Oncological outcomes in patients with stage I testicular seminoma and nonseminoma: pathological risk factors for relapse and feasibility of surveillance after orchiectomy

Excellent survival in relapsed stage I testicular cancer

BACKGROUND

Two thirds of patients with germ-cell cancer (GCC) present as clinical stage I (CSI). Following orchiectomy, active surveillance (AS) has become their standard management. However, 15-50% of patients eventually relapse with metastatic disease after AS. Relapses need to be detected early in order to achieve cure and avoid overtreatment.

METHODS

We retrospectively analyzed consecutive GCC patients treated at two Swiss academic centers between 2010 and 2020. Patients with stage IS and extragonadal primaries were excluded. We compared disease characteristics and survival outcomes of patients relapsed from initial CSI to patients with de novo metastatic disease. Primary endpoint was the IGCCCG category at the time of relapse. Main secondary endpoints were progression-free survival (PFS) and overall survival (OS).

RESULTS

We identified 360 GCC patients with initial CSI and 245 de novo metastatic patients. After a median follow-up of 47 months, 81 of 360 (22.5%) CSI patients relapsed: 41 seminoma (Sem) and 40 non-seminoma (NSem) patients. All Sems relapsed in the IGCCCG good prognosis group. NSem relapsed with good 29/40 (72.5%) and intermediate 11/40 (27.5%) prognostic features; 95.1% of relapses occurred within five years post-orchiectomy. Only 3 relapsed NSem patients died from metastatic disease. Five-year OS for relapsed CSI patients was 100% for Sem and 87% (95% CI: 61-96%) for NSem patients; five-year PFS was 92% (95% CI: 77-97) and 78% (95% CI: 56-90) for Sem and NSem, respectively. When stratified by IGCCCG prognostic groups, good risk relapsed patients had a trend towards better OS and PFS as compared to de novo metastatic patients.

CONCLUSIONS

GCC patients who relapse after initial CSI can be detected early by active surveillance and have an excellent survival.

Comprehensive characteristics of pathological subtypes in testicular germ cell tumor: Gene expression, mutation and alternative splicing

Background

Testicular germ cell tumor (TGCT) is the most common tumor in young men, but molecular signatures, especially the alternative splicing (AS) between its subtypes have not yet been explored.

Methods

To investigate the differences between TGCT subtypes, we comprehensively analyzed the data of gene expression, alternative splicing (AS), and somatic mutation in TGCT patients from the TCGA database. The gene ontology (GO) enrichment analyses were used to explore the function of differentially expressed genes and spliced genes respectively, and Spearman correlation analysis was performed to explore the correlation between differential genes and AS events. In addition, the possible patterns in which AS regulates gene expression were elaborated by the ensemble database transcript atlas. And, we identified important transcription factors that regulate gene expression and AS and functionally validated them in TGCT cell lines.

Results

We found significant differences between expression and AS in embryonal carcinoma and seminoma, while mixed cell tumors were in between. GO enrichment analyses revealed that both differentially expressed and spliced genes were enriched in transcriptional regulatory pathways, and obvious correlation between expression and AS events was determined. By analyzing the transcript map and the sites where splicing occurs, we have demonstrated that AS regulates gene expression in a variety of ways. We further identified two pivot AS-related molecules (SOX2 and HDAC9) involved in AS regulation, which were validated in embryonal carcinoma and seminoma cell lines. Differences in somatic mutations between subtypes are also of concern, with our results suggesting that mutations in some genes (B3GNT8, CAPN7, FAT4, GRK1, TACC2, and TRAM1L1) occur only in embryonal carcinoma, while mutations in KIT, KARS, and NRAS are observed only in seminoma.

Conclusions

In conclusion, our analysis revealed the differences in gene expression, AS and somatic mutation among TGCT subtypes, providing a molecular basis for clinical diagnosis and precise therapy of TGCT patients.

