Intraoperative and early postoperative complications in postchemotherapy retroperitoneal lymphadenectomy among patients with germ cell tumors using validated grading classifications

[New tumor markers for testicular cancer - in the here and now and in the future]

Germ cell tumors of the testis are the most common tumor entities in young men. Since the introduction of platinum-based chemotherapy in the 1970s, most patients can be cured despite the aggressiveness of germ cell tumors. Optimal serum tumor markers are required for diagnostics, therapy monitoring and aftercare, and these are subject to high requirements. The conventional testicular tumor markers human chorionic gonadotropin (hCG), alpha fetoprotein (AFP) and lactate dehydrogenase (LDH) only meet these requirements with insufficient sensitivity (30-70%). The markers investigated in recent decades, such as PLAP, CEA and NSE, have not become established. Currently, miRNA-371 is being researched in particular. Reliable findings are available for initial staging with significantly better specificities of miRNA-371 compared to conventional tumor markers. Further prospective studies are being conducted for other possible clinical applications, such as follow-up care, therapy monitoring or residual tumors, in order to investigate the revolutionary potential of miRNA-371 in these areas as well. Research is also currently being conducted on circulating tumor cells (CTCs) and cell-free DNA (cfNA) in various areas of application. With regard to germ cell tumors of the testis, however, these analyses are still in their infancy, but it is hoped that this will provide a further sufficient opportunity to use serum tumor markers.

Short and long-term outcomes of arterial and caval replacement during postchemotherapy retroperitoneal lymph node dissection in metastatic testicular cancer

BACKGROUND AND OBJECTIVE

For patients with metastatic testicular cancer undergoing retroperitoneal lymph node dissection (RPLND), the burden of metastatic disease can require consideration for resection and replacement of major vessels despite chemotherapy. We aimed to clarify the outcomes for patients undergoing these major vascular procedures in a modern era.

METHODS

Between 2000 and 2020, 2,054 patients with metastatic testicular cancer underwent a PC-RPLND; of those men, 41 also underwent an aortic, iliac, and/or inferior vena cava (IVC) resection. For men who required a vascular resection, clinicopathologic and operative details were collected. Kaplan-Meier curves were generated to estimate overall survival.

RESULTS

The median preoperative mass size was 9cm in the retroperitoneum. Viable malignancy or teratoma was present in 85% of resected specimens. Following PC-RPLND and vascular resection, 22 (54%) patients recurred. The median (IQR) time to relapse was 4.6 (2.5-8.0) months. 18 (44%) patients died of disease. The overall complication rate was 56%. Ten (24%) patients had Clavien-Dindo III/IV complications, with 2 postoperative mortalities. The median overall survival was 14.9 months. Among the 41 patients, 18 patients had re-operative PC-RPLND and vascular resection; the re-operative PC-RPLND patients had significantly worse survival compared to initial attempt at PC-RPLND (9.3 vs. 162 months, P = 0.03).

CONCLUSIONS

The overall survival rate for patients undergoing PC-RPLND with resection of the aorta, IVC, and/or iliac artery is 45% at 2 years. For patients with limited treatment options, these complex surgeries may offer survival benefit with an acceptable morbidity profile.

Lymph Node Dissection in Testicular Cancer: The State of the Art and Future Perspectives

PURPOSE OF REVIEW

This narrative review provides a comprehensive overview of the evolving role of retroperitoneal lymph node dissection (RPLND) in the management of testicular cancer (TC). It explores the significance of RPLND as both a diagnostic and therapeutic tool, highlighting its contribution to accurate staging, its impact on oncological outcomes, and its influence on subsequent treatment decisions.

RECENT FINDINGS

RPLND serves as an essential diagnostic procedure, aiding in the precise assessment of lymph node involvement and guiding personalized treatment strategies. It has demonstrated therapeutic value, particularly in patients with specific risk factors and disease stages, contributing to improved oncological outcomes and survival rates. Recent studies have emphasized the importance of meticulous patient selection and nerve-sparing techniques to mitigate complications while optimizing outcomes. Additionally, modern imaging and surgical approaches have expanded the potential applications of RPLND. In the context of TC management, RPLND remains a valuable and evolving tool. Its dual role in staging and therapy underscores its relevance in contemporary urological practice. This review highlights the critical role of RPLND in enhancing patient care and shaping treatment strategies, emphasizing the need for further research to refine patient selection and surgical techniques.

Postchemotherapy robotic retroperitoneal lymph node dissection for non-seminomatous germ cell tumors in the lateral decubitus position: oncological and functional outcomes

PURPOSE

Retroperitoneal lymph node dissection (RPLND) is recommended for residual masses following chemotherapy for non-seminomatous germ cell tumors (NSGCT). Recently, aberrant recurrence patterns were reported in patients who underwent robotic RPLND. We aimed to evaluate perioperative safety in addition to functional and early oncological outcomes of postchemotherapy robotic RPLND (pcR-RPLND) for NSGCT.

