Postchemotherapy Resection of Residual Mass in Nonseminomatous Germ Cell Tumor

Resection of Residual Masses After Chemotherapy for Metastatic Nonseminomatous Germ Cell Tumors in Adolescents and Adults

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in the Journal of Clinical Oncology, to patients seen in their own clinical practice.Optimal treatment of patients with testicular germ cell tumors requires a coordinated multidisciplinary approach, so that surgery, chemotherapy, and, when appropriate, radiation therapy can be integrated into a coherent and comprehensive treatment plan. Nonseminomatous germ cell tumors (NSGCT) are often a mixture of teratoma and cancer (choriocarcinoma, embryonal carcinoma, seminoma, and/or yolk sac tumor). While the cancers are highly sensitive to and often cured by chemotherapy, teratoma is resistant to chemotherapy and radiation therapy and generally must be resected surgically to be successfully treated. Therefore, the standard of care for metastatic NSGCT is to resect all resectable residual masses after chemotherapy. If such resection reveals only teratoma and/or necrosis/fibrosis, then patients are put on a surveillance schedule to monitor for relapse. If viable cancer is found and there are positive margins or 10% or more of any of the residual masses consists of viable cancer, then two cycles of adjuvant chemotherapy should be considered.

CT Rendering and Radiomic Analysis in Post-Chemotherapy Retroperitoneal Lymph Node Dissection for Testicular Cancer to Anticipate Difficulties for Young Surgeons

Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) in non-seminomatous germ-cell tumor (NSTGCTs) is a complex procedure. We evaluated whether 3D computed tomography (CT) rendering and their radiomic analysis help predict resectability by junior surgeons. The ambispective analysis was performed between 2016-2021. A prospective group (A) of 30 patients undergoing CT was segmented using the 3D Slicer software while a retrospective group (B) of 30 patients was evaluated with conventional CT (without 3D reconstruction). CatFisher's exact test showed a p-value of 0.13 for group A and 1.0 for Group B. The difference between the proportion test showed a p-value of 0.009149 (IC 0.1-0.63). The proportion of the correct classification showed a p-value of 0.645 (IC 0.55-0.87) for A, and 0.275 (IC 0.11-0.43) for Group B. Furthermore, 13 shape features were extracted: elongation, flatness, volume, sphericity, and surface area, among others. Performing a logistic regression with the entire dataset, n = 60, the results were: Accuracy: 0.7 and Precision: 0.65. Using n = 30 randomly chosen, the best result obtained was Accuracy: 0.73 and Precision: 0.83, with a p-value: 0.025 for Fisher's exact test. In conclusion, the results showed a significant difference in the prediction of resectability with conventional CT versus 3D reconstruction by junior surgeons versus experienced surgeons. Radiomic features used to elaborate an artificial intelligence model improve the prediction of resectability. The proposed model could be of great support in a university hospital, allowing it to plan the surgery and to anticipate complications.

Robotic post-chemotherapy retroperitoneal lymph node dissection for testicular cancer: A multicenter collaborative study

OBJECTIVES

To evaluate the perioperative and oncological/functional outcomes of robotic post-chemotherapy retroperitoneal lymph node dissection for testicular cancer.

METHODS AND MATERIALS

In this retrospective study, we included patients who underwent robotic post-chemotherapy retroperitoneal lymph node dissection at 7 academic centers between 2011 and 2021. Patients' characteristics, perioperative findings, as well as oncological and functional outcomes are reviewed. Relationships with the main outcome (90-day complications) were analyzed using multivariable logistic regression.

RESULTS

A total of 90 patients with a median (IQR) age of 30 (25-37) years were included. The main primary histologic type was non-seminomatous germ cell tumor (89%). Seven patients (8%) were electively converted to open. Median estimated blood loss, operative time, and length of hospital stay were 150 ml, 5.6 hours, and 2 days, respectively. Final pathology revealed teratoma in 49 (55%), necrosis/fibrosis in 29 (32%), and viable germ cell tumor in 12 (13%) patients. The 90-day complication rate was 16.7%, most of which were low-grade (Clavien-Dindo < III) and managed conservatively. On multivariable analysis, pure seminoma (odds ratio 17.4) and bilateral dissection template (odds ratio 4.2) were independently associated with 90-day complications. No 90-day hospital readmission was recorded. With a median (IQR) follow-up of 16 (4-32) months, 6 (6.7%) patients had disease recurrence and there was 1 cancer-related death.

CONCLUSION

With appropriate patient selection at centers with expertise in testicular cancer and minimally invasive surgery, robotic post-chemotherapy retroperitoneal lymph node dissection appears safe and effective, although longer follow-up is warranted.

Post-chemotherapy modified template retroperitoneal lymph node dissection in patients with nonseminomatous germ cell tumours

INTRODUCTION/BACKGROUND

Although a full bilateral template RPLND is thought to be the standard of care for the management of postchemotherapy retroperitoneal residual masses for nonseminomatous germ cell tumors (NSGCT), in the past decade modified templates have become increasingly popular. In this study, we aimed to present our oncological and perioperative outcomes of consecutive seventeen NSGCT patients who underwent a modified template unilateral PC-RPLND for retroperitoneal residual disease.

