geneva, Switzerland, 1970-2012: incidence trends, survival and risk of second cancer

BACKGROUND

This paper describes the testicular cancer trends for incidence, survival, socio-economic status (SES) disparities and second cancer occurrence in Geneva, Switzerland, a high-risk population.

METHODS

We included all testicular germ-cell tumors recorded in the population-based Geneva cancer registry during the period 1970-2012. Changes in incidence trends were assessed using Joinpoint regression to calculate the annual percentage change (APC). Overall and cancer-specific survivals (OS, CSS) were estimated by Kaplan Meyer methods. To evaluate the risk of a second cancer we calculated the Standardized Incidence Ratios (SIR) using the Geneva population incidence rates.

RESULTS

The average annual testicular cancer rate was 7.32/100 000 men, with a non-significant increasing trend during the study period. The highest rates were observed among men younger than 39 years. Despite a trend toward earlier diagnosis, 14% of patients were diagnosed at a late stage. Patients with non-seminoma tumours and patients with low SES were more often diagnosed with an advanced stage. Both OS and CSS improved during the study period but with strong differences by age, stage, morphology and SES. The risk for developing a second cancer was more than doubled. This risk was particularly high for a contralateral testicular cancer, bladder cancer and pancreatic cancer.

CONCLUSIONS

Overall, there was no substantial increase in the incidence of testicular cancer in Geneva in recent decades, however the prognosis has improved. The high risk of developing a second cancer, the differences in stage at diagnosis and survival by SES, require enhanced awareness and surveillance by clinicians, patients and men in general.

Testicular Cancer mortality in Brazil: trends and predictions until 2030

BACKGROUND

Despite the fact that testicular cancer presents good prognosis, wide variations in mortality rates have been reported internationally. In Brazil, mortality trends and estimates have not been fully assessed. The objective of the study presented herein is to analyze the mortality trends for testicular cancer in Brazil in the period 2001-2015 and calculate mortality predictions for the period 2016-2030.

METHODS

This is a population-based ecological study that utilized information of the Mortality Information System, on testicular cancer-related deaths in Brazil. Mortality trends were analyzed by Joinpoint regression, and Nordpred was utilized for the calculation of predictions.

RESULTS

The mortality rate for men, standardized to the world population, varied between 0.36/100,000 for the year 2001, to 0.41/100,000 for the year 2015. There was an increasing trend for Brazil (APC = 1.3% CI95% 0.6; 2.0) and the Southeast region (APC = 1.5% CI95%0.2; 2.7). When analyzing Brazilian data for the period 2016-2030, predictions indicate 2888 deaths due to testicular cancer, which corresponds to a 26.6% change when compared to the 2011-2015 period. This change is mostly explained by an increase in the risk of death (14.2%) when compared with modifications in the demographic structure (12.4%).

CONCLUSIONS

Testicular cancer mortality in Brazil presents increasing trends, and until 2030 these rates continue to increase.

Organ-sparing procedures in GU cancer: part 2-organ-sparing procedures in testicular and penile tumors

PURPOSE

Organ-sparing surgery (OSS) is recommended in selected patients with testicular tumors and penile cancer (PC). The functional and psychological impacts of organ excision for these genital tumors are profound. In this review, we summarize the indications, techniques and outcomes of OSS for these two tumors.

METHODS

PubMed^® was searched for relevant articles up to December 2018. For Testicular sparing surgery (TSS) search, keywords used were; testicular tumors alone and in combination with "testicular sparing surgery", "partial orchiectomy" and outcomes. For penile conserving surgery (PCS), keywords used were: penile cancer alone and in combination with "penile conserving surgery", "partial penectomy" and outcomes. Because of the low quality of available evidence, a narrative rather that systematic review has been performed.

RESULTS

Indications of TSS are tumors ≤ 2 cm in solitary testis or bilateral tumors and no rete testis invasion. Prerequisites include normal testosterone and luteinizing hormone levels and patient compliance with follow-up. Indications for PCS are distal penile lesions with clinical stage ≤ T1. Adequate penile stump (3 cm) is required after surgery to maintain forward urine stream. Frozen section helps to reduce the risk of recurrence. Local recurrence after PCS is not associated with reduced survival and can be managed with another PCS in selected patients. The reported oncological and functional outcomes following TSS and PCS are adequate.

CONCLUSIONS

In properly selected patient OSS in testicular and penile tumors has a comparable oncological outcome to total organ excision with added advantages of preserving organ function and psychological well-being.

Conditional risk of relapse in patients with germ cell testicular tumors: personalizing surveillance in clinical stage 1 disease

PURPOSE OF REVIEW

Germ cell testicular tumors (GCTTs) are the most common malignancy in young men, and the incidence is increasing worldwide. Most patients present with clinical stage I (CS1) disease, and active surveillance is being increasingly adopted as the preferred initial treatment modality. In this review, we describe the concept of conditional risk of relapse (CRR), an evolving risk estimate for CS1 GCTT patients on active surveillance who have not relapsed.

