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Mousa A, Anson-Cartwright L, Atenafu EG, Jewett MAS, Bedard P, Jiang DM, Glicksman R, Chung P, Warde P, O'Malley M, Prendeville S, Hamilton RJ. Primary retroperitoneal lymph node dissection for metastatic non-seminomatous germ cell tumours: outcomes and adjuvant chemotherapy. BJU Int 2024. [PMID: 38967557 DOI: 10.1111/bju.16448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
OBJECTIVES To compare the outcomes and treatment burden of primary retroperitoneal lymph node dissection (pRPLND) alone versus pRPLND + adjuvant chemotherapy (AC) in patients with pathological stage II (PSII) non-seminomatous germ cell tumours (NSGCT). PATIENTS AND METHODS Retrospective review of the Princess Margaret Cancer Center eTestes cancer database identified patients with PSII NSGCT after pRPLND between 1995 and 2020. The primary outcome was relapse-free survival (RFS). Secondary outcomes included disease-specific survival (DSS), burden of relapse treatment, and factors associated with relapse. RESULTS A total of 109 PSII patients were included in the study. There were 96 patients treated with pRPLND alone and 13 treated with pRPLND + AC. The median follow-up was 61 months. The 5-year RFS was 72% for the pRPLND-only group vs 92% for the pRPLND + AC group (hazard ratio [HR] 4.372, 95% confidence interval [CI] 0.59-32.36; P = 0.11). Within the pRPLND-only group the 5-year RFS differed by pN stage (pN1 = 94% vs pN2/N3 = 67%, P = 0.03). Despite a higher relapse rate within the pRPLND-only group, the DSS was similar at 5 years (98% pRPLND only vs 100% pRPLND + AC, P = 0.48). Only 24 (25%) of the patients in the pRPLND-only group required any subsequent chemotherapy. Despite achieving similar survival, the cumulative post-RPLND treatment burden was less for the pRPLND-only group than the pRPLND+AC group overall (average 1.23 vs 2.46 cycles of chemotherapy per patient in group). CONCLUSION The majority of patients with PSII NSGCT treated with pRPLND alone do not experience a recurrence or require chemotherapy. Despite a lower relapse risk when AC is given, no difference in survival was seen but higher chemotherapy burden was entertained. AC may constitute overtreatment for most patients with PSII NSGCT treated with pRPLND.
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Affiliation(s)
- Ahmad Mousa
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lynn Anson-Cartwright
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Biostatistics Core, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michael A S Jewett
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Philippe Bedard
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Di Maria Jiang
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Peter Chung
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Padraig Warde
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Martin O'Malley
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Susan Prendeville
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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Małkiewicz B, Świrkosz G, Lewandowski W, Demska K, Szczepaniak Z, Karwacki J, Krajewski W, Szydełko T. Lymph Node Dissection in Testicular Cancer: The State of the Art and Future Perspectives. Curr Oncol Rep 2024; 26:318-335. [PMID: 38430323 PMCID: PMC11021343 DOI: 10.1007/s11912-024-01511-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 03/03/2024]
Abstract
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.
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Affiliation(s)
- Bartosz Małkiewicz
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wrocław Medical University, Wrocław, Poland.
| | - Gabriela Świrkosz
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wrocław Medical University, Wrocław, Poland
| | - Wojciech Lewandowski
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wrocław Medical University, Wrocław, Poland
| | - Katarzyna Demska
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wrocław Medical University, Wrocław, Poland
| | - Zuzanna Szczepaniak
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wrocław Medical University, Wrocław, Poland.
