[When is surgical resection of metastases in testicular germ cell tumors indicated and is there a scientific basis?]

[Positron emission tomography in germ cell tumors in men : Possibilities and limitations]

BACKGROUND

Conventional radiographic imaging may fail to safely distinguish clinical stage I from stage IIA germ cell cancer, to localize isolated tumor marker relapses, and to equivocally identify the viability of postchemotherapy residual masses.

OBJECTIVES

To provide an overview of the diagnostic value and limitations of functional imaging by positron emission tomography with 2‑deoxy-2-[fluorine-18]fluoro-D-glucose with computed tomography (¹⁸F-FDG-PET-CT) in male germ cell cancer.

MATERIALS AND METHODS

A narrative review based on a literature search of PubMed/MEDLINE for original articles published from 1990-2018 and conference proceedings of ASCO (American Society of Clinical Oncology) and EAU (European Association of Urology) annual meetings 2014-2017 is presented.

RESULTS

¹⁸F-FDG-PET-CT does not improve diagnostic accuracy compared to conventional CT imaging clinical stage (CS) I disease. Particularly PET-negativity of postchemotherapy residual masses of seminomas >3 cm in size guide decision-making against further additional treatment. Even PET-positive residues must not result in relapse. For nonseminoma, the value of PET imaging is reduced by potential mature teratoma components, which are commonly PET negative.

CONCLUSIONS

Current guidelines recommend ¹⁸F-FDG-PET-CT 6-8 weeks postchemotherapy for viability assessment of seminoma residues >3 cm in size. Exceptional circumstances, in which ¹⁸F-FDG-PET-CT may be helpful, include: (1) detection of active disease in CS IS, (2) viability assessment of residual masses >1 cm where complete secondary resection is impossible, (3) staging at marker relapse with unconspicuous conventional CT scan, (4) early response assessment during chemotherapy.

Is there still a place for retroperitoneal lymph node dissection in clinical stage 1 nonseminomatous testicular germ-cell tumours? A retrospective clinical study

Background

Primary retroperitoneal lymph node dissection (RPLND) ultimately lost its role as the standard management of clinical stage (CS) 1 nonseminomatous (NS) testicular germ cell tumours (GCTs) in Europe when the European Germ Cell Cancer Consensus Group released their recommendations in 2008. Current guide-lines recommend surgery only for selected patients but reasons for selection remain rather ill-defined. We evaluated the practice patterns of the management of CS1 patients and looked specifically to the role of RPLND among other standard treatment options.

Methods

We retrospectively evaluated the treatment modalities of 75 consecutive patients treated for CS1 NS at one centre during 2008–2017. The patients undergoing RPLND were selected for a closer review. Particular reasons for surgery, clinical features of patients, and therapeutic outcome were analyzed using descriptive statistical methods.

Results

Twelve patients (16%) underwent nerve-sparing RPLND, nine surveillance, 54 had various regimens of adjuvant chemotherapy. Particular reasons for surgery involved illnesses precluding chemotherapy (n = 2), patients´ choice (n = 4), and teratomatous histology of the primary associated with equivocal radiologic findings (n = 6). Five patients had lymph node metastases, two received additional chemotherapy. Antegrade ejaculation was preserved in all cases. One patient had a grade 2 complication that was managed conservatively. All RPLND-patients remained disease-free.

Conclusions

Primary RPLND is a useful option in distinct CS1 patients, notably those with concurrent health problems precluding chemotherapy, and those with high proportions of teratoma in the primary associated with equivocal radiological findings. Informed patient’s preference represents another acceptable reason for the procedure. RPLND properly suits the needs of well-selected patients with CS1 nonseminoma and deserves consideration upon clinical decision-making.

[Limits of surgery in uro-oncology]

The limits of cancer surgery in uro-oncology are characterized by a carefully weighed risk of surgical feasibility and oncological necessity. The limits of uro-oncological cancer surgery do not represent fixed dogmas but ideally these more or less cognitive boundaries move based on new scientific findings, improved imaging modalities, optimized surgical techniques and perioperative care. The limits of cancer surgery are defined by patient-specific parameters, the biological aggressiveness of the tumor itself, the skills and expertise of the surgeon, and adequate perioperative care of the patient. Dependent on the origin of the cancers of the upper and lower urogenital tract, the specific particularities of each individual cancer in terms of prognosis need to be known, taking into consideration the newest molecular insights and modern multimodality treatment regimes. Only the consideration of the above mentioned basics will allow the best decision to be made with the patient concerning the optimal individual treatment. The current article highlights general parameters of the patient, tumor and surgeon which might define the limits of cancer surgery in uro-oncology. In addition, specific clinical scenarios are discussed with regard to surgery limits in cancer of the kidney, the prostate and the testis.