Clinical features and prognostic factors in patients diagnosed with lymphovascular invasion of testicular germ-cell tumors: Analysis based on the SEER database

Background

Lymphovascular invasion (LVI) is a high-risk factor for testicular germ-cell tumors (TGCT), but a prognostic model for TGCT-LVI patients is lacking. This study aimed to develop a nomogram for predicting the overall survival (OS) of TGCT-LVI patients.

Methods

A complete cohort of 3288 eligible TGCG-LVI patients (training cohort, 2300 cases; validation cohort, 988 cases) were obtained from the Surveillance, Epidemiology, and End Results database. Variables screened by multivariate Cox regression analysis were used to construct a nomogram, which was subsequently evaluated using the consistency index (C-index), time-dependent receiver operating characteristic curve (ROC), and calibration plots. The advantages and disadvantages of the American Joint Committee on Cancer (AJCC) staging system and the nomogram were assessed by integrated discrimination improvement (IDI) and net reclassification improvement (NRI). Decision-analysis curve (DCA) was used to measure the net clinical benefit of the nomogram versus the AJCC staging system. Finally, Kaplan-Meier curves were used to evaluate the ability to identify different risk groups between the traditional AJCC staging system and the new risk-stratification system built on the nomogram.

Results

Nine variables were screened by multivariate Cox regression analysis to construct the nomogram. The C-index (training cohort, 0.821; validation cohort, 0.819) and time-dependent ROC of 3-, 5-, and 9-year OS between the two cohorts suggested that the nomogram had good discriminatory ability. Calibration curves showed good consistency of the nomogram. The NRI values of 3-, 5-, and 9-year OS were 0.308, 0.274, and 0.295, respectively, and the corresponding values for the validation cohort were 0.093, 0.093, and 0.099, respectively (P<0.01). Additionally, the nomogram had more net clinical benefit as shown by the DCA curves, and the new risk-stratification system provided better differentiation than the AJCC staging system.

Conclusions

A prognostic nomogram and new risk-stratification system were developed and validated to assist clinicians in assessing TGCT-LVI patients.

Biomarkers of disease recurrence in stage I testicular germ cell tumours

Stage I testicular cancer is a disease restricted to the testicle. After orchiectomy, patients are considered to be without disease; however, the tumour is prone to relapse in ~4-50% of patients. Current predictive markers of relapse, which are tumour size and invasion to rete testis (in seminoma) or lymphovascular invasion (in non-seminoma), have limited clinical utility and are unable to correctly predict relapse in a substantial proportion of patients. Adjuvant therapeutic strategies based on available biomarkers can lead to overtreatment of 50-85% of patients. Discovery and implementation of novel biomarkers into treatment decision making will help to reduce the burden of adjuvant treatments and improve patient selection for adjuvant therapy.

Surveillance versus Adjuvant Treatment with Chemotherapy or Radiotherapy for Stage I Seminoma: A Systematic Review and Meta-Analysis According to EAU COVID-19 Recommendations

Background and Objectives: During the coronavirus disease 2019 (COVID-19) outbreak, the European Association of Urology (EAU) Guidelines Office Rapid Reaction Group (GORRG) recommended that patients with clinical stage I (CSI) seminoma be offered active surveillance (AS). This meta-analysis aimed to evaluate the efficacy of AS versus adjuvant treatment with chemotherapy or radiotherapy for improving the overall survival (OS) of CSI seminoma patients. Materials and Methods: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed/Medline, EMBASE, and Cochrane Library databases were searched. The primary outcome was 5-year OS, and the secondary outcome was the 5-year relapse-free survival (RFS). The outcomes were analyzed as odds ratios (ORs) and 95% confidence intervals (CIs). Results: A total of 14 studies were included. Overall, the quality scores were relatively high, and little publication bias was noted. In terms of the 5-year OS, 7 studies were analyzed; there was no significant difference between AS and adjuvant treatment (OR, 0.99; 95% CI, 0.41−2.39; p = 0.97). In terms of 5-year RFS, 12 studies were analyzed. Adjuvant treatment reduced the risk of 5-year recurrence by 85% compared with AS (OR, 0.15; 95% CI, 0.08−0.26; p < 0.001). Conclusions: In terms of the OS in CSI seminoma patients, no intergroup difference was noted, so it is reasonable to offer AS, as recommended by the EAU GORRG until the end of the COVID-19 pandemic. However, since there is a large intergroup difference in the recurrence rate, further research on the long-term (>5 years) outcomes is warranted.