RECENT FINDINGS

At diagnosis, patients are often counseled about their initial risk of relapse based on known risk factors present at diagnosis. However, the risk estimate becomes less informative in patients who have survived a period of time without experiencing relapse. CRR, on the other contrary, provides specific information on a patient's evolving risk of relapse over time. This dynamic estimate can be used to tailor surveillance protocols based on future risk of relapse within risk subgroups.

SUMMARY

Implementation of CRR in patients on active surveillance can reduce the burden of follow-up, the number of physician visits and tests, and lower costs for the healthcare system. Finally, CRR estimates provide patients with a meaningful, evolving risk estimate, and may help reassure patients and reduce potential anxiety while continuing active surveillance.

Update on epidemiologic considerations and treatment trends in testicular cancer

PURPOSE OF REVIEW

We aim to give an overview of the epidemiology and treatment trends of testicular germ cell tumors (TGCTs), with an emphasis on recent trends.

RECENT FINDINGS

The incidence of TGCT appears to be increasing, particularly in developed countries, although the reasons are not well understood. There is evidence of racial differences in predisposition to TGCT, with white men having highest risk and men of African or Asian descent having lower risk. In the United States, the incidence of TGCT among Hispanics appears to be rising most quickly. A recent genomic analysis indicates there is no highly penetrant major TGCT susceptibility gene. Incorporation of multidisciplinary care has led to excellent long-term cure rates; however, access to care and insurance remains barriers in young men. Recent treatment trends have centered on maximizing oncologic outcomes while minimizing long-term morbidity.

SUMMARY

Emerging population-level data provide critical insight into the evolving demographics of TGCT, which may allow for elucidation of biologic and environmental determinants of TGCT. Further, identification of socioeconomic barriers to excellent clinical outcomes will allow for targeted interventions to patients with unique demographic and socioeconomic considerations. Treatment trend analyses suggest that the field is moving toward minimizing treatment-related morbidity.

OCT4 immunohistochemistry after staging laparoscopic retroperitoneal lymphadenectomy for testicular tumor

Twenty to thirty percent of patients with clinical stage I testicular tumor have metastases in the retroperitoneum. The aim of this study was to evaluate the role of OCT4 immunohistochemistry in histopathologic diagnosis of lymph node metastases in patients with nonseminomatous germ cell testicular tumors. All clinical stage I patients with staging laparoscopic retroperitoneal lymphadenectomy from 2001 until 2009 were included. Archived materials of dissected lymph nodes were reassessed and additional immunohistochemical staining with OCT4 antibody was performed in patients diagnosed as free from metastases. Each slide was visually estimated for the percentage of tumor cells showing nuclear immunoreactivity for OCT4. The study included 93 patients, of which 30 (32.3%) had initially positive retroperitoneal lymph nodes. Of the remaining 63 patients, materials were missing for 5 patients, so additional immunohistochemical staining was performed in 58 patients. Of these, two (3.4%) patients were OCT4 positive, suggesting a conclusion that they were initially misdiagnosed as stage I and metastasis free. OCT4 proved its value in detecting retroperitoneal metastases. Staging laparoscopic retroperitoneal lymphadenectomy for nonseminomatous germ cell testicular tumors in clinical stage I is a reasonable option for selected patients.

Serum Levels of MicroRNA-371a-3p (M371 Test) as a New Biomarker of Testicular Germ Cell Tumors: Results of a Prospective Multicentric Study

PURPOSE

Previous studies suggested that serum levels of microRNA (miR)-371a-3p (so-called M371 test) have a much higher sensitivity and specificity than the classic markers of testicular germ cell tumors (GCTs) and are applicable toward both seminoma and nonseminoma. We sought to confirm the usefulness of this test as a novel biomarker for GCT.

PATIENTS AND METHODS

In a prospective, multicentric study, serum samples of 616 patients with testicular GCTs and 258 male controls were examined for serum levels of miRNA-371a-3p (miR levels) by quantitative polymerase chain reaction. The GCT population encompassed 359 patients with seminoma and 257 with nonseminoma; 371 had clinical stage I disease, 201 had systemic disease, and 46 had relapses. Paired measurements before and after orchiectomy were performed in 424 patients; 118 with systemic disease had serial measurements during treatment. miR levels were compared with those of β-human chorionic gonadotropin, α-fetoprotein, and lactate dehydrogenase.

RESULTS

For the primary diagnosis of GCT, the M371 test showed a sensitivity of 90.1%, a specificity of 94.0%, an area under the curve of 0.966 upon receiver operating characteristic analysis, and a positive predictive value of 97.2%. α-Fetoprotein, β-human chorionic gonadotropin, and lactate dehydrogenase had sensitivities of less than 50% in seminoma and slightly higher sensitivities in nonseminomas. miR levels were significantly associated with clinical stage, primary tumor size, and response to treatment. Relapses had elevated miR levels that subsequently dropped to normal upon remission. Teratoma did not express miR-371a-3p.