MATERIALS AND METHODS

We retrospectively evaluated the medical records of 17 consecutive NSGCT patients who underwent modified template unilateral PC-RPLND in our university hospital between 2017 and 2020. All patients had normal serum tumour markers with residual disease in the retroperitoneum. Surgical characteristics including the size of the retroperitoneal residual mass, residual tumor pathology, removed lymph nodes, positive percentage of removed lymph nodes, accompanying operations, complications, mean operation time and hospital stay, and long-term results including survival and antegrade ejaculation were evaluated.

RESULTS

Eleven patients underwent left and six right-sided surgery. Median residual lymph node diameter was 41mm. Median hospitalisation time was 3.5 days. Median follow-up time was 10.5 months. Necrosis/fibrosis was seen in 6 patients, and teratoma in 11 patients. No viable tumour was seen. No patients died in the follow-up period. None of the patients relapsed during follow-up. Ten/seventeen patients had antegrade ejaculation.

CONCLUSIONS

Modified template unilateral PC-RPLND leads to very good oncological outcomes with decreased perioperative morbidity as well as better antegrade ejaculation rates. Low volume retroperitoneal disease seems to fit this procedure best.

Tumor Marker Decline in Predicting Treatment Outcome among Poor-Risk Testicular Germ Cell Tumors-A Tertiary Cancer Center Data

Lakshmi Haridas K.Introduction  Testicular germ cell tumors are rare in India. Despite the advances in chemotherapy, poor-risk testicular nonseminomatous germ cell tumors (NSGCT) remain as a clinical challenge. Various prognostic factors have been described in this rare disease. The Indian data in this regard is scarce. Our study is the first attempt to assess the tumor marker decline with respect to treatment outcome in poor-risk NSGCT in Indian patients. Materials and Methods  This retrospective study was done among newly diagnosed poor-risk NSGCT, treated at genitourinary clinic, at our tertiary cancer center during the period 2017 to 2019. The prognostic significance of tumor marker decline in them was correlated with 2-year progression-free survival (PFS) and 2-year overall survival (OS). Statistical Methods  The association between two variables were assessed using chi-squared/Fischer's exact test. The PFS and OS were estimated using Kaplan-Meier method and the significance difference between survival curves was tested using log rank test. The risk for survival was estimated using cox regression analysis. A p -value of <0.05 was considered as significant. Results  Out of 11 eligible patients, four (36%) had favorable tumor marker decline and seven (64%) had unfavorable decline. The 2-year PFS among favorable and unfavorable decline group were 66.7 and 42.9%, respectively ( p -0.358), and the 2-year OS was 66.7 and 71.4%, respectively ( p -0.974). Teratoma was not found to be a significant factor in our study. Tumors with only beta human chorionic gonadotropin (βHCG) elevation were observed to have good outcome. Postchemotherapy unresectable residual disease showed a significant trend toward inferior survival, the 2-year PFS was 38 versus 100% ( p -0.188) and the 2-year OS was 62.5 versus 100% ( p -0.334) in patients with and without unresectable residual disease, respectively. Conclusion  Majority of our poor-risk NSGCT patients had unfavorable tumor marker decline and progressive events. However, the survival difference was not significant, given the small sample size. Tumors with only βHCG elevation were observed to have good outcome. Postchemotherapy unresectable residual disease showed a significant trend toward inferior survival.

Emerging Role of Biomarkers in Testicular Germ Cell Tumors

PURPOSE OF REVIEW

This review will focus on biomarkers in testicular germ cell tumors (TGCT), focusing on microRNAs with high potential clinical application to drive management of TGCT. We explore the mechanism of action of microRNAs, literature to date, and how microRNAs may be incorporated into clinical practice in the near future.

RECENT FINDINGS

MicroRNAs are small non-coding RNAs found in blood which play an important role in post-transcriptional gene regulation and have been explored in TGCT for the past 15 years. More recently, results show they are promising biomarkers for diagnosis with impressive sensitivity and specificity, while also being cost-effective. MicroRNAs will likely play a critical role in areas of unmet need in GCT in the next decade, as they have many of the characteristics of an ideal biomarker. Ongoing prospective clinical trials evaluating microRNA-371 will be eagerly awaited and will help inform decision-making in real-world application.

Editorial by Bendu K. Konneh, John T. Lafin and Aditya Bagrodia on pp. 341-342 of this issue: MicroRNA-371a-3p as a blood-based biomarker in testis cancer

MicroRNAs (miRNAs) are small noncoding RNAs involved in the regulation of mRNA transcription and translation, and possess all desirable features of an ideal tumor marker. Of almost 31 different miRNA clusters identified in germ cell tumors (GCTs), miR-371a-3p has shown exceptionally high sensitivity and specificity for both seminomatous and nonseminomatous GCTs. It is easily obtainable and correlates well with tumor burden. Recent multi-institutional prospective studies have shown promising test characteristics for miR-371a-3p as a diagnostic blood-based biomarker for GCT prior to orchiectomy including 80%-100% sensitivity and 90%-100% specificity. This accuracy may address other unmet needs in the management of patients with GCT. Early studies have suggested the utility of miR-371a-3p in detecting occult nodal metastasis in high-risk clinical stage I and early stage II disease. Ongoing clinical trials including SWOG 1823 and AGCT1531 are specifically designed to confirm the utility of miR-371a-3p in clinical stage I GCT. Despite its strong association with viable GCT after treatment with chemotherapy, miR-371a-3p does not seem to accurately predict the presence of teratoma in residual lesions. Also, standardization of extraction and interpretation methods is a necessary step to assure uniform results across different institutions.