| | - Jakub Karwacki
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wrocław Medical University, Wrocław, Poland
| | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wrocław Medical University, Wrocław, Poland
| | - Tomasz Szydełko
- University Center of Excellence in Urology, Wrocław Medical University, Wrocław, Poland
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Chavarriaga J, Atenafu EG, Mousa A, Langleben C, Anson-Cartwright L, Jewett M, Hamilton RJ. Propensity-matched Analysis of Open Versus Robotic Primary Retroperitoneal Lymph Node Dissection for Clinical Stage II Testicular Cancer. Eur Urol Oncol 2024:S2588-9311(24)00032-4. [PMID: 38278693 DOI: 10.1016/j.euo.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/07/2023] [Accepted: 01/04/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Open retroperitoneal lymph node dissection (O-RPLND) is the accepted standard surgical approach to treat retroperitoneal nodal disease in testis cancer. Increasingly, robotic RPLND (R-RPLND) is being performed due to the potential for lower blood loss, shorter length of stay, and accelerated recovery. OBJECTIVE We have performed a propensity score matching (PSM) analysis comparing the survival and perioperative outcomes of O- and R-RPLND. DESIGN, SETTING, AND PARTICIPANTS Analyzing the data from all patients who underwent primary RPLND at our center between 1990 and 2022, we used PSM to create a 2:1 (O-RPLND:R-RPLND) matched cohort. INTERVENTION Primary O-RPLND versus R-RPLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was time to relapse. The secondary endpoints included operating time, length of stay, estimated blood loss (EBL), and surgical complications. Relapse-free survival rates were calculated using the Kaplan-Meier method, and log-rank tests were used to compare perioperative outcomes of O-RPLND versus R-RPLND. KEY FINDINGS AND LIMITATIONS A total of 178 patients underwent primary RPLND: 137 O-RPLND and 41 R-RPLND. After PSM, 26 patients in the R-RPLND group were matched with 38 in the O-RPLND group. After matching, no significant baseline differences were noted. After a median follow-up of 23.5 mo (interquartile range 4.4-59.2), one (3.8%) relapse was noted in the R-RPLND group versus three (7.8%) in the O-RPLND group; however, this was not significant (hazard ratio 0.65, 95% confidence interval 0.07-6.31, p = 0.7097). No in-field relapses occurred in either cohort. R-RPLND was associated with a shorter length of stay (1 vs 5 d, p < 0.0001) and lower EBL (200 vs 300 ml, p = 0.032), but longer operative time (8.8 vs 4.3 h, p < 0.0001). CONCLUSIONS R-RPLND offers low morbidity and improved perioperative outcomes, while maintaining oncologic efficacy of the open approach. PATIENT SUMMARY To the best of our knowledge, this is the first study to compare open and robotic retroperitoneal lymph node dissection (R-RPLND) using a propensity score-matched system. We encourage the discussion and inclusion of primary R-RPLND into the standard of care algorithm for patients with de novo clinical stage (CS) II and relapsed CS I with CS II equivalent disease.
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Affiliation(s)
- Julian Chavarriaga
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada.
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Ahmad Mousa
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Carley Langleben
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Lynn Anson-Cartwright
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Michael Jewett
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada.
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Vasudeo V, Khanna A, Pratihar SK, Jaipuria J, Chakraborty A, Rawal SK, Singh A. Robot-assisted retroperitoneal lymph node dissection for post-chemotherapy residual mass in testicular cancer: Long-term experience from a tertiary care centre. J Minim Access Surg 2023; 19:288-295. [PMID: 36629220 PMCID: PMC10246628 DOI: 10.4103/jmas.jmas_141_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/03/2022] [Accepted: 07/09/2022] [Indexed: 12/12/2022] Open
Abstract
Objectives To present our intermediate to long-term oncological and functional outcomes of robot-assisted retroperitoneal lymph node dissection (RA-RPLND) in post-chemotherapy (PC) residual mass in testicular cancers. To the best of our knowledge, this is the largest single-centre experience of RA-RPLND for in such setting. Methods Prospectively maintained database of carcinoma testis patients undergoing RA-RPLND from February 2012 to September 2021 was reviewed. Patient demographics, tumour stage and risk groups and chemotherapy details were recorded. Intraoperative details and post-operative complications were also noted. Pathological outcomes included were lymph node yield and histopathology report. Further, follow-up was done for recurrence and antegrade ejaculation status. Results Total of 37 cases were done for PC residual masses. International germ cell cancer collaborative group good, intermediate and poor risk proportion was 18 (48.6%), 14 (37.8%) and 5 (13.5%), respectively. Bilateral full template dissection, unilateral modified template dissection and residual mass excision was performed in 59.5% (22/37), 35.1% (13/37) and 5.4% (2/37) patients, respectively. The median size of the excised residual mass was 3.45 cm interquartile range (IQR 2-6 cm), with the largest being 9 cm. The median lymph nodal yield was 19. The most common histology was necrosis (n = 24, 65%), followed by teratoma (n = 11, 30%) and viable malignancy (n = 2, 5%). Antegrade ejaculation was reported in 32 patients (86.4%). After a median follow-up of 41 (IQR 14-64) months, only one patient had a recurrence. Conclusions RA-PC-RPLND is thus a safe, feasible and oncologically effective option for selected patients. With increasing experience, larger masses can also be dealt with efficiently.
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Affiliation(s)
- Vivek Vasudeo
- Department of Uro-Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Ashish Khanna
- Department of Uro-Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | | | - Jiten Jaipuria
- Department of Uro-Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Arnab Chakraborty
- Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Sudhir Kumar Rawal
- Department of Uro-Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Amitabh Singh
- Department of Uro-Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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Kordan Y, Köseoğlu E, Esen B, Özkan A, Kiremit MC, Kılıç M, Esen T. Postchemotherapy robotic retroperitoneal lymph node dissection for non-seminomatous germ cell tumors in the lateral decubitus position: oncological and functional outcomes. World J Urol 2023; 41:1101-1107. [PMID: 36806014 DOI: 10.1007/s00345-023-04329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/05/2023] [Indexed: 02/23/2023] Open
Abstract
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.