CONCLUSION

The M371 test outperforms the classic markers of GCT with both a sensitivity and a specificity greater than 90%. All histologic subgroups, except teratoma, express this marker. The test could be considered for clinical implementation after further validation.

MicroRNAs as Biomarkers for Germ Cell Tumors

Two clusters of microRNAs have been discovered highly expressed by seminoma and nonseminoma germ cell tumors. They are secreted in blood of patients with testicular germ cell tumors and can be extracted from the serum or plasma and quantified by real-time-polymerase chain reaction. Results have confirmed the feasibility of the technique and demonstrated that sensitivity and specificity of those microRNAs in detecting viable germ cell tumors are higher than with current methods. If operation characteristics are confirmed in larger studies, those microRNAs will be valuable to manage equivocal clinical scenarios characterized by high uncertainty and high risk of over-treatment or under-treatment.

A nomogram for predicting survival and retroperitoneal lymph node dissection treatment in patients with resected testicular germ cell tumors

BACKGROUND AND OBJECTIVES

To build nomogram incorporating potential prognostic factors for predicting survival outcomes of testicular germ cell tumors (TGCT) patients after resection of the primary tumor.

METHODS

Data of TGCT patients from the Surveillance, Epidemiology, and End Results database (2010-2016) who underwent resection of the primary tumor were collected. Overall survival (OS) and cancer-specific survival (CSS) were analyzed by using Cox regression models, nomogram, Kaplan-Meier method, and log-rank test.

RESULTS

We identified 7272 TGCT patients. Age at diagnosis, histology, tumor size, American Joint Committee on Cancer (AJCC) staging system, and number of metastases sites were independent prognostic factors and were integrated into nomograms. The nomograms had higher C-indexes for both OS and CSS compared with the AJCC 7th staging system (0.881 vs 0.831 and 0.895 vs 0.856, respectively). Moreover, the new stratification of risk groups based on the nomograms showed a more significant distinction between Kaplan-Meier curves for survival outcomes than the AJCC staging system. Retroperitoneal lymph node dissection was associated with statistically improved survival probability in the nomogram middle-risk group in resected TGCT patients.

CONCLUSION

The novel nomogram-based staging system could provide satisfactory risk stratification and survival prediction ability beyond traditional AJCC staging systems.

The role of 18F-FDG-PET/CT in evaluating retroperitoneal masses -Keeping your eye on the ball!

Background

Testicular germ cell tumour is the commonest malignancy affecting males aged between 15 and 35, with an increased relative risk amongst those with a history of cryptorchidism. In patients presenting with locoregional metastatic disease, retroperitoneal and pelvic soft tissue masses are common findings on ultrasound and computed tomography, which has several differential diagnoses within this demographic cohort. On staging ¹⁸F-FDG-PET/CT, understanding the typical testicular lymphatic drainage pathway facilitates prompt recognition of the pathognomonic constellation of unilateral absence of testicular scrotal activity, and FDG-avid nodal masses along the drainage pathway. We describe the cases of three young males presenting with abdominopelvic masses, in whom FDG-PET/CT was helpful in formulating a unifying diagnosis of metastatic seminoma, retrospectively corroborated by a history of testicular maldescent.

Case presentations

In all three cases, the patients were males aged in their 30s and 40s who were brought to medical attention for back and lower abdominal pain of varying duration. Initial imaging evaluation with computed tomography and/or ultrasound revealed large abdominopelvic soft tissue masses, with lymphoproliferative disorders or soft tissue sarcomas being high on the list of differential diagnoses.

As such, they were referred for staging FDG-PET/CT, all of whom demonstrated the pathognomonic constellation of, 1) unilateral absence of scrotal testicular activity, and 2) FDG-avid nodal masses along the typical testicular lymphatic drainage pathway. These characteristic patterns were corroborated by a targeted clinical history and examination which revealed a history of cryptorchidism, and elevated β-hCG in two of three patients. All were subsequently confirmed as metastatic seminoma on biopsy and open resection.

Conclusion

These cases highlight the importance of clinical history and examination for the clinician, as well as a sound knowledge of the typical testicular lymphatic drainage pathway for the PET physician, which would assist with prompt recognition of the characteristic imaging patterns on FDG-PET/CT. It further anecdotally supports the utility of FDG-PET/CT in evaluating undiagnosed abdominopelvic masses, as well as a potential role in the initial staging of germ cell tumours in appropriately selected patients.

Serum Tumour Markers in Testicular Germ Cell Tumours: Frequencies of Elevated Levels and Extents of Marker Elevation Are Significantly Associated with Clinical Parameters and with Response to Treatment

Introduction

Although serum tumor markers beta human chorionic gonadotropin (bHCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH) are well-established tools for the management of testicular germ cell tumours (GCTs), there are only few data from contemporary cohorts of primary GCT patients regarding these biomarkers. Our aim was to evaluate marker elevations in testicular GCTs and to document their associations with various clinical characteristics.