METHODS

A total of 25 patients with NSGCT who underwent a pcR-RPLND between January 2011 and June 2022 were evaluated retrospectively. Descriptive statistics were provided for demographics, clinical characteristics, intraoperative and postoperative parameters. Functional and oncological outcomes were recorded.

RESULTS

The median patient age was 28.9 years (IQR 21.5-32.4). The median retroperitoneal tumor size was 2.6 cm (IQR 1.5-3.5). Intraoperative complications occurred in only one case and the open conversion rate was 12%. There were seven cases with postoperative complications (Clavien grade II: 5 and IIIa: 2). Patients were followed for a median of 33.2 months (IQR 14.8-43.0). Antegrade ejaculation was preserved in 85.7% of the patients. Two patients (8%) relapsed and both had out-of-field recurrences at unusual sites (perinephric fat and omentum). Of those, one patient died (4%) of testicular cancer.

CONCLUSION

pcR-RPLND is a feasible and technically reproducible procedure with favorable perioperative morbidity, low rate of complications, and acceptable postoperative ejaculatory function. Although the recurrence rate was low (8%), recurrences were observed at unusual sites. Further studies are required to investigate any association between the robotic approach and aberrant recurrence patterns.

Development of machine learning models integrating PET/CT radiomic and immunohistochemical pathomic features for treatment strategy choice of cervical cancer with negative pelvic lymph node by mediating COX-2 expression

Objectives: We aimed to establish machine learning models based on texture analysis predicting pelvic lymph node metastasis (PLNM) and expression of cyclooxygenase-2 (COX-2) in cervical cancer with PET/CT negative pelvic lymph node (PLN).

Methods: Eight hundred and thirty-seven texture features were extracted from PET/CT images of 148 early-stage cervical cancer patients with negative PLN. The machine learning models were established by logistic regression from selected features and evaluated by the area under the curve (AUC). The correlation of selected PET/CT texture features predicting PLNM or COX-2 expression and the corresponding immunohistochemical (IHC) texture features was analyzed by the Spearman test.

Results: Fourteen texture features were reserved to calculate the Rad-score for PLNM and COX-2. The PLNM model predicting PLNM showed good prediction accuracy in the training and testing dataset (AUC = 0.817, p < 0.001; AUC = 0.786, p < 0.001, respectively). The COX-2 model also behaved well for predicting COX-2 expression levels in the training and testing dataset (AUC = 0.814, p < 0.001; AUC = 0.748, p = 0.001). The wavelet-LHH-GLCM ClusterShade of the PET image selected to predict PLNM was slightly correlated with the corresponding feature of the IHC image (r = −0.165, p < 0.05). There was a weak correlation of wavelet-LLL-GLRLM LongRunEmphasis of the PET image selected to predict COX-2 correlated with the corresponding feature of the IHC image (r = 0.238, p < 0.05). The correlation between PET image selected to predict COX-2 and the corresponding feature of the IHC image based on wavelet-LLL-GLRLM LongRunEmphasis is considered weak positive (r = 0.238, p=<0.05).

Conclusion: This study underlined the significant application of the machine learning models based on PET/CT texture analysis for predicting PLNM and COX-2 expression, which could be a novel tool to assist the clinical management of cervical cancer with negative PLN on PET/CT images.

Indications, feasibility and outcome of robotic retroperitoneal lymph node dissection for metastatic testicular germ cell tumours

Data on robotic retroperitoneal lymph node dissection (R-RPLND) for metastatic testicular germ cell tumours (mTGCTs) are scarce and the use of R-RPLND itself is still under debate. The aim of our study was to evaluate the indications, feasibility and outcomes of R-RPLND, with special emphasis on differences between primary R-RPLND (pR-RPLND) and post-chemotherapeutic R-RPLND (pcR-RPLND) in mTGCTs. We retrospectively analysed the data of patients who underwent R-RPLND for mTGCT between November 2013 and September 2019 in two centres in Germany. Indications, operative technique, intra- and postoperative complications and oncologic outcome were analysed. Twenty-three mTGCT patients underwent R-RPLND (7 pR-RPLND, 16 pcR-RPLND). For pR-RPLND versus pcR-RPLND, median time of surgery was 243 min [interquartile range (IQR) 123-303] versus 359 min (IQR 202-440, p = 0.154) and median blood loss 100 mL (IQR 50-200) versus 275 mL (IQR 100-775, p = 0.018). Intra- and postoperative complications were more frequent in pcR-RPLND (pcR-RPLND: intra/post: 44%/44%; pR-RPLND: intra/post: 0%/29%). However, these were only statistically significant in the case of intraoperative complications (intra: p = 0.036, post: p = 0.579). Intraoperative complications (n = 7), conversions (n = 4) and transfusions (n = 4) occurred in pcR-RPLND patients only. After a median follow-up of 16.3 months (IQR 7.5-35.0) there were no recurrences or deaths. R-RPLND displays a valuable, minimally invasive treatment option in mTGCT. However, R-RPLND is challenging and pcR-RPLND especially bears a considerable risk of complications. This operation should be limited to patients with an easily accessible residual tumour mass and to surgeons experienced in robotic surgery and TGCT treatment.