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Affiliation(s)
- Yakup Kordan
- School of Medicine, Department of Urology, Koç University, Istanbul, 34010, Turkey
| | - Ersin Köseoğlu
- School of Medicine, Department of Urology, Koç University, Istanbul, 34010, Turkey
| | - Barış Esen
- School of Medicine, Department of Urology, Koç University, Istanbul, 34010, Turkey.
| | - Arif Özkan
- School of Medicine, Department of Urology, Koç University, Istanbul, 34010, Turkey
| | - Murat Can Kiremit
- School of Medicine, Department of Urology, Koç University, Istanbul, 34010, Turkey
| | - Mert Kılıç
- Department of Urology, VKF American Hospital, Istanbul, Turkey
| | - Tarık Esen
- School of Medicine, Department of Urology, Koç University, Istanbul, 34010, Turkey
- Department of Urology, VKF American Hospital, Istanbul, Turkey
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6
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Garg H, Mansour AM, Psutka SP, Kim SP, Porter J, Gaspard CS, Dursun F, Pruthi DK, Wang H, Kaushik D. Robot-assisted retroperitoneal lymph node dissection: a systematic review of perioperative outcomes. BJU Int 2023. [PMID: 36754376 DOI: 10.1111/bju.15986] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
OBJECTIVE To assess the safety and feasibility of robot-assisted retroperitoneal lymph node dissection (R-RPLND) and to compare the perioperative outcomes of R-RPLND with open RPLND (O-RPLND), as RPLND forms an integral part of the management of testis cancer and R-RPLND is a minimally invasive treatment option for this disease. MATERIALS AND METHODS The PubMed® , Scopus® , Cochrane Central Register of Controlled Trials, and Web of Science™ databases were searched for studies reporting perioperative outcomes of primary and post-chemotherapy R-RPLND and studies comparing R-RPLND with O-RPLND. RESULTS The search yielded 42 articles describing R-RPLND, including five comparative studies. The systematic review included 4222 patients (single-arm studies, n = 459; comparative studies, n = 3763). Of 459 patients in the single-arm studies, 271 underwent primary R-RPLND and 188 underwent post-chemotherapy R-RPLND. For primary R-RPLND, the operative time ranged from 175 to 540 min and the major complication rate was 4.1%. For post-chemotherapy R-RPLND, the operative time ranged from 134 to 550 min and the major complication rate was 8.5%. The conversion rate to open surgery was 2.2% in primary R-RPLND and 9.0% in post-chemotherapy R-RPLND. In comparison with O-RPLND, R-RPLND was associated with a lower transfusion rate (14.5% vs 0.9%, P < 0.001) and a lower complication rate (18.5% vs 7.8%, P = 0.002). CONCLUSION Robot-assisted RPLND has acceptable perioperative outcomes in both the primary and post-chemotherapy settings but a notable rate of conversion to open surgery in the post-chemotherapy setting. Compared with O-RPLND, R-RPLND is associated with a lower transfusion rate and fewer overall complications. Given the potential impact of selection bias, the optimal patient selection criteria for R-RPLND remain to be elucidated.
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Affiliation(s)
- Harshit Garg
- Department of Urology, University of Texas Health, San Antonio, TX, USA
| | - Ahmed M Mansour
- Department of Urology, University of Texas Health, San Antonio, TX, USA
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Simon P Kim
- Division of Urology, University of Colorado-Denver, Denver, CO, USA
| | - James Porter
- Department of Urology, Swedish Medical Center, Seattle, WA, USA
| | | | - Furkan Dursun
- Department of Urology, University of Texas Health, San Antonio, TX, USA
| | - Deepak K Pruthi
- Department of Urology, University of Texas Health, San Antonio, TX, USA
| | - Hanzhang Wang
- Department of Urology, University of Texas Health, San Antonio, TX, USA
| | - Dharam Kaushik
- Department of Urology, University of Texas Health, San Antonio, TX, USA
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Tachibana I, Kern SQ, Douglawi A, Tong Y, Mahmoud M, Masterson TA, Adra N, Foster RS, Einhorn LH, Cary C. Primary Retroperitoneal Lymph Node Dissection for Patients With Pathologic Stage II Nonseminomatous Germ Cell Tumor-N1, N2, and N3 Disease: Is Adjuvant Chemotherapy Necessary? J Clin Oncol 2022; 40:3762-3769. [PMID: 35675585 DOI: 10.1200/jco.22.00118] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/22/2022] [Accepted: 04/27/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE According to National Comprehensive Cancer Network guidelines, adjuvant chemotherapy (AC) has been advocated after primary retroperitoneal lymph node dissection (RPLND) to reduce the risk of relapse in pathologic nodal (pN) stage pN2 or pN3, whereas surveillance is preferred for pN1. We sought to explore the oncologic efficacy of primary RPLND alone for pathologic stage II in nonseminomatous germ cell tumors (NSGCTs) to reduce overtreatment with chemotherapy. METHODS Patients with pathologic stage II NSGCT after primary RPLND between 2007 and 2017 were identified. Patients were excluded for elevated preoperative serum tumor markers, receipt of AC, or if pure teratoma or primitive neuroectodermal tumor elements were found in the retroperitoneal pathology. RESULTS We identified 117 patients with active NSGCT in the retroperitoneum after primary RPLND. We excluded seven patients who lacked meaningful follow-up and 13 patients who received AC. There were 97 patients treated with RPLND alone: 41 pN1, 46 pN2, and 10 pN3. In total, 77 of 97 patients had not recurred after a median follow-up time of 52 months. The 2-year recurrence-free survival (RFS) was 80.3%, and the 5-year RFS was 79%. No differences in RFS were noted among nodal stage-pN1, pN2, and pN3-on Kaplan-Meier analysis. Lymphovascular invasion in the orchiectomy specimen, a high-risk pathologic feature, was also predictive of recurrence after primary RPLND. All 20 patients who recurred were treated with first-line chemotherapy and remained continuously disease free. CONCLUSION Most men with pathologic stage II disease treated with surgery alone in our series never experienced a recurrence. We did not observe a difference in recurrences between patients with pN1 and pN2. The recommendation for AC for pN2 disease may be overtreatment in most patients.
