Management of Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer

Outcomes of active surveillance of clinical stage I non-seminomatous germ cell tumors: sub-analysis of the multi-institutional nationwide case series of the Japanese Urological Association

Objective

To evaluate the survival rate and risk factors of distant metastasis in stage I non-seminomatous germ cell tumor (NSGCT) cases without adjuvant treatments.

Methods

A national testicular cancer survey of cases newly diagnosed in 2005 and 2008 was conducted by the Japanese Urological Association in 2011. In 159 stage I NSGCT cases, 132 were followed by active surveillance after high orchiectomy. Their recurrence-free survival rate (RFS) was compared with 27 cases that received adjuvant treatments, and clinical and pathological parameters were explored to identify significant risk factors of recurrence.

Results

Within a median follow-up period of 30.3 months (range: 0.3-65.6 months), 16 (12.1%) of the 132 surveillance cases relapsed at 2.8-51.2 months after high orchiectomy (median: 8.35 months). The 2-year RFS rate was 90%. Eleven (68.8%) cases relapsed within 1 year, and five (31.3%) cases relapsed in 3 years or more. Half (50%) of the recurrences were detected by imaging studies alone, 37.5% by imaging combined with tumor markers, and 12.5% by tumor marker elevation alone. The only significant risk factor of recurrence was the existence of embryonal carcinoma elements in the primary testicular tumor (P = 0.0068). There was no significant difference in RFS between cases with active surveillance and adjuvant treatments.

Conclusions

The present report is the first large scale study of clinical stage I NSGCTs in Japan. Active surveillance appears to be an effective treatment option for patients with clinical stage I NSGCTs.

Testicular cancer: The usage of central review for pathology diagnosis of orchiectomy specimens

BACKGROUND

Radical orchiectomy specimens present a unique set of challenges for pathology assessment owing to their rarity and complexity. This study compares second opinion pathology reports generated at a single, large academic institution to primary reports from outside hospitals.

METHODS

A database search was conducted for orchiectomy cases that were sent to our institution for management of testicular cancer from 2014 to 2015. Cases sent for consultation without a finalized diagnosis from the outside hospitals were excluded. A total of 221 consecutive cases were evaluated for comparison of final diagnoses between the outside institution and central pathology review.

RESULTS

This study revealed significant discrepancy involving multiple parameters between original and second opinion pathology reports. Of 221 cases of germ cell tumors assessed, 31% showed some discrepancy of histologic subtype. Overall, reporting of lymphovascular invasion changed in 22% of cases; of those, initially called positive 23% were changed to negative and of those initially called negative 12% were changed to positive. Although the overall discrepancy for spermatic cord invasion was 9%, an initial positive diagnosis was negated 35% of the time. The pathologic stage was altered in 23% of cases, mostly secondary to differences interpreting lymphovascular and spermatic cord invasion.

CONCLUSION

Pathologists evaluating orchiectomy specimens should be aware of the major pitfalls in classification and staging, many of which may affect patient management.

Retroperitoneal lymph node dissection: an update in testicular malignancies

Management of testicular cancer has evolved through many breakthroughs. The decades of zeal to improve oncologic adequacy and to decrease morbidity has led to the current scientific knowledge of retroperitoneal lymph node dissection templates. Retroperitoneal lymph node dissection (RPLND) has potential for staging, prognostication and therapeutic importance in the management of testicular malignancy. RPLND has overcome limitations of current imaging which understage 30% of stage I disease and overstage 25-30% of stage II disease. For low-volume disease, RPLND is curative in up to 90% cases without adjuvant therapy and has important role in postchemotherapy residual disease. Risk of recurrence after RPLND is 1% and follow-up imaging can be limited, thus avoiding their potential risk of radiation exposure. RPLND reveals vital information of disease nature and guide adjuvant therapy. Despite the long evolution period, certain controversies still surround RPLND. We aim to refine this challenging management in the following manuscript based on available evidence.

Oncological Outcomes in Japanese Men Undergoing Orchiectomy for Stage I Testicular Germ Cell Tumor

BACKGROUND

The objective of this study was to retrospectively review oncological outcomes in patients with stage I testicular germ cell tumor (GCT).