Patients and Methods

A total of 422 consecutive patients with GCTs were retrospectively analysed regarding serum levels of bHCG, AFP, and LDH during the course of treatment. Additionally, the following characteristics were recorded: histology, age, laterality, clinical stage (CS), pT-stage, and tumour size. Marker elevations were first tabulated in dichotomized way (elevated: yes/no) in various subgroups and second as continuous measured serum values. Descriptive statistical methods were employed to look for differences among subgroups and for associations of elevations with clinical parameters.

Results

In all GCT patients, the frequencies of elevated levels of bHCG, AFP, LDH, and bHCG or AFP were 37.9%, 25.6%, 32.9%, and 47.6%; in pure seminomas 28%, 2.8%, 29.1%, and 30.3%; and in nonseminoma 53.0%, 60.1%, 38.7%, and 73.8%. Significant associations were noted with pT-stages >pT1, clinical stages >CS1, tumour size, and younger age. Frequencies of marker elevations dropped significantly after treatment, but LDH levels remained elevated in 30.5%-34.1%. Relapsing patients (n=27) had elevated levels of bHCG, AFP, and LDH in 25.9%, 22.2%, and 29.6%, respectively, thirteen of whom with a changed marker pattern.

Conclusions

The classical GCT-biomarkers correlate with treatment success. Clinical utility is limited due to proportions of < 50% of patients with elevated levels and the low specificity of LDH. The elevation rates are significantly associated with histology, clinical and pT-stages, tumour size, and younger age. Individual marker patterns may change upon relapse. Clinically, ideal biomarkers are yet to be found.

The Role of Robotic Retroperitoneal Lymph Node Dissection for Testis Cancer

Retroperitoneal lymph node dissection (RPLND) is complex; however, recent advances in technology have allowed adoption of the robotic platform for highly select cases. Initial case series have shown improved cosmesis, less blood loss, and decreased length of stay compared with open RPLND. Our preference for performing robotic RPLND is via a transperitoneal approach with the patient in the supine position, thus facilitating a bilateral template dissection identical to that used in all our open procedures. Robotic RPLND should mimic the open approach with regard to oncologic principles and should only be performed by clinicians well versed in open RPLND.

[Stage 1 germ-cell tumour]

Stage I germ-cell tumors are rare and highly curable diseases. As such, management of these tumours should carefully follow guidelines. Initial management is based on orchiectomy and several options as adjuvant therapy. Pro's and con's should be discussed with the patient for a personalized management. Patients with stage 1 germ-cell tumours should be addressed to expert centers.

[Testicular tumors: A diagnostic challenge of imaging]

OBJECTIVES

Reviewing the characterization and the follow-up imaging of testicular tumors.

MATERIAL AND METHODS

Literature review (PubMed, Medline) of urological and radiological studies dealing with testicular tumors using keywords: Testicular tumors; Color Doppler ultrasound; US elastography; Magnetic resonance imaging; Contrast enhanced sonography.

RESULTS

Ultrasound remains the basic exam for the tumor characterization. Among the other techniques, MRI, elastography, contrast enhanced ultrasound, although still in evaluation, will be increasingly used in the future. The frequency of benign Leydig cell tumors justifies a testicular preservation approach, through improvement of characterization, monitoring or tumorectomy. The follow-up of testicular lesions must be indicated on precise indications: follow-up of the contralateral testicle in the case of germi cell tumor, follow-up by of a supposed benign lesion, such as a small Leydig cell tumor in an infertile patient, follow-up when ultra-sound findings are not sufficiently worrying to require immediate diagnosis but which include pejorative criteria. The tumor markers and the extension screening remain systematic.

CONCLUSION

The era of total orchiectomy for any uncertain testicular lesion is over. We try the challenge of characterization, and define management's algorithms based on clinical biological data and suspected nature of the tumor at imaging.

Testicular germ cell tumor: a comprehensive review

Testicular tumors are the most common tumors in adolescent and young men and germ cell tumors (TGCTs) account for most of all testicular cancers. Increasing incidence of TGCTs among males provides strong motivation to understand its biological and genetic basis. Gains of chromosome arm 12p and aneuploidy are nearly universal in TGCTs, but TGCTs have low point mutation rate. It is thought that TGCTs develop from premalignant intratubular germ cell neoplasia that is believed to arise from the failure of normal maturation of gonocytes during fetal or postnatal development. Progression toward invasive TGCTs (seminoma and nonseminoma) then occurs after puberty. Both inherited genetic factors and environmental risk factors emerge as important contributors to TGCT susceptibility. Genome-wide association studies have so far identified more than 30 risk loci for TGCTs, suggesting that a polygenic model fits better with the genetic landscape of the disease. Despite high cure rates because of its particular sensitivity to platinum-based chemotherapy, exploration of mechanisms underlying the occurrence, progression, metastasis, recurrence, chemotherapeutic resistance, early diagnosis and optional clinical therapeutics without long-term side effects are urgently needed to reduce the cancer burden in this underserved age group. Herein, we present an up-to-date review on clinical challenges, origin and progression, risk factors, TGCT mouse models, serum diagnostic markers, resistance mechanisms, miRNA regulation, and database resources of TGCTs. We appeal that more attention should be paid to the basic research and clinical diagnosis and treatment of TGCTs.