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Affiliation(s)
- Isamu Tachibana
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Sean Q Kern
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Antoin Douglawi
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Yan Tong
- Department of Statistics, Indiana University, Indianapolis, IN
| | - Mohammad Mahmoud
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Timothy A Masterson
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Nabil Adra
- Department of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - Richard S Foster
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Lawrence H Einhorn
- Department of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - Clint Cary
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
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Aldrink JH, Glick RD, Baertschiger RM, Kulaylat AN, Lautz TB, Christison-Lagay E, Grant CN, Tracy E, Dasgupta R, Brown EG, Mattei P, Rothstein DH, Rodeberg DA, Ehrlich PF. Update on pediatric testicular germ cell tumors. J Pediatr Surg 2022; 57:690-699. [PMID: 33975708 DOI: 10.1016/j.jpedsurg.2021.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/25/2021] [Accepted: 04/01/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Testicular germ cell tumors are uncommon tumors that are encountered by pediatric surgeons and urologists and require a knowledge of appropriate contemporary evaluation and surgical and medical management. METHOD A review of the recommended diagnostic evaluation and current surgical and medical management of children and adolescents with testicular germ cell tumors based upon recently completed clinical trials was performed and summarized in this article. RESULTS In this summary of childhood and adolescent testicular germ cell tumors, we review the initial clinical evaluation, surgical and medical management, risk stratification, results from recent prospective cooperative group studies, and clinical outcomes. A summary of recently completed clinical trials by pediatric oncology cooperative groups is provided, and best surgical practices are discussed. CONCLUSIONS Testicular germ cell tumors in children are rare tumors. International collaborations, data-sharing, and enrollment of patients at all stages and risk classifications into active clinical trials will enhance our knowledge of these rare tumors and most importantly improve outcomes of patients with testicular germ cell tumors. LEVEL OF EVIDENCE This is a review article of previously published and referenced level 1 and 2 studies, but also includes expert opinion level 5, represented by the American Pediatric Surgical Association Cancer Committee.
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Affiliation(s)
- Jennifer H Aldrink
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH 43205, United States.