PATIENTS AND METHODS

This study included 265 consecutive Japanese men undergoing orchiectomy for stage I testicular GCT, and a retrospective review of their records was performed.

RESULTS

Of these 265 patients, 192 and 73 were pathologically classified with seminoma and nonseminoma, respectively. Prophylactic radiation and chemotherapy were performed in 62 patients with seminoma and 6 with nonseminoma, respectively. Disease recurrence occurred in 12 seminoma patients, of whom 11 had not received prophylactic radiation therapy; however, all 12 achieved a complete response to bleomycin, etoposide and cisplatin therapy. Of the nonseminoma patients, 19 experienced disease recurrence and were then treated with bleomycin, etoposide and cisplatin followed additionally by the surgical resection of residual tumors and salvage chemotherapy in 7 and 4, respectively. There was no cancer-specific death in the 265 patients, and 5-year recurrence-free survival rates in patients with seminoma and nonseminoma were 92.6 and 72.8%, respectively. Furthermore, following factors appeared to be significantly associated with recurrence-free survival in these patients: age, T classification, microvascular invasion and adjuvant therapy for those with seminoma, and microvascular invasion for those with nonseminoma.

CONCLUSIONS

Despite a generally favorable prognosis in Japanese men with stage I testicular GCT, intensive follow-up or prophylactic therapy should be considered for men with possible risk factors of disease recurrence.

Management of Stage I Nonseminomatous Germ Cell Tumors

Testis cancer represents the model for a curable malignancy. Although there is consensus about the appropriate management of metastatic (clinical stage [CS] IIC-III) nonseminomatous germ cell tumor (NSGCT) in terms of the chemotherapy regimens, number of cycles, and the surgical resection of postchemotherapy residual masses, there remains controversy regarding the appropriate management of low-stage NSGCT (CSI-IIB). In this article, the benefits and drawbacks of each treatment option are reviewed; an evidence-based approach when confronted with such a patient and how to best select a treatment avenue based on the patient's clinical and pathologic features are also discussed.

Concurrent Testicular and Bladder Cancer in a 57-year-old Man

We present a rare finding of concurrent right testis non-seminomatous mixed germ cell tumor and muscle invasive urothelial carcinoma of the bladder in a 57-year-old homeless man. The socioeconomic factors and the disease presentation caused a treatment dilemma in terms of the appropriate type of neoadjuvant chemotherapy. The patient ultimately underwent upfront surgery with retroperitoneal lymph node dissection and radical cystoprostatectomy followed by adjuvant cisplatin-based chemotherapy.

Risk factors for relapse in patients with clinical stage I testicular nonseminomatous germ cell tumors

Prediction of oncological outcomes facilitates individualized risk-adapted management for clinical stage I testicular nonseminomatous germ cell tumors (CS I NSGCTs). We investigated risk factors for relapse following orchidectomy, with particular focus on patients with active surveillance. Patients with CS I NSGCTs treated by retroperitoneal lymph node dissection (RPLND), chemotherapy, or surveillance between January 1997 and December 2009 were identified. Demographic and post-operative records were collected. Disease-specific survival and progression-free survival (PFS) rates were estimated using Kaplan-Meier analysis. Cox regression analysis was used to confirm variables that influenced disease relapse. A median follow-up period of 82 months was achieved in 89 patients, of whom 9 (8 in surveillance and 1 in chemotherapy group) had relapses. Cumulative 5-year PFS rates were 74.1, 92.3, and 100 % for the surveillance, chemotherapy, and RPLND groups, respectively (p = 0.01). The relapse rate was significantly higher in patients presented with lymphatic/vascular invasion (LVI) than in those without LVI (26.6 vs. 6.8 %, p = 0.02). In the surveillance group, a higher relapse rate was associated with history of cryptorchidism (50 vs. 13.3 %, p = 0.02) and an age older than 13 years (33.3 vs. 5.9 %, p = 0.04). On multivariate analysis, patient age (OR 1.16; p = 0.05), history of cryptorchidism (OR 0.09; p = 0.01), and LVI (OR 12.10; p = 0.01) were significantly associated with relapse during surveillance. The disease-free period is short in the patients with surveillance. LVI, patient age, and history of cryptorchidism may be used as predictors for relapse during surveillance.