Testicular Germ-Cell Tumors with Spermatic Cord Involvement: A Retrospective International Multi-Institutional Experience

The 8th Edition of the American Joint Committee on Cancer (AJCC) Staging Manual designates discontinuous involvement of spermatic cord soft tissue by testicular germ cell tumors as a metastatic deposit. We conducted a retrospective international multi-institutional study to validate the current recommendations. Thirty-three (72%) nonseminomatous and 13 (28%) seminomatous testicular germ cell tumors were collected from 15 institutions in America, Europe, and Asia. Testicular tumor size ranged from 1.3 to 18.0 cm (mean: 6.1). Cases were classified as discontinuous involvement of spermatic cord soft tissue (n = 26), continuous cord involvement (n = 17), or cord lymphovascular invasion (n = 3). The mean follow-up was 39 months. Clinical stage for discontinuous involvement of spermatic cord soft-tissue patients was I (local disease) in 2/24 (8%), II (regional disease) in 6/24 (25%), and III (distant disease) in 16/24 (67%) cases; 16 (67%) patients presented with distant metastasis. Clinical stage for continuous cord involvement patients was I in 9/17 (53%), II in 4/17 (23%), and III in 4/17 (23%); 4 (23%) patients presented with distant metastasis. Disease progression was seen in 4 patients with discontinuous involvement of spermatic cord soft tissue and 5 with continuous cord-involvement (p = 0.699). When comparing discontinuous and continuous cord involvement, a significant difference was found in cord margin status (p = 0.044), spermatic cord tumor size (p = 0.016), lymph-node involvement (p = 0.037), distant metastasis (p = 0.010), individual clinical stage (p = 0.003), and nonadvanced vs. advanced disease (p = 0.003) at presentation. In multivariate analysis, after adjusting for age, histology, testicular tumor size, percent of embryonal carcinoma, lymphovascular invasion, and cord margin status, discontinuous involvement of spermatic cord soft tissue was significantly associated (p = 0.011) with advanced clinical stage at presentation. Our findings support the designation of metastatic disease for discontinuous involvement of spermatic cord soft tissue, as introduced by the 8th edition of the AJCC staging.

Testicular germ cell tumours' clinical stage I: comparison of surveillance with adjuvant treatment strategies regarding recurrence rates and overall survival-a systematic review

PURPOSE

Testicular germ cell tumours (GCTs) represent the most common malignancy in young adult males with two thirds of all cases presenting with clinical stage I (CSI). Active surveillance is the management modality mostly favoured by current guidelines. This systematic review assesses the treatment results in CSI patients concerning recurrence rate and overall survival in non-seminoma (NS) and pure seminoma (SE) resulting from surveillance in comparison to adjuvant strategies.

METHODS/SYSTEMATIC REVIEW

We performed a systematic literature review confining the search to most recent studies published 2010-2021 that reported direct comparisons of surveillance to adjuvant management. We searched Medline and the Cochrane Library with additional hand-searching of reference lists to identify relevant studies. Data extraction and quality assessment of included studies were performed with stratification for histology (NS vs. SE) and treatment modalities. The results were tabulated and evaluated with descriptive statistical methods.