| | - Richard D Glick
- Division of Pediatric Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, New Hyde Park, NY, United States
| | - Reto M Baertschiger
- Division of General and Thoracic Surgery, The Hospital for Sick Kids, University of Toronto, Toronto, Ontario, Canada
| | - Afif N Kulaylat
- Division of Pediatric Surgery, Department of Surgery, Penn State Children's Hospital, Hershey, PA, United States
| | - Timothy B Lautz
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, United States
| | - Emily Christison-Lagay
- Department of Surgery, Division of Pediatric Surgery, Yale-New Haven Children's Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Christa N Grant
- Division of Pediatric Surgery, Department of Surgery, Penn State Children's Hospital, Hershey, PA, United States
| | - Elisabeth Tracy
- Department of Surgery, Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, United States
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Medical Center, University of Cincinnati, Cincinnati OH, United States
| | - Erin G Brown
- Division of Pediatric Surgery, Department of Surgery, University of California Davis, Sacramento, CA, United States
| | - Peter Mattei
- General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - David H Rothstein
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, United States
| | - David A Rodeberg
- Department of Surgery, Division of Pediatric Surgery, East Carolina University, Greenville, NC, United States
| | - Peter F Ehrlich
- Department of Surgery, Mott Children's Hospital, University of Michigan, Ann Arbor, MI, United States
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9
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Grenabo Bergdahl A, Månsson M, Holmberg G, Fovaeus M. Robotic retroperitoneal lymph node dissection for testicular cancer at a national referral centre. BJUI COMPASS 2022; 3:363-370. [PMID: 35950045 PMCID: PMC9349583 DOI: 10.1002/bco2.149] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/04/2022] [Accepted: 03/14/2022] [Indexed: 11/14/2022] Open
Abstract
Objectives We aim to determine if robot‐assisted retroperitoneal lymph node dissection (R‐RPLND) can be performed as a safe option to open RPLND in selected patients with metastatic germ cell cancer. Patients and methods This population‐based prospective study was performed at a one of two national referral centres for RPLND in Sweden. All patients referred during January 2017–March 2021 were screened for possible inclusion. R‐RPLND was performed using the Da Vinci Xi surgical system. Perioperative parameters, postoperative complications (Clavien–Dindo), final pathology, preservation of antegrade ejaculation and relapse rates were evaluated. Classifiers for selecting patients to open versus robotic RPLND were analysed by logistic regression modelling. The median follow‐up was 23 months. Results Of 87 patients referred, 29 were selected for R‐RPLND, 19 in a post‐chemotherapy setting. In median, retroperitoneal tumour diameter was 18 mm, BMI 24 kg/m2, operative time 433 min, estimated blood loss 50 ml and length of stay 3 days. One patient underwent open conversion due to failure to progress. Four patients had Clavien–Dindo grade 3 complications, of which three were chylous‐related. No in‐field recurrences occurred during follow‐up. Conclusion This population‐based study suggests that R‐RPLND can be safely performed in at least one third of patients referred for an RPLND. A relatively high rate of lymph‐leakage may represent a potential drawback. Tumour size may be the most important discriminator when deciding on robotic versus open RPLND. Further studies with longer follow‐up are needed to validate the results.
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Affiliation(s)
- Anna Grenabo Bergdahl
- Department of Urology, Institute of Clinical Science Sahlgrenska Academy at the University of Göteborg Göteborg Sweden
- Department of Urology Region Västra Götaland, Sahlgrenska University Hospital Gothenburg Sweden
| | - Marianne Månsson
- Department of Urology, Institute of Clinical Science Sahlgrenska Academy at the University of Göteborg Göteborg Sweden
| | - Göran Holmberg
- Department of Urology, Institute of Clinical Science Sahlgrenska Academy at the University of Göteborg Göteborg Sweden
- Department of Urology Region Västra Götaland, Sahlgrenska University Hospital Gothenburg Sweden
| | - Magnus Fovaeus
- Department of Urology, Institute of Clinical Science Sahlgrenska Academy at the University of Göteborg Göteborg Sweden
- Department of Urology Region Västra Götaland, Sahlgrenska University Hospital Gothenburg Sweden
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10
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Nason GJ, Hamilton RJ. Robotic RPLND for stage IIA/B nonseminoma: the Princess Margaret Experience. World J Urol 2022; 40:335-342. [PMID: 34988650 DOI: 10.1007/s00345-021-03899-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/17/2021] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Retroperitoneal lymph node dissection (RPLND) is a treatment option for men in a primary and post-chemotherapy setting. The aim of this review was to explore the published data looking at feasibility, safety and outcomes of robotic RPLND for CSI/II NSGCT but we will in particular highlight how we have approached adoption of robotic RPLND at the Princess Margaret. METHODS A review and summary of the published data to date was performed regarding the role of robotic RPLND for stage IIA/B nonseminoma. RESULTS Published series of robotic RPLND to date have proven feasibility and safety in experienced centres. Less blood loss, shorter length of stay and decreased morbidity are promising findings. Our data from Princess Margaret strengthen the argument of oncologic efficacy as we operated only on patients with known retroperitoneal disease (Stage at RPLND was IIA (n = 15, 55.6%), IIB (n = 9, 33.3%), IIC (n = 1, 3.7%) and III (n = 2, 7.4%)), did not use adjuvant chemotherapy and found a relapse rate (11%) similar to open RPLND. CONCLUSIONS The debate is ongoing regarding the role of robotic RPLND- the excellent oncological outcomes achieved by an open RPLND are the minimum starting point for robotic RPLND. Until such time that robotic RPLND is proven to be gold standard it should be performed in experienced centres by high volume RPLND surgeons and in the setting of a protocol.
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Affiliation(s)
- G J Nason
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University of Toronto, 610 University Avenue - Suite - 3-130, Toronto, ON, M5G 2M9, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University of Toronto, 610 University Avenue - Suite - 3-130, Toronto, ON, M5G 2M9, Canada.
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11
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Indications, feasibility and outcome of robotic retroperitoneal lymph node dissection for metastatic testicular germ cell tumours. Sci Rep 2021; 11:10700. [PMID: 34021196 PMCID: PMC8140155 DOI: 10.1038/s41598-021-89823-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/30/2021] [Indexed: 12/26/2022] Open
Abstract
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.