Severe Complications in Testicular Germ Cell Tumors: The Choriocarcinoma Syndrome

Testicular germ cell tumors (TGCTs) represent the most common solid tumor in young men and is a model of curable cancer. The effectiveness of cisplatin-based chemotherapy secures more than 95% of patients' 5-years survival rate. However, some high-risk patients with a very advanced disease develop choriocarcinoma syndrome (CS) connected with acute respiratory failure with poor prognosis and high mortality rate shortly after beginning systemic chemotherapy. CS was first described as a syndrome with hemorrhage from metastatic sites in patients with TGCTs with significantly high choriogonadotropin level. Acute hemorrhage to lung metastases is typical, but hemorrhage can occur from any metastatic site. Patognomic of choriocarcinoma cells is an invasion of small blood vessels within CS. The incidence of CS in patients with TGCTs are not well-defined and can vary across the world. To date, there are a few case reports and small retrospective series reporting a connection between systemic chemotherapy and the development of CS in metastatic TGCTs. CS is known to be triggered by massive tumor cell lysis as a result of chemotherapy and cytokine release, aggravated with alveolar hemorrhage. This can lead to a consecutive superinfection, furthered with neutropenia after chemotherapy, acute respiratory distress syndrome, rising to systemic inflammatory response, resulting in multiorgan failure and death. A reasonably effective approach in patients with extensive disease could be a shortened course of chemotherapy as well as a reduction of dosage in induction chemotherapy before full-dose chemotherapeutical regimen; however, current data regarding optimal treatment approach are limited. Patients' referral to tertiary centers and the administration of induction chemotherapy in an intensive care unit setting could further improve the treatment outcome.

Reclassification of good-risk seminoma: prognostic factors, novel biomarkers and implications for clinical management

Germ cell tumors represent 11% of the cancers diagnosed in adolescent males and are the most common solid tumors in adult men between the ages of 20 and 35. Pure seminoma accounts for around 50% of all testicular germ cell tumors. The prognostic classification of the International Germ Cell Cancer Collaborative Group for good-prognosis seminoma includes both nodal disease and pulmonary visceral metastases. In this article, we analyzed recent data on prognosis and outcome of good-prognosis seminoma to revise the traditional classification of the disease and improve tailored treatment.

Robotic Postchemotherapy Retroperitoneal Lymph Node Dissection for Testicular Cancer

BACKGROUND

Postchemotherapy retroperitoneal lymph node dissection (pcRPLND) is mandated in patients with nonseminomatous germ cell tumor found to have residual masses after chemotherapy. Performed via the open approach, pcRPLND can incur significant perioperative morbidity.

OBJECTIVE

To demonstrate the feasibility of robotic pcRPLND (r-pcRPLND) and provide evidence for its selection criteria.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective search identified 93 patients undergoing pcRPLND between April 2007 and March 2018, comprising 30 r-pcRPLND and 63 open pcRPLND (o-pcRPLND) procedures performed by a single surgeon.

INTERVENTION

r-pcRPLND and o-pcRPLND.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Baseline clinicopathologic characteristics and intraoperative variables including operating room (OR) time, estimated blood loss (EBL), resection of adjacent organs, and intraoperative consultation with other surgical services were recorded. Hospital length of stay (LOS) and perioperative complications were assessed as per the Clavien-Dindo classification, and oncologic outcomes such as nodal yield, histologic distribution, pathologic staging, time to recurrence, and cancer-specific survival were compared.

RESULTS AND LIMITATIONS

r-pcRPLND was performed in a well-selected cohort with lower clinical stage (p=0.006), favorable International Germ Cell Cancer Collaborative Group classification (p=0.01), and smaller retroperitoneal mass (p=0.001). o-pcRPLND required more frequent bilateral template dissection (88.9% vs 43.3%; p<0.001), resection of adjacent organs (36.5% vs 10%; p=0.007), consultation with other surgical services (46% vs 2%; p<0.001), and auxiliary procedures (54.0% vs 20%; p=0.003) to achieve complete oncologic control. OR time was similar between the two groups (o-pcRPLND 375min vs r-pcRPLND 388min; p=0.16) and EBL was significantly lower in r-pcRPLND (234 vs 825ml; p<0.001). Median LOS was significantly shorter after r-pcRPLND (2 vs 7d; p<0.001). A total of 31 patients (33%) suffered postoperative complications, of whom 18 (19.4%) had major complications. Nodal yield was similar (o-pcRPLND 23 vs r-pcRPLND 24; p=0.8). The distribution of lesion histology (necrosis/teratoma/GCT) was also similar pcRPLND (o-pcRPLND 25.4%/57.1%/17.4% vs r-pcPLND 33.3%/50%/16.7%; p=0.51). Overall, tumor recurred in 15 patients (16.1%), including three following r-pcRPLND (10%), all outside the operative field. On univariate analysis, surgical approach was not a significant predictor of time to recurrence (p=0.34). One limitation was that antegrade ejaculation was not assessed.

