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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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McHugh DJ, Gleeson JP, Feldman DR. Testicular cancer in 2023: Current status and recent progress. CA Cancer J Clin 2024; 74:167-186. [PMID: 37947355 DOI: 10.3322/caac.21819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/25/2023] [Accepted: 09/29/2023] [Indexed: 11/12/2023] Open
Abstract
Testicular germ cell tumor (GCT) is the most common solid tumor in adolescent and young adult men. Progress in the management of GCT has been made in the last 50 years, with a substantial improvement in cure rates for advanced disease, from 25% in the 1970s to nearly 80%. However, relapsed or platinum-refractory disease occurs in a proportion, 20% of whom will die from disease progression. This article reviews the current evidence-based treatments for extracranial GCT, the acute and chronic toxic effects that may result, and highlights contemporary advances and progress in the field.
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Affiliation(s)
- Deaglan J McHugh
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
| | - Jack P Gleeson
- Cancer Research, College of Medicine and Health, University College Cork, Cork, Ireland
- Medical Oncology Department, Cork University Hospital, Cork, Ireland
| | - Darren R Feldman
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
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3
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Fonini JS, de Araujo PHXN, D'Ambrosio PD, Salerno JVDO, Ciaralo PPD, Terra RM, Pêgo-Fernandes PM. Prolonged survival after thoracic metastasectomy