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12
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Robotic retroperitoneal lymph node dissection for primary and post-chemotherapy testis cancer. J Robot Surg 2021; 16:369-375. [PMID: 33982173 DOI: 10.1007/s11701-021-01252-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/08/2021] [Indexed: 10/21/2022]
Abstract
The role of retroperitoneal lymph node dissection (RPLND) in testicular cancer is well established in both the primary and post-chemotherapy setting. The aim of this study was to report our 2 years oncological outcomes of robotic RPLND. A retrospective review was performed of all patients undergoing robotic RPLND by a single surgeon at Princess Margaret Cancer Centre. Demographic, perioperative, and oncologic data were analyzed using descriptive statistics. Between September 2014 and June 2020, 141 patients underwent an RPLND [33 (23.4%) were primary, 108 (76.6%) were post-chemotherapy]. 27 (19.1%) patients underwent a robotic bilateral template nerve-sparing RPLND. RPLND indication was primary (i.e. pre-chemotherapy) in 18 (66.7%), and post-chemotherapy in 9 (33.3%) patients. Stage at RPLND was 2A (n = 15, 55.6%), 2B (n = 9, 33.3%), 2C (n = 1, 3.7%) and 3 (n = 2, 7.4%). Median OR time (incision to closure) was 525 min and blood loss was 200 ml. Nerve sparing was performed in all but one case. Six (22.2%) adjuvant procedures were performed including two (7.4%) vascular repairs. Median length of stay was 2 days. Viable tumor was detected in 17 (63%) and teratoma in 9 (33.3%). Median follow-up was 31.3 months. No adjuvant chemotherapy was given. Three patients (11.1%) relapsed: 2 out-of-field and 1 with both in-field and out-of-field disease. Robotic RPLND can be performed safely. Long-term follow-up of series such as ours, enriched with patients with viable disease and/or teratoma, and not treated with adjuvant chemotherapy is required to ensure oncological outcomes are comparable to the open approach.
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13
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Schermerhorn SMV, Christman MS, Rocco NR, Abdul-Muhsin H, L'Esperance JO, Castle EP, Stroup SP. Learning Curve for Robotic-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection. J Endourol 2021; 35:1483-1489. [PMID: 33559522 DOI: 10.1089/end.2020.0549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Robotic retroperitoneal lymph node dissection (R-RPLND) is a challenging procedure. We hypothesized that surgical times and operative complications would decrease as surgeons became more facile with R-RPLND. Materials and Methods: We retrospectively reviewed 121 consecutive R-RPLNDs performed at Naval Medical Center San Diego and Mayo Clinic Arizona by 4 fellowship trained robotic surgeons between 2008 and 2018. Linear regression was used to analyze independent predictors of setup time, operative time, and lymph node counts. Logistic regression was used to analyze open conversions, overall complications, and high-grade complications. Variables included as independent predictors were: sequential case number, surgeon, clinical stage, chemotherapy status, RPLND template, and body mass index. Univariate and multivariate analyses were conducted. Statistical significance was established at α = 0.05. Results: There was no change in setup time with case number (p = 0.317), but differences were noted between surgeons. Operative times decreased with increasing case number (p < 0.001) but were negatively affected by clinical stage III testis cancer (p = 0.029) and history of chemotherapy exposure (p = 0.050). Surgical times are predicted to decrease by 1 hour after 44 cases. Lymph node counts were dependent only on the surgeon. No factors were predictive of open conversions. Fewer overall complications occurred as experience was gained (p = 0.001), but high-grade complications could not be predicted. Conclusions: Consistent with the learning curves shown for other technologically advanced surgical techniques, experience appears to improve surgical times and lower complication rates for R-RPLND.
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Affiliation(s)
| | - Matthew S Christman
- Urology Department, Naval Medical Center San Diego, San Diego, California, USA
| | - Nicholas R Rocco
- Urology Department, Naval Medical Center San Diego, San Diego, California, USA
| | | | - James O L'Esperance
- Urology Department, Naval Medical Center San Diego, San Diego, California, USA
| | - Erik P Castle
- Department of Urology, Mayo Clinic, Phoenix, Arizona, USA
| | - Sean P Stroup
- Urology Department, Naval Medical Center San Diego, San Diego, California, USA
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14
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Roboterassistierte Lymphonodektomie bei nicht seminomatösen Keimzelltumoren. Aktuelle Urol 2021; 52:18-22. [PMID: 33525021 DOI: 10.1055/a-1166-3262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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15
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Affiliation(s)
- Riccardo Autorino
- Division of Urology, Department of Surgery, VCU Health, 980118, Richmond, VA, 23298-0118, USA.
