FOLLOW-UP AFTER RADICAL ORCHIECTOMY FOR TESTICULAR CANCER

Oncologic Surveillance After Surgical Resection for Renal Cell Carcinoma: A Novel Risk-Based Approach

Purpose

The appropriate duration of surveillance for renal cell carcinoma (RCC) after radical or partial nephrectomy remains unknown, and evidence to support current guidelines are lacking. Herein, we provide an approach to surveillance that balances the risk of recurrence versus the risk of non-RCC death.

Patients and Methods

We identified 2,511 patients who underwent surgery for M0 RCC between 1990 and 2008. Patients were stratified for analysis by pathologic stage (pT1Nx-0, pT2Nx-0, pT3/4Nx-0, and pTanyN1), relapse location (abdomen, chest, bone, and other), age (< 50, 50 to 59, 60 to 69, 70-79 and ≥ 80 years), and Charlson comorbidity index (CCI; ≤ 1 and ≥ 2). Risks of disease recurrence and non-RCC death were estimated by using parametric models for time-to-failure with Weibull distributions. Surveillance duration was estimated at the point when the risk of non-RCC death exceeded the risk of recurrence.

Results

At a median follow-up of 9.0 years (interquartile range, 6.4 to 12.7 years), a total of 676 patients developed recurrence. By using a competing-risk model, vastly different surveillance durations were appreciated. Specifically, among patients with pT1Nx-0 disease and a CCI ≤ 1, risk of non-RCC death exceeded that of abdominal recurrence risk at 6 months in patients age 80 years and older but failed to do so for greater than 20 years in patients younger than age 50 years. For patients with pT1Nx-0 disease but a CCI ≥ 2, the risk of non-RCC death exceeded that of abdominal recurrence risk already at 30 days after surgery, regardless of patient age.

Conclusion

We present an individualized approach to RCC surveillance that bases the duration of follow-up on the interplay between competing risk factors of recurrence and non-RCC death. This strategy may improve the balance between the derived benefit from surveillance and medical resource allocation.

Quality of care for testis cancer

This article explores the delivery of high quality care in patients with testicular cancer. Critical issues relate to an individualized, risk-stratified, and multidisciplinary approach to patient care at centers of excellence and subsequent close patient follow-up. The necessary integration of multiple therapeutic modalities makes testis cancer outcomes highly susceptible to variations in quality of care, which deserves further investigation in well designed population-based studies.

Stage I seminoma in a 15-year-old boy

Seminomas are very rare tumours in children and adolescents. We describe a case of seminoma in a 15-year-old boy who was managed with orchidectomy but no adjuvant therapy. He remains relapse-free 8 years after surgery as determined by clinical, radiological and serological surveillance. This study emphasizes the uncertainty over the need for adjuvant treatment in the management of seminoma in the adolescent patient, in particular in prepubescent children.

Detection of testicular ultrasonographic lesions in severe male infertility

PURPOSE

We retrospectively assessed the number and histology of testicular lesions diagnosed clinically and by ultrasonography in a population of infertile men.

MATERIALS AND METHODS

From October 2000 to January 2003, 560 infertile men underwent physical examination, hormonal assessment (follicle-stimulating hormone, luteinizing hormone, testosterone) and scrotal ultrasonography. Eight men were diagnosed with focal testicular ultrasonographic lesions. In 4 cases there was a palpable lesion and in the other 4 cases the lesion was not palpable, diagnosed by ultrasonography (1 was cryptorchid). Only cases of lesions with clear-cut ultrasonographic edges and no history of recent genital infections were considered for explorative surgery through the groin. Microcalcifications were reported if present. The testicle was only preserved when frozen section examination revealed a benign lesion and the margins were negative.

RESULTS

Gynecomastia was not present in any patient. No microcalcifications were observed. Follicle-stimulating hormone was high in all patients (range 19.8 to 66.0 mUI/ml, mean 34.4). Luteinizing hormone levels were variable (range 1.32 to 28 mUI/ml, mean 12.3). Testosterone was normal in all cases (range 2.82 to 6.25 ng/ml, mean 4.2). Ultrasonographic features of the lesions were hypoechoic area (6 patients) and mixed hyper-hypoechoic area (2 patients). Histological outcomes of Leydig cell tumor (in 3 patients), focal Leydig cell hyperplasia (1 patient), fibrosis (1 patient), diffuse Leydig cell hyperplasia (1 patient), classic seminoma (1 patient) and embryonal carcinoma (in 1 patient) were observed.

CONCLUSIONS

Of 560 infertile patients 8 (1.4%) showed focal testicular lesions, 2 (0.4%) were diagnosed with germ cell tumors and 3 (0.5%) with interstitial cell neoplasms. The malignant tumors were both palpable and in 2 of 3 cases Leydig cell tumors were diagnosed only with ultrasonography.

High Incidence of Benign Testicular Neoplasms Diagnosed by Ultrasound

PURPOSE

We evaluated the clinical and histological significance of incidental ultrasonographic focal testicular lesions and assessed whether a conservative surgical approach may put the patient at higher oncological risk due to insufficient surgical eradication.

MATERIALS AND METHODS

From October 2000 to May 2002 all patients with infertility, scrotal swelling, scrotal pain, varicocele, scrotal trauma or erectile dysfunction underwent scrotal ultrasonography. A total of 1,320 patients were investigated. Focal testicular lesions were found in 27 patients (2%), palpable nodules were present in 17 (63%) and nonpalpable incidental lesions were diagnosed in 10. Nodule diameter was 3 to 24 mm. All patients underwent explorative surgery via inguinotomy and preventive clamping of the spermatic cord. The nodules were completely removed with biopsy of the resection margins. Nonpalpable lesions were removed under ultrasonographic guidance. The testicle was only preserved when frozen section revealed a benign lesion and margins were negative.

RESULTS

Of the 17 cases of palpable lesions (diameter 3 to 24 mm) conservative surgery was performed in 8 (47%). Definitive histological diagnosis showed Leydig cell tumor in 2 (25%), and large cell calcifying Sertoli's cell tumor, adenomatoid tumor, pseudofibrotic tumor of the tunica albuginea, epidermoid cyst, tubular fibrosis and non-Hodgkin's lymphoma in each 1 (12.5%). The remaining 9 patients (53%) underwent orchidectomy. Definitive histological examination revealed pure seminoma in 4 patients (44%), embryonal carcinoma in 4 (44%) and diffuse Leydig cell hyperplasia in 1 (12%). Seven of the 10 pts (70%) with nonpalpable nodules (diameter 4 to 16 mm) underwent conservative surgery. Histological study revealed focal Leydig cell hyperplasia in 1 case (10%), fibrosis in 3 (30%), infarction in 2 (20%) and mesothelial hyperplasia in 1 (10%). Orchiectomy was performed in the remaining 3 pts. Histology showed diffuse Leydig cell tumor in 2 pts (20%) and adenomatoid tumor with abscessed areas in 1 (10%). Neither atrophy nor local relapse was observed in pts who underwent conservative treatment during followup (mean: 1 month, range 19 to 9).

CONCLUSIONS

The incidental diagnosis of testicular ultrasound alterations is increasing and 80% show a benign histology. In these cases a conservative surgical approach is the best option and it does not expose the patient to the risk of relapse.