RESULTS

Thirty-four studies met the inclusion criteria. In NS patients relapse rates were 12 to 37%, 0 to 10%, and 0 to 11.8% for surveillance, chemotherapy and for retroperitoneal lymph node dissection (RPLND) while overall survival rates were 90.7-100%, 91.7-100%, and 97-99.1%, respectively. In SE CSI, relapse rates were 0-22.3%, 0-5%, and 0-12.5% for surveillance, radiotherapy, chemotherapy, while overall survival rates were 84.1-98.7%, 83.5-100%, and 92.3-100%, respectively.

CONCLUSION

In both histologic subgroups, active surveillance offers almost identical overall survival as adjuvant management strategies, however, at the expense of higher relapse rates. Each of the management strategies in CSI GCT patients have specific merits and shared-decision-making is advised to tailor treatment.

Improving outcomes in germ cell cancers using miRNA

Owing to advances in treatment paradigms across the last five decades, testicular cancer is now eminently curable. However, current serum tumour and imaging biomarkers lack adequate sensitivity, specificity, and predictive value. Subsequently, their utility in detecting active malignancy and informing treatment decisions is minimal in a large proportion of men with testicular cancer. Micro-ribonucleic acids (miRNA), pertinently miR-371a-3p, offer a new tool, which based on early data, appears to fill many of the gaps that existing biomarkers leave. This paper reviews the evolution of the technology, potential limitations, and discusses the clinical relevance of miRNA as it moves towards the clinic.

Construction and Validation of a Nomogram for Predicting Progression- Free Survival in Patients with Early-Stage Testicular Germ Cell Tumor

BACKGROUND

Testicular Germ Cell Tumor (TGCT) is the most common malignant tumor in young men, but there is a lack of a prediction model to evaluate the prognosis of patients with TGCT.

OBJECTIVE

To explore the prognostic factors for Progression-Free Survival (PFS) and construct a nomogram model for patients with early-stage TGCT after radical orchiectomy.

METHODS

Patients with TGCT from The Cancer Genome Atlas (TCGA) database were used as the training cohort; univariate and multivariate cox analysis was performed. A nomogram was constructed based on the independent prognostic factors. Patients from the Nanfang Hospital affiliated with Southern Medical University were used as the cohort to validate the predictive ability using the nomogram model. Harrell's concordance index (C-index) and calibration plots were used to evaluate the nomogram.

RESULTS

A total of 110 and 62 patients with TGCT were included in the training cohort and validation cohort, respectively. Lymphatic Vascular Invasion (LVI), American Joint Committee on Cancer (AJCC) stage and adjuvant therapy were independent prognostic factors in multivariate regression analyses and were included to establish a nomogram. The C-index in the training cohort for 1- , 3-, and 5-year PFS were 0.768, 0.74, and 0.689, respectively. While the C-index for 1-, 3-, and 5- year PFS in the external validation cohort were 0.853, 0.663 and 0.609, respectively. The calibration plots for 1-, 3-, and 5-year PFS in the training and validation cohort showed satisfactory consistency between predicted and actual outcomes. The nomogram revealed a better predictive ability for PFS than AJCC staging system.

CONCLUSION

The nomogram as a simple and visual tool to predict individual PFS in patients with TGCT could guide clinicians and clinical pharmacists in therapeutic strategy.

Liquid Biopsies in the Clinical Management of Germ Cell Tumor Patients: State-of-the-Art and Future Directions

Liquid biopsies constitute a minimally invasive means of managing cancer patients, entailing early diagnosis, follow-up and prediction of response to therapy. Their use in the germ cell tumor field is invaluable since diagnostic tissue biopsies (which are invasive) are often not performed, and therefore only a presumptive diagnosis can be made, confirmed upon examination of the surgical specimen. Herein, we provide an overall review of the current liquid biopsy-based biomarkers of this disease, including the classical, routinely used serum tumor markers—the promising microRNAs rapidly approaching the introduction into clinical practice—but also cell-free DNA markers (including DNA methylation) and circulating tumor cells. Finally, and importantly, we also explore novel strategies and challenges for liquid biopsy markers and methodologies, providing a critical view of the future directions for liquid biopsy tests in this field, highlighting gaps and unanswered questions.