Concordance and prediction ability of original and reviewed vascular invasion and other prognostic parameters of clinical stage I nonseminomatous germ cell testicular tumors after retroperitoneal lymph node dissection

PURPOSE

We reviewed the slides of patients with clinical stage I nonseminomatous germ cell testicular tumors who underwent retroperitoneal lymph node dissection to evaluate the concordance between original and reviewed vascular invasion status, and other histological correlates.

MATERIALS AND METHODS

Between 2002 and 2007 at our institution 202 consecutive patients underwent retroperitoneal lymph node dissection. We requested the slides of 183 patients who underwent orchiectomy elsewhere. The risk of nodal metastasis was considered high in those with vascular invasion and/or greater than 90% embryonal carcinoma, and low in those with no vascular invasion and embryonal carcinoma less than 90%. Using Cohen's κ we assessed the concordance index between original and reviewed parameters (vascular invasion and risk category). Using the chi-square test we also evaluated the association between nodal status at retroperitoneal lymph node dissection and original vs reviewed parameters.

RESULTS

The original report did not contain vascular invasion information on 98 of 183 cases (53.4%). A total of 164 patients were evaluable since we had no slides for 19. Vascular invasion absence and presence were confirmed in 27 (73.0%) and 30 (78.9%) of 37 patients, respectively (Cohen's κ = 0.16). Low and high risk status was confirmed in 20 of 28 patients (71.4%) and in 47 of 64 (50.6%), respectively (Cohen's κ = 0.22). Reviewed vascular invasion and risk category were significantly associated with nodal status at retroperitoneal lymph node dissection (chi-square test p = 0.03 and 0.01, respectively), although the original parameters were not.

CONCLUSIONS

In half of the patients no information was available on vascular invasion in the original reports. Concordance between original and reviewed reports was generally poor. Reviewed parameters better predicted nodal status at retroperitoneal lymph node dissection. These findings may have important implications in clinical practice.

Laparoscopic retroperitoneal lymph node dissection with therapeutic intent in men with clinical stage I nonseminomatous germ cell tumors

BACKGROUND AND PURPOSE

Laparoscopic retroperitoneal lymph node dissection (RPLND) as a primary means of therapy for patients with clinical stage I nonseminomatous germ-cell tumors (NSGCTs) remains controversial. The object of this study was to assess the outcomes of patients with clinical stage I NSGCTs who underwent laparoscopic RPLND with therapeutic intent.

PATIENTS AND METHODS

We retrospectively reviewed the pathologic and clinical outcomes of 26 consecutive patients who underwent a laparoscopic RPLND with therapeutic intent for clinical stage I NSGCT from July 2006 to March 2009. Patients underwent an extended template laparoscopic RPLND including dissection behind the great vessels. A full bilateral dissection was performed if metastatic disease was discovered intraoperatively.

RESULTS

Of the 26 patients, 9 (35%) were discovered to have pathologic stage II disease. The mean number of nodes removed at the time of laparoscopic RPLND was 28 (range 6-82). Of six patients found to have pN₁ disease, four (67%) did not receive adjuvant chemotherapy and are without evidence of disease at a mean follow-up of 24 months. Two (12%) patients with pathologically confirmed stage I disease had recurrence after laparoscopic RPLND, both outside of the retroperitoneum.

CONCLUSION

Laparoscopic RPLND with therapeutic intent can be performed with acceptable oncologic efficacy with the additional benefit of decreased morbidity and shorter convalescence times. Early data suggest that patients with pathologic N₁ disease can be safely observed after laparoscopic RPLND, although longer follow-up and additional patients are needed to validate these results.

Retroperitoneal lymph node dissection with no adjuvant chemotherapy in clinical stage I nonseminomatous germ cell tumours: long-term outcome and analysis of risk factors of recurrence

BACKGROUND

The best management for patients with clinical stage I (CS1) nonseminomatous germ cell tumours (NSGCT) is still under debate.