| | - Francesco Porpiglia
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano, Italy
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16
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Blok JM, van der Poel HG, Kerst JM, Bex A, Brouwer OR, Bosch JLHR, Horenblas S, Meijer RP. Clinical outcome of robot-assisted residual mass resection in metastatic nonseminomatous germ cell tumor. World J Urol 2020; 39:1969-1976. [PMID: 32955662 PMCID: PMC8217018 DOI: 10.1007/s00345-020-03437-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/31/2020] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To evaluate the outcome of robot-assisted residual mass resection (RA-RMR) in nonseminomatous germ cell tumor (NSGCT) patients with residual tumor following chemotherapy. PATIENTS AND METHODS Retrospective medical chart analysis of all patients with NSGCT undergoing RA-RMR at two tertiary referral centers between January 2007 and April 2019. Patients were considered for RA-RMR in case of a residual tumor between 10 and 50 mm at cross-sectional computed tomography (CT) imaging located ventrally or laterally from the aorta or vena cava, with normalized tumor markers following completion of chemotherapy, and no history of retroperitoneal surgery. RESULTS A total of 45 patients were included in the analysis. The Royal Marsden stage before chemotherapy was IIA in 13 (28.9%), IIB in 16 (35.6%), IIC in 3 (6.7%) and IV in 13 patients (28.9%). The median residual tumor size was 1.9 cm (interquartile range [IQR] 1.4-2.8; range 1.0-5.0). Five procedures (11.1%) were converted to an open procedure due to a vascular injury (n = 2), technical difficulty (n = 2) or tumor debris leakage (n = 1). A postoperative adverse event occurred in two patients (4.4%). Histopathology showed teratoma, necrosis and viable cancer in 29 (64.4%), 14 (31.1%), and two patients (4.4%), respectively. After a median follow-up of 41 months (IQR 22-70), one patient (2.2%) relapsed in the retroperitoneum. The one- and 2-year recurrence-free survival rate was 98%. CONCLUSION RA-RMR is an appropriate treatment option in selected patients, potentially providing excellent cure rates with minimal morbidity. Long-term outcome data are needed to further support this strategy and determine inclusion and exclusion criteria.
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Affiliation(s)
- Joost M Blok
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands. .,Department of Urology, The Netherlands Cancer Institute, Utrecht, The Netherlands.
| | - Henk G van der Poel
- Department of Urology, The Netherlands Cancer Institute, Utrecht, The Netherlands
| | - J Martijn Kerst
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Axel Bex
- Department of Urology, The Netherlands Cancer Institute, Utrecht, The Netherlands
| | - Oscar R Brouwer
- Department of Urology, The Netherlands Cancer Institute, Utrecht, The Netherlands
| | - J L H Ruud Bosch
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Simon Horenblas
- Department of Urology, The Netherlands Cancer Institute, Utrecht, The Netherlands
| | - Richard P Meijer
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands.
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17
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Taylor J, Becher E, Wysock JS, Lenis AT, Litwin MS, Jipp J, Langenstroer P, Johnson S, Bjurlin MA, Tan HJ, Lane BR, Huang WC. Primary Robot-assisted Retroperitoneal Lymph Node Dissection for Men with Nonseminomatous Germ Cell Tumor: Experience from a Multi-institutional Cohort. Eur Urol Focus 2020; 7:1403-1408. [PMID: 32682794 DOI: 10.1016/j.euf.2020.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/26/2020] [Accepted: 06/22/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Primary robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for men with nonseminomatous germ cell tumor (NSGCT) is an alternative to open RPLND for stage I and select stage II patients. OBJECTIVE To report the complication rates and oncologic outcomes from a multi-institutional series, and to estimate reduction in chemotherapy by using upfront minimally invasive surgery. DESIGN, SETTING, AND PARTICIPANTS A retrospective chart review of men undergoing primary robot-assisted RPLND between 2014 and 2019 in five institutions by eight urologists experienced in testis cancer and robotic surgery. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Variables such as demographic and clinicopathologic information, operative parameters and complication rates, oncologic outcomes, sexual recovery, and hospital length of stay were collected. Descriptive statistics are presented. RESULTS AND LIMITATIONS Forty-nine patients were analyzed with a median follow-up of 15.0 mo (interquartile range 6.5-29.1 mo). Median operative time was 288 min, estimated blood loss was 100 ml, and lymph node yield was 32. Median length of stay was 1 d. There were nine postoperative complications, 44% (4/9) of which were Clavien grade 1. There were no Clavien grade IV complications. Twenty-one patients had metastatic NSGCT (42.8%), of whom nine (18.4%) received adjuvant chemotherapy. Four patients experienced recurrence (three out-of-field and one in-field recurrence). Limitations include the retrospective study design and various surgical techniques among surgeons. CONCLUSIONS Primary robot-assisted RPLND for NSGCT can be performed safely, with low complication rates and acceptable oncologic outcomes reducing the need for chemotherapy. For a population in which compliance with surveillance is typically challenging, robot-assisted RPLND may improve quality of care and outcomes for patients with NSGCT. PATIENT SUMMARY In experienced centers, robot-assisted retroperitoneal lymph node dissection can be performed safely with similar oncologic outcomes to an open approach, while providing an option that may reduce the need for chemotherapy.