Testicular Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Testicular cancer is relatively uncommon and accounts for <1% of all male tumors. However, it is the most common solid tumor in men between the ages of 20 and 34 years, and the global incidence has been steadily rising over the past several decades. Several risk factors for testicular cancer have been identified, including personal or family history of testicular cancer and cryptorchidism. Testicular germ cell tumors (GCTs) comprise 95% of malignant tumors arising in the testes and are categorized into 2 main histologic subtypes: seminoma and nonseminoma. Although nonseminoma is the more clinically aggressive tumor subtype, 5-year survival rates exceed 70% with current treatment options, even in patients with advanced or metastatic disease. Radical inguinal orchiectomy is the primary treatment for most patients with testicular GCTs. Postorchiectomy management is dictated by stage, histology, and risk classification; treatment options for nonseminoma include surveillance, systemic therapy, and nerve-sparing retroperitoneal lymph node dissection. Although rarely occurring, prognosis for patients with brain metastases remains poor, with >50% of patients dying within 1 year of diagnosis. This selection from the NCCN Guidelines for Testicular Cancer focuses on recommendations for the management of adult patients with nonseminomatous GCTs.

Distinct telomere length and molecular signatures in seminoma and non-seminoma of testicular germ cell tumor

Testicular germ cell tumors (TGCTs) are classified into two main subtypes, seminoma (SE) and non-seminoma (NSE), but their molecular distinctions remain largely unexplored. Here, we used expression data for mRNAs and microRNAs (miRNAs) from The Cancer Genome Atlas (TCGA) to perform a systematic investigation to explain the different telomere length (TL) features between NSE (n = 48) and SE (n = 55). We found that TL elongation was dominant in NSE, whereas TL shortening prevailed in SE. We further showed that both mRNA and miRNA expression profiles could clearly distinguish these two subtypes. Notably, four telomere-related genes (TelGenes) showed significantly higher expression and positively correlated with telomere elongation in NSE than SE: three telomerase activity-related genes (TERT, WRAP53 and MYC) and an independent telomerase activity gene (ZSCAN4). We also found that the expression of genes encoding Yamanaka factors was positively correlated with telomere lengthening in NSE. Among them, SOX2 and MYC were highly expressed in NSE versus SE, while POU5F1 and KLF4 had the opposite patterns. These results suggested that enhanced expression of both TelGenes (TERT, WRAP53, MYC and ZSCAN4) and Yamanaka factors might induce telomere elongation in NSE. Conversely, the relative lack of telomerase activation and low expression of independent telomerase activity pathway during cell division may be contributed to telomere shortening in SE. Taken together, our results revealed the potential molecular profiles and regulatory roles involving the TL difference between NSE and SE, and provided a better molecular understanding of this complex disease.

Testicular Cancer-Surgical Treatment

Testicular Germ Cell Tumor (GCT) is the most common solid tumor in men between the ages of 20-44. Men diagnosed with GCT have excellent survival rates due to advances in the multimodal treatment paradigm of chemotherapy, radiation therapy, and surgery. When considering the adequate treatment, several variables should be investigated and known to select the proper procedure. Therefore, when considering Testicular Intra-Epithelial Neoplasia, organ-sparring treatment, such as radiotherapy or organ-sparring surgery should be considered, reaching a cure rate of 98%. However, when the case is of a seminoma or a non-seminoma, orchiectomy is usually the chosen procedure, reaching an oncological cure rate of 80-85%, when there is no metastasis. Retroperitoneal Lymph Node Dissection (RPLND) is generally considered as a treatment option for non-seminomas, when lymph nodes are compromised. There are three different RPLND techniques: open, laparoscopic, and robotic. The open approach is as effective as the other two in its oncological efficiency. Although, when considering both laparoscopic and robotic approach, hospital stays are significantly reduced, better cosmetic results, and less complications when compared to the open approach. Both laparoscopic and robotic approaches require extensive experience and have a steep learning curve, while also providing similar outcome, however, recent studies have been pointing out a slight increase of advantages on the robotic approach. Therefore, further studies are necessary to assert the robotic approach superiority. Also, it is noteworthy that new technologies are on the rise, improving the laparoscopic approach, requiring further studies after their uses are consolidated.