Between a Rock and a Hard Place: An Epigenetic-Centric View of Testicular Germ Cell Tumors

Simple Summary

This minireview focuses on the role of epigenetics in testicular cancer. A working model is developed that postulates that epigenetic features that drive testicular cancer malignancy also enable these tumors to be cured at a high rate with chemotherapy. Chemoresistance may occur by epigenetic uncoupling of malignancy and chemosensitivity, a scenario that may be amenable to epigenetic-based therapies.

Abstract

Compared to many common solid tumors, the main genetic drivers of most testicular germ cell tumors (TGCTs) are unknown. Decades of focus on genomic alterations in TGCTs including awareness of a near universal increase in copies of chromosome 12p have failed to uncover exceptional driver genes, especially in genes that can be targeted therapeutically. Thus far, TGCT patients have missed out on the benefits of targeted therapies available to treat most other malignancies. In the past decade there has been a greater appreciation that epigenetics may play an especially prominent role in TGCT etiology, progression, and hypersensitivity to conventional chemotherapy. While genetics undoubtedly plays a role in TGCT biology, this mini-review will focus on the epigenetic “states” or features of testicular cancer, with an emphasis on DNA methylation, histone modifications, and miRNAs associated with TGCT susceptibility, initiation, progression, and response to chemotherapy. In addition, we comment on the current status of epigenetic-based therapy and epigenetic biomarker development for TGCTs. Finally, we suggest a unifying “rock and a hard place” or “differentiate or die” model where the tumorigenicity and curability of TGCTs are both dependent on common but still ill-defined epigenetic states.

Management of residual disease after chemotherapy in germ cell tumors

PURPOSE OF REVIEW

Although testicular cancer remains a highly curable malignancy, challenges and uncertainty still remain in certain aspects of management. Residual disease after chemotherapy in patients with germ cell tumors (GCT) remains one of these challenges. We aim to highlight the recent literature on the management of residual disease after chemotherapy in GCT and the emerging innovations that may provide further guidance into this area.

RECENT FINDINGS

A subset of patients with GCT will have residual disease after chemotherapy, and management of these patients involves highly skilled multidisciplinary experts including medical oncologists, surgeons, radiologists, and pathologists. Management options depend on histologic subtype, either seminoma or nonseminoma, and involve size criteria, possible further imaging modalities, and tumor markers. Even with these tools at highly specialized expert centers, uncertainty in management remains, and recent literature has explored the use of newer biomarkers to aid in these cases.

SUMMARY

Postchemotherapy residual masses in GCT can prove to be complicated cases to manage. Balancing survival with quality of life outcomes is important and requires a multidisciplinary team experienced in treating GCT.

Surgical treatment of metastatic germ cell cancer

Among young men between the ages of 15 and 40 years, germ cell cancer is the most common solid tumor [1]. The worldwide incidence of germ cell cancer is 70 000 cases. Compared to all solid tumors of men, germ cell cancer accounts for 1% of all male tumors. Nevertheless, the mortality of this rare tumor entity is about 13% since 9507 patients died worldwide of germ cell cancer. The improvement in survival of germ cell cancer patients is due to a multimodal treatment of germ cell cancer including cisplatin-based chemotherapy and surgery leading to higher cure-rates even in advanced stages [1], whereas the increasing incidence of germ cell cancers cannot be thoroughly explained. In this article we review the current indications for surgery in metastatic germ cell cancers, highlight the strength and weaknesses of techniques and indications and raise the question how to improve surgical treatment in metastatic germ cell cancer.

Surgical strategies for postchemotherapy testis cancer

The surgical management of disseminated disease has long been an essential component in the management of patients with testis cancer. While the indications for surgery have been narrowed since the advent of cisplatin based chemotherapy, resection remains essential to provide long-term survival. The indications for surgery vary by histology and rely on adequate preoperative imaging to evaluate for residual disease. Surgery for postchemotherapy testis cancer is challenging and requires that surgeons be prepared for extraretroperitoneal resections and adjunctive procedures as necessary. Herein, we review the imaging options that are essential for surgical planning and the various surgical techniques that are often necessary in this challenging situation.

Advanced Testis Cancer

Management of advanced testis cancer requires dedicated attention to the nuances of the disease to not only optimize cure but also ensure lifelong health. We are rapidly entering an era of precision medicine with novel biomarker discoveries that will undoubtedly change the treatment paradigm in both early- and late-stage disease.