CONCLUSIONS

With rigorous patient selection, r-pcRPLND can be safely performed and may reduce perioperative morbidity while maintaining oncologic proficiency.

PATIENT SUMMARY

Resection of residual retroperitoneal mass after chemotherapy in patients with metastatic testicular cancer can be performed safely via a robotic approach. Robotic surgery can reduce the morbidity of the procedure.

Sentinel node biopsy in clinical stage I testicular cancer enables early detection of occult metastatic disease

Objectives

To report the long‐term results of the sentinel node (SN) approach in patients with clinical stage I testicular tumours in our facility.

Patients and Methods

We conducted an analysis of 27 consecutive patients suspected of clinical stage I testicular germ cell tumour (TGCT) and treated with an SN procedure at our tertiary referral centre. SNs were identified using lymphoscintigraphy with or without single‐photo‐emission computed tomography with CT (SPECT/CT). Patients underwent laparoscopic retroperitoneal SN excision with inguinal orchiectomy. Patients with a tumour‐positive SN underwent adjuvant treatment. Follow‐up was conducted according to then‐current guidelines.

Results

In two patients, no SNs were visualized on scintigraphy. In the remaining 25 patients, a median (range) of 3 (1–4) SNs per patient were removed. Two patients showed no malignancy on histopathological examination of the testis. Of the 23 patients diagnosed with TGCT (16 seminomas, seven non‐seminomas), three (13.0%) had occult metastatic disease. All 23 patients were without evidence of disease at a median (range) follow‐up of 63.9 (29.0–143.4) months.

Conclusion

The SN procedure allows early identification of patients with occult metastatic disease in clinical stage I TGCT, enabling early treatment.

Recommendations for surveillance and follow-up of men with testicular germ cell tumors: a multidisciplinary consensus conference by the Italian Germ cell cancer Group and the Associazione Italiana di Oncologia Medica

BACKGROUND

No compelling evidence is available about surveillance and follow-up of patients with testicular germ cell tumour (TGCT).

METHODS

In the light of the best clinical evidence, the Italian Germ cell cancer Group (IGG) and the Associazione Italiana di Oncologia Medica (AIOM) set up a multidisciplinary national consensus conference, involving 42 leading experts and 3 TGCT survivors. A minimum of 50% of votes was required in order to achieve a consensus recommendation on 29 questions.

RESULTS

Recommendations have been summarized in three tables, divided by stage I seminoma, stage I nonseminoma and the advanced disease, which may be useful for clinicians to appropriately choose the clinical investigation and its timing during the surveillance and follow-up of TGCT patients based on an accurate estimation of their risk of disease relapse.

CONCLUSIONS

The IGG-AIOM consensus recommendations may help clinicians to choose appropriate clinical investigations for the surveillance and follow-up of TGCT patients.

Distinct Metabolic Features of Seminoma and Embryonal Carcinoma Revealed by Combined Transcriptome and Metabolome Analyses

Seminoma and embryonal carcinoma (EC), two typical types of testicular germ cell tumors (TGCTs), present significant differences in growth behavior, expression characteristics, differentiation potential, clinical features, therapy, and prognosis. The purpose of this study was to compare the distinctive or preference metabolic pathways between seminoma and EC. The Cancer Genome Atlas revealed that many genes encoding metabolic enzymes could distinguish between seminoma and EC. Using well-characterized cell line models for seminoma (Tcam-2 cells) and EC (NT2 cells), we characterized their metabolite profiles using ultraperformance liquid chromatography coupled to Q-TOF mass spectrometry (UPLC/Q-TOF MS). In general, the integrated results from transcriptome and metabolite profiling revealed that seminoma and EC exhibited distinctive characteristics in the metabolisms of amino acids, glucose, fatty acids, sphingolipids, nucleotides, and drugs. Notably, an attenuation of citric acid cycle/mitochondrial oxidative phosphorylation and sphingolipid biosynthesis as well as an increase in arachidonic acid metabolism and (very) long-chain fatty acid abundance occurred in seminoma as compared with EC. Our study suggests histologic subtype-dependent metabolic reprogramming in TGCTs and will lead to a better understanding of the metabolic signatures and biology of TGCT subtypes.

m6A RNA modification and its writer/reader VIRMA/YTHDF3 in testicular germ cell tumors: a role in seminoma phenotype maintenance

BACKGROUND

Covalent RNA modifications, such as N-6-methyladenosine (m⁶A), have been associated with various biological processes, but their role in cancer remains largely unexplored. m⁶A dynamics depends on specific enzymes whose deregulation may also impact in tumorigenesis. Herein, we assessed the differential abundance of m⁶A, its writer VIRMA and its reader YTHDF3, in testicular germ cell tumors (TGCTs), looking for clinicopathological correlates.