Testicular Cancer Biomarkers: A Role for Precision Medicine in Testicular Cancer

Testicular germ cell tumors (TGCTs) represent the most common solid tumors among men aged 15 to 34 years. Fortunately, recent advances have made testicular cancer a highly curable disease. Despite the high cure rates, there are still several areas in testis cancer care where treatment decisions are controversial and guided only with clinical factors and historic serum tumor markers. Unfortunately, unlike other genitourinary malignancies, modern research techniques have not been widely tested or applied to germ cell tumors, perhaps as a result of excellent prognosis in this cohort of young men. Despite this, there remain numerous challenges and pitfalls in testis cancer care that need to be addressed. A reliable set of biomarkers could be extremely useful in helping risk-stratify patients, detect relapse early, guide surgical decision-making, and tailor follow-up. Current tumor markers (Alpha-fetoprotein, human chorionic gonadotrophin, and lactate dehydrogenase) have low accuracy and low sensitivity when used not only as diagnostic but also as prognostic and predictive markers. In twenty-first century medicine, there is a role for further prognostic stratification and the development of novel biomarkers that offer greater sensitivity and specificity for TGCTs. Despite the initial promising results, the majority of preclinical biomarkers do not, as yet have a proven validated role in clinical practice, and future prospective trials are needed to support and confirm the results of cohort studies. In this narrative review, we aimed to highlight the recent innovations in the development and implementation of novel testicular tumor markers and discuss their clinical applications and limitations in the management of this disease.

Sociodemographic and Provider Based Disparities in the Management of Stage I Testicular Cancer

INTRODUCTION

The treatment paradigm for stage I testicular cancer has changed in the setting of accurate staging, reliable followup and a greater understanding of treatment related side effects. We assessed the influences on management decisions in patients with stage I testicular cancer.

METHODS

We retrospectively identified 121 patients with stage I testicular cancer who were evaluated at our institution from 1999 to 2013. Sociodemographic characteristics, pathological features and provider specific factors were compared in patients who underwent surveillance vs treatment. Differences in medians and proportions were determined using the Kruskal-Wallis and chi-square tests. Multivariate logistic regression analysis was performed to identify independent predictors of treatment.

RESULTS

A total of 87 patients had stage I nonseminomatous germ cell tumor and 34 had pure seminoma. Patients with nonseminomatous germ cell tumor who were evaluated before 2011 and those seen by urological oncologists were more likely to undergo primary retroperitoneal lymph node dissection (p <0.01). Patients with nonseminomatous germ cell tumor who were evaluated by medical oncologists more often received chemotherapy (p <0.01). For nonseminomatous germ cell tumors treatment was independently associated with advanced tumor stage and lymph node invasion (OR 15.3, 95% CI 3.26-71.95, p = 0.001). In patients with pure seminoma the use of radiation therapy decreased from 40% to 5% after 2010 while surveillance increased from 47% to 74% (p = 0.056) and no recorded variable was predictive of treatment.

CONCLUSIONS

Advanced stage and lymph node invasion in patients with stage I nonseminomatous germ cell tumor are drivers of treatment. Management also depends on the specialty of the treating provider, suggesting the possibility of bias during patient counseling. In turn, this suggests the need for patient assessment through a multidisciplinary approach.