OBJECTIVE

We evaluated the long-term oncologic outcome of retroperitoneal lymph node dissection (RPLND) in patients with CS1 NSGCTs and reevaluated the traditional predictors of recurrence in a set of patients not undergoing adjuvant treatment.

DESIGN, SETTING, AND PARTICIPANTS

Between 1985 and 1995, 322 consecutive CS1 NSGCT patients underwent primary RPLND not followed by adjuvant chemotherapy in a single referral centre. Patients were followed until relapse for a median time of 17 yr.

MEASUREMENTS

We estimated the crude cumulative incidence of any recurrence. Categories pN and pT, vascular invasion (VI), percentage of embryonal carcinoma, and presence of teratoma were evaluated as 2-yr recurrence predictors of event in a binary logistic model.

RESULTS AND LIMITATIONS

Fifty patients had a recurrence (46 in ≤ 2 yr and only 4 [1.2%] in > 2 yr). The 10-yr recurrence incidence was 15.2%. Significant predictors of recurrence at multivariable analysis were pN+, pT > 1, and the presence of VI. However, the discriminative ability of the model was modest (Harrell C = 0.74); only 9% and 3% of patients had a predicted recurrence probability > 30% and > 50%, respectively.

CONCLUSIONS

RPLND alone could prevent recurrence in 85% of patients and minimise late relapses to 1.2%. Most patients could avoid the immediate and late toxicity of chemotherapy. Prognostic parameters combined into the multivariable model appeared of limited use in identifying a subset of patients at high risk of recurrence.

High-risk clinical stage I NSGCT: the case for RPLND

INTRODUCTION

High-risk clinical stage I NSGCT patients are at significant risk of harbouring occult metastatic disease. In these patients, treatment options consist of retroperitoneal lymph node dissection (RPLND) or two cycles of primary BEP chemotherapy. Both these options provide a nearly 100% cure rate.

MATERIALS AND METHODS

We review the rationale for both treatments.

CONCLUSIONS

Advantages of RPLND include high cure rate with single modality therapy eliminating the need for chemotherapy with its attendant long-term toxicities in the majority of patients.

Controversies in the management of early-stage germ cell tumors

The optimal management of clinical stage I testicular germ cell tumors remains controversial despite a cure rate of 99%. Alternatives for stage I nonseminomas include close surveillance, retroperitoneal lymph node dissection, and chemotherapy. For pure seminomas, the options are surveillance, chemotherapy, and radiation. Understanding the pros and cons of each approach may help in choosing a management plan.

A case of spermatic cord teratoma in low-stage testicular cancer managed by surveillance

BACKGROUND

A 25-year-old male presented to his local urologist with new-onset right testicular pain and swelling detected on self examination. A scrotal ultrasound scan showed a right testicular mass, suspicious for neoplasm. Serum levels of alpha-fetoprotein and human chorionic gonadotropin were found to be elevated at 920.2 microg/l and 637.4 U/l, respectively. The patient underwent right inguinal orchiectomy and was diagnosed with nonseminomatous germ cell tumor of the right testis, composed of yolk sac tumor, teratoma, and embryonal carcinoma with no evidence of metastatic disease. He opted to remain under surveillance rather than undergo primary chemotherapy or retroperitoneal lymph node dissection for his clinical stage I disease. Serologic relapse at 4 months after orchiectomy was successfully treated with bleomycin, etoposide and cisplatin (BEP) chemotherapy.

INVESTIGATIONS

Surveillance comprised regular clinic visits, measurement of serum levels of alpha-fetoprotein, human chorionic gonadotropin and lactate dehydrogenase, chest X-ray and CT of the abdomen and pelvis. Pathology of the testicular mass was reviewed.

DIAGNOSIS

A 1.7 cm nodule anterior to the right psoas muscle suspicious for metastatic disease that was seen on CT 16 months after orchiectomy was pathologically confirmed as recurrent mature teratoma in the spermatic cord. Additionally, one of eleven interaortocaval lymph nodes showed evidence of teratoma.

MANAGEMENT

Bilateral nerve-sparing retroperitoneal lymph node dissection with complete excision of the right spermatic cord was performed. The patient has since remained disease-free, with normal levels of serum tumor markers and no evidence of metastasis on chest X-ray and abdominal CT.