METHODS

In silico analysis of TCGA data disclosed altered expression of VIRMA (52%) and YTHDF3 (48%), prompting subsequent validation. Formalin-fixed paraffin-embedded tissues from 122 TGCTs (2005-2016) were selected. RNA extraction, cDNA synthesis and real-time qPCR (Taqman assays) for VIRMA and YTHDF3 were performed, as well as immunohistochemistry for VIRMA, YTHDF3 and m⁶A, for staining intensity assessment. Associations between categorical variables were assessed using Chi square and Fisher's exact test. Distribution of continuous variables between groups was compared using the nonparametric Mann-Whitney and Kruskal-Wallis tests. Biomarker performance was assessed through receiver operating characteristics (ROC) curve construction and a cut-off was established by Youden's index method. Statistical significance was set at p < 0.05.

RESULTS

In our cohort, VIRMA and YTHDF3 mRNA expression levels differed among TGCT subtypes, with Seminomas (SEs) depicting higher levels than Non-Seminomatous tumors (NSTs) (p < 0.01 for both). A positive correlation was found between VIRMA and YTHDF3 expression levels. VIRMA discriminated SEs from NSTs with AUC = 0.85 (Sensitivity 77.3%, Specificity 81.1%, PPV 71.6%, NPV 85.3%, Accuracy 79.7%). Immunohistochemistry paralleled transcript findings, as patients with strong m⁶A immunostaining intensity depicted significantly higher VIRMA mRNA expression levels and stronger VIRMA immunoexpression intensity (p < 0.001 and p < 0.01, respectively).

CONCLUSION

Abundance of m⁶A and expression of VIRMA/YTHDF3 were different among TGCT subtypes, with higher levels in SEs, suggesting a contribution to SE phenotype maintenance. VIRMA and YTHDF3 might cooperate in m⁶A establishment in TGCTs, and their transcript levels accurately discriminate between SEs and NSTs, constituting novel candidate biomarkers for patient management.

Current pharmacotherapy for testicular germ cell cancer

INTRODUCTION

With the implementation of platinum-based chemotherapy, germ cell tumors (GCTs) became a model for a curable solid tumor, with survival rates of 95% in all patients with >80% survival in metastatic stages.

AREAS COVERED

Herein, the authors review the current standards of adjuvant chemotherapy for stage I GCTs as well as first-line and salvage treatments for metastatic disease. Novel approaches for refractory disease are also reviewed.

EXPERT OPINION

Active surveillance should be considered for all stage I patients and is the preferred approach for stage I seminoma. In stage I non-seminomas with vascular invasion, one cycle of bleomycin, etoposide, and cisplatin (BEP) substantially reduces the relapse risk. For most advanced GCTs, BEP remains the first-line standard of care. For poor prognosis disease treatment, stratification according to tumor marker decline is recommended. The role of primary high-dose chemotherapy (HDCT) for selected very high-risk patients remains to be prospectively evaluated. Salvage HDCT at relapse seems superior to conventional chemotherapy, retrospectively. The treatment of multiply relapsed disease remains challenging. The gemcitabine/oxaliplatin/paclitaxel (GOP) protocol is considered the standard for refractory disease. However, overall, outcomes are poor and new treatment approaches are urgently needed with targeted therapies so far failing to yield relevant clinical activity.

MRI of testicular malignancies

Although testicular carcinoma represents approximately only 1% of solid neoplasms in men, it is the most common malignancy between young men. The two main histologic categories are testicular germ cell tumors (TGCTs), including seminomas and nonseminomas, accounting for 90-95% of testicular neoplasms and sex cord-stromal tumors. Scrotal MRI, including a multiparametric protocol, has been proposed as a valuable supplemental imaging technique in the investigation of testicular pathology. Recently, the Scrotal and Penile Imaging Working Group appointed by the board of the European Society of Urogenital Radiology has produced recommendations on when to perform scrotal MRI. Regarding intratesticular masses, MRI of the scrotum may be used for their characterization, when US findings are indeterminate and for local staging of TGCTs, when organ-sparing surgery is planned. Differentiation between seminomas and nonseminomas is possible based on MRI features, when clinically needed. Scrotal MRI may also help in differentiating between TGCTs and nongerm cell tumors. Functional information based on diffusion-weighted imaging and dynamic contrast-enhanced MRI data improve testicular mass lesion characterization. Preliminary observations on diffusion tensor imaging, magnetization transfer imaging, and proton MR spectroscopy bring about new data in the understanding of testicular microstructure and pathophysiology.