The present and future of serum diagnostic tests for testicular germ cell tumours

Testicular germ cell tumours (GCTs) are the most common malignancy occurring in young adult men and the incidence of these tumours is increasing. Current research priorities in this field include improving overall survival for patients classified as being 'poor-risk' and reducing late effects of treatment for patients classified as 'good-risk'. Testicular GCTs are broadly classified into seminomas and nonseminomatous GCTs (NSGCTs). The conventional serum protein tumour markers α-fetoprotein (AFP), human chorionic gonadotrophin (hCG) and lactate dehydrogenase (LDH) show some utility in the management of testicular malignant GCT. However, AFP and hCG display limited sensitivity and specificity, being indicative of yolk sac tumour (AFP) and choriocarcinoma or syncytiotrophoblast (hCG) subtypes. Furthermore, LDH is a very nonspecific biomarker. Consequently, seminomas and NSGCTs comprising a pure embryonal carcinoma subtype are generally negative for these conventional markers. As a result, novel universal biomarkers for testicular malignant GCTs are required. MicroRNAs are short, non-protein-coding RNAs that show much general promise as biomarkers. MicroRNAs from two 'clusters', miR-371-373 and miR-302-367, are overexpressed in all malignant GCTs, regardless of age (adult or paediatric), site (gonadal or extragonadal) and subtype (seminomas, yolk sac tumours or embryonal carcinomas). A panel of four circulating microRNAs from these two clusters (miR-371a-3p, miR-372-3p, miR-373-3p and miR-367-3p) is highly sensitive and specific for the diagnosis of malignant GCT, including seminoma and embryonal carcinoma. In the future, circulating microRNAs might be useful in diagnosis, disease monitoring and prognostication of malignant testicular GCTs, which might also reduce reliance on serial CT scanning. For translation into clinical practice, important practical considerations now need addressing.

Management of stage I testicular germ cell tumours

Clinical stage I testicular germ cell tumours (TGCT) are highly curable neoplasms. The treatment of stage I testicular cancer is complex and requires a multidisciplinary approach. Standard options after radical orchiectomy for seminoma include active surveillance, radiation therapy or 1-2 cycles of carboplatin, and options for nonseminoma include active surveillance, retroperitoneal lymph node dissection (RPLND) or 1-2 cycles of bleomycin plus etoposide plus cisplatin (BEP). All the options should be discussed with each patient and treatment choices should be made by shared decision making as virtually all patients with clinical stage I TGCT can be cured of their disease. Long-term survival of men with stage I disease is ∼99% and care must be taken to limit the long-term risks of treatment. Orchiectomy is curative in the majority of patients. The management of clinical stage I TGCT remains controversial among experts at high-volume centres throughout the world. The main controversy is whether to overtreat a substantial number of patients with stage I disease to prevent relapse, or to observe and treat only patients who experience disease relapse as adjuvant treatment and surveillance strategy both bring curative outcome. Thus, a summary of the available evidence in stage I disease and recommendations for disease management from a high-volume centre such as Indiana University might be of interest to treating clinicians.

Do Histopathologic Variables Affect the Reporting of Lymphovascular Invasion in Testicular Germ Cell Tumors?

OBJECTIVES

Identification of lymphovascular invasion (LVI) in testicular germ cell tumors (GCTs) is a challenging yet important aspect of cancer staging that can alter therapeutic management. Our study aimed to identify pathologic features that affect the reporting of LVI.

METHODS

Pathology report and slide review of orchiectomies performed at our institution between 2007 and 2013 for testicular GCTs were performed.

RESULTS

Seminomas grossed by residents had a higher rate of reported LVI compared with specimens grossed by pathology assistants (46% vs 15%). Tumor displacement artifact was more frequent in seminomas vs mixed GCTs (60% vs 38%). LVI concordance was high upon review (κ = 0.77), with displacement artifact present in all discrepancies. Tumor emboli from cases reported to have LVI had a higher frequency of tumor cohesiveness, smooth contours, and adherence to vessel walls compared with tumor emboli that were considered pseudo-LVI. Presence of fibrin and RBCs were features found at a similar frequency in emboli that were reported as LVI compared with those deemed artifactual.