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Affiliation(s)
| | | | | | - Andrew T Lenis
- University of California Los Angeles, Los Angeles, CA, USA
| | - Mark S Litwin
- University of California Los Angeles, Los Angeles, CA, USA
| | - Jacob Jipp
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Marc A Bjurlin
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hung-Jui Tan
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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18
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Supron AD, Cheaib JG, Biles MJ, Schwen Z, Allaf M, Pierorazio PM. Primary robotic retroperitoneal lymph node dissection following orchiectomy for testicular germ cell tumors: a single-surgeon experience. J Robot Surg 2020; 15:309-313. [PMID: 32572754 DOI: 10.1007/s11701-020-01107-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/18/2020] [Indexed: 12/01/2022]
Abstract
The objectives were to evaluate the safety and oncologic efficacy of primary robotic retroperitoneal lymph node (R-RPLND) dissection for testicular germ cell tumors. A retrospective analysis was performed on all primary R-RPLND cases performed by a single surgeon, who performs both open and R-RPLND at a high-volume academic institution, between August 2013 and August 2019. Data on patient demographics, operative techniques, perioperative outcomes, and tumor characteristics were obtained. 28 men were identified who underwent primary R-RPLND. The majority of patients (N = 21, 75%) had clinical stage I disease, and a bilateral template was more commonly performed than either single side alone (N = 13, 46%). Of note, two cases involving clinical stage II disease were converted electively from robotic to open procedures at the discretion of the surgeon. R-RPLND patients experienced no intraoperative complications. The median follow-up time was 8 months (interquartile range 4-29 months). One (4%) patient developed a disease recurrence at 10 months after R-RPLND. Conclusion: primary R-RPLND is a safe and efficacious procedure for carefully selected men with stage I and II non-seminomatous germ cell tumors of the testis. Long-term data are needed to evaluate the comparative oncologic efficacy with open surgery and the notably high rate of chylous ascites.
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Affiliation(s)
- Andrew D Supron
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Joseph G Cheaib
- The James Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael J Biles
- The James Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zeyad Schwen
- The James Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohamad Allaf
- The James Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Phillip M Pierorazio
- The James Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Nason GJ, Chung P, Warde P, Huddart R, Albers P, Kollmannsberger C, Booth CM, Hansen AR, Bedard PL, Einhorn L, Nichols C, Rendon RA, Wood LA, Jewett MAS, Hamilton RJ. Controversies in the management of clinical stage 1 testis cancer. Can Urol Assoc J 2020; 14:E537-E542. [PMID: 32569575 DOI: 10.5489/cuaj.6722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
In November 2018, The Canadian Testis Cancer Workshop was convened. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician’s assistants, residents and fellows, nurses, patients and patient advocacy groups. One of the goals of the workshop was to discuss the challenging areas of testis cancer care where guidelines may not be specific. The objective was to distill through discussion around cases, expert approach to working through these challenges. Herein we present a summary of discussion from the workshop around controversies in the management of clinical stage 1 (CS1) disease. CS1 represents organ confined non-metastatic testis cancer that represents approximately 70-80% of men at presentation. Regardless of management, CS1 has an excellent prognosis. However, without adjuvant treatment, approximately 30% of CS1 nonseminomatous germ cell tumors (NSGCT) and 15% of CS1 seminoma relapse. The workshop reviewed that while surveillance has become the standard for the majority of patients with CS1 disease there remains debate in the management of patients at high-risk of relapse. The controversy in the management of CS1 testis cancer surrounds the optimal balance between the morbidity of overtreatment and the identification of patients who may derive most benefit from adjuvant treatment. The challenge lies in a shared decision process where discussion of options extends beyond the simple risk of relapse but to include the long-term toxicities of adjuvant treatments and the favorable cancer-specific survival.
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Affiliation(s)
- Gregory J Nason
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Peter Chung
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
| | - Padraig Warde
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
| | - Robert Huddart
- The Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Peter Albers
- Department of Urology, Heinrich-Heine University, Medical Faculty, Düsseldorf, Germany
| | - Christian Kollmannsberger
- British Columbia Cancer Agency Vancouver Cancer Centre, University of British Columbia, Vancouver, BC, Canada
| | - Christopher M Booth
- Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - Aaron R Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Philippe L Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Lawrence Einhorn
- Department of Oncology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Craig Nichols
- Testicular Cancer Multidisciplinary Clinic, Virginia Mason Medical Center, Seattle, WA, United States
| | - Ricardo A Rendon
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Lori A Wood
- Division of Medical Oncology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Michael A S Jewett
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
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