Management of residual masses in testicular germ cell tumors

INTRODUCTION

About 50% of all patients with advanced testicular cancer demonstrate residual retroperitoneal or extraretroperitoneal masses. About two thirds of the masses harbour necrosis/fibrosis only whereas as about 10% and 40% harbour vital cancer or teratoma. Appropriate therapy will result in a high cure rate if performed properly. Areas covered: This review article covers the indication, the surgical technique and the oncological outcome of PC-RPLND and resection of extraretroperitoneal residual masses following chemotherapy in patients with advanced testis cancer. Expert commentary: Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours. Patients with nonseminomas, residual masses < 1cm and good prognosis can undergo active surveillance. In all other cases, PC-RPLND with or without resection of adjacent organs needs to be performed for curative intent. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.

Protective role of N-acetylcysteine (NAC) on human sperm exposed to etoposide

Background

Although recent progress in cancer treatment has increased patient survival and improved quality of life, reproductive side effects are still for concern. One way to decrease gonadal impairment is to use cytoprotectors. In testicular cancer, etoposide is generally used in combination with other agents, but there are no in-vitro studies of sperm exposure to etoposide and cytoprotectors, namely N-acetylcysteine (NAC).

Methods

Twenty semen samples were individually divided into five groups: control, incubation with NAC alone, incubation with etoposide alone, sequential exposure of NAC followed by etoposide (pre-treatment) and sequential exposure of etoposide followed by NAC (post-treatment). Sperm characteristics, chromatin condensation (aniline blue), DNA fragmentation (TUNEL), oxidative stress (OxyDNA labelling) and glutathione quantification were used to evaluate the capabilities of NAC as a prophylactic (pre-treatment) or ameliorator (post-treatment) agent over the effects caused in sperm during in-vitro exposure to etoposide.

Results

No deleterious effects were observed on sperm motility or sperm membrane integrity. Results revealed that prophylactic use of NAC (pre-treatment) increased rates of immature sperm chromatin as compared to ameliorator use of NAC (post-treatment), and increased rates of sperm DNA fragmentation in relation to controls. Pre and post-treatment with NAC increased oxidative levels in comparison to controls, but also increased levels of cellular antioxidant glutathione.

Conclusions

The results indicate that NAC has the ability to counteract etoposide-induced toxicity rather than preventing the etoposide cytotoxic effects over sperm DNA, suggesting that the administration of NAC to cells formerly exposed to etoposide is preferable to its prophylactic use. As the results evidenced that NAC seems to be more efficient in attenuating sperm etoposide cytotoxic effects instead of being used as a chemoprophylactic agent, this reinforces the idea that there might be a new NAC mechanism over DNA.

Preservation of Ejaculatory Function After Postchemotherapy Retroperitoneal Lymph Node Dissection (PC-RPLND) in Patients With Testicular Cancer: Template vs. Bilateral Resection

Background: Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays a crucial role in treatment of metastatic non-seminomatous germ cell cancer.

Objective: To evaluate the functional outcome regarding the preservation of ejaculatory function comparing a bilateral vs. unilateral template resection in PC-RPLND patients. In addition, oncological safety and perioperative complications of the unilateral template resection was compared to the full bilateral one.

Design/Setting/Participants: Between 2003 and 2018, 504 RPLNDs have been performed in 434 patients. The database of consecutive patients was queried to identify 171 patients with PC-RPLND after 1st line chemotherapy for a non-seminoma with or without bilateral template resection. Re-Do's, late relapse, salvage patients, and thoraco-abdominal approaches were excluded. Indication for a template resection was a unilateral residual mass mainly <5 cm as published (1).

Outcome, Measurement, and Statistical Analysis: Descriptive statistics were used to report preoperative features, postoperative outcomes and patterns of recurrence, on the overall population and after stratification for the type of resection (bilateral vs. unilateral). Kaplan-Meier analyses were used to describe recurrence- and cancer-specific mortality-free survival rates at different time points.

Results and Limitations: Overall, 90 and 81 patients underwent unilateral and bilateral radical resection, respectively. Median size of residual mass was 7 cm for bilateral and 4 cm for unilateral template resection. Clinical stage II and III were present in 31 and 69% of patients, respectively. Median follow-up was 14.5 months (IQR 3.3–37.6). The 1- and 2-year recurrence-free survival rates were 91 and 91%, and 77 and 72% for patients treated with unilateral template and bilateral resection, respectively (p = 0.0078). Median time to recurrence was 9.5 and 9 months in template and bilateral resection group, respectively.

Adjunctive procedures were performed in 56 patients (33%) and were significantly more frequent in the bilateral resection group (43 vs. 23%, p = 0.006). The overall high-grade complication rate (Clavien-Dindo ≥ III) was 6, 3, and 9% in unilateral template and bilateral resection group, respectively (p = 0.6). The rate of preservation of antegrade ejaculation was significantly higher in the unilateral group.

Conclusions: Antegrade ejaculation in patients undergoing unilateral template resection with a residual mass <5 cm can be preserved at a much higher rate. Moreover, this surgical procedure is oncologically safe in terms of mid-term recurrence and CSM-free survival rates. This data undermines the growing evidence of limited PC-RPLND being justifiable in strictly unilateral residual mass <5 cm. This data has to be confirmed with a longer follow-up regarding in-field and retroperitoneal recurrences.