CONCLUSIONS

Grosser type, tumor subtype, tumor displacement artifact, and characteristics of tumor emboli are pathologic features that affect the interpretation of LVI in testicular GCTs. Pathologists should be aware of these variables to more accurately diagnose LVI.

A refined risk stratification scheme for clinical stage 1 NSGCT based on evaluation of both embryonal predominance and lymphovascular invasion

BACKGROUND

Active surveillance is an increasingly accepted approach for managing patients with germ-cell tumors (GCTs) after an orchiectomy. Here we investigate a time-to-relapse stratification scheme for clinical stage 1 (CS1) nonseminoma GCT (NSGCT) patients according to factors associated with relapse and identify a group of patients with a lower frequency and longer time-to-relapse who may require an alternative surveillance strategy.

PATIENTS AND METHODS

We analyzed 266 CS1 GCT patients from the IRB-approved DFCI GCT database that exclusively underwent surveillance following orchiectomy from 1997 to 2013. We stratified NSGCT patients according to predominance of embryonal carcinoma (EmbP) and lymphovascular invasion (LVI), using a 0, 1, and 2 scoring system. Cox regression and conditional risk analysis were used to compare each NSGCT group to patients in the seminomatous germ-cell tumor (SGCT) category. Median time-to-relapse values were then calculated among those patients who underwent relapse. Relapse-free survival curves were generated using the Kaplan-Meier method.

RESULTS

Fifty (37%) NSGCT and 20 (15%) SGCT patients relapsed. The median time-to-relapse was 11.5 versus 6.3 months for the SGCT and NSGCT groups, respectively. For NSGCT patients, relapse rates were higher and median time-to-relapse faster with increasing number of risk factors (RFs). Relapse rates (%) and median time-to-relapse (months) were 25%/8.5 months, 41%/6.8 months and 78%/3.8 months for RF0, RF1 and RF2, respectively. We found a statistically significant difference between SGCT and patients with one or two RFs (P < 0.001) but not between SGCT and NSGCT RF0 (P = 0.108).

CONCLUSION

NSGCT patients grouped by a risk score system based on EmbP and LVI yielded three groups with distinct relapse patterns -and patients with neither EmbP nor LVI appear to behave similar to SGCT.

Clinical profile, treatment and survival outcome of testicular tumors: a pakistani perspective

BACKGROUND

Testicular cancer management is considered a marvel of modern science with excellent treatment results. Pakistan has a distinct ethnic variation and geographic distribution but data regarding clinical presentation of testicular tumors and their management is under reported. The objective of this study was to determine clinical profile, treatment modalities and survival outcome of testicular tumors in the Pakistani population.

MATERIALS AND METHODS

A retrospective review of patients who received treatment for testicular cancer at Shaukat Khanum Cancer Hospital from January 2009 to December 2012 was performed. Patient demographics, clinical features at presentation and treatment modalities were assessed. For categorical variables chi square test was used. Survival was calculated using Kaplan Meier survival curves and Log rank test was employed to determine significance.

RESULTS

The most common tumor was mixed germ cell tumor in 49% patients. For all tumor variants except seminoma, stage III was the most common clinical stage at presentation. Majority of patients with non seminomatous germ cell tumors presented in the15-30 year age group as compared to seminoma which was most prevalent in the 30-40 year age group. Orchiectomy followed by chemotherapy was the most common treatment modality in 80% patients. Expected 5 year survival for seminomas and non- seminomatous germ cell tumors was 96% and 90% respectively which was not significantly different (p=0.2).

CONCLUSIONS

Despite a distinct clinical profile of testicular tumors in Pakistani population, survival is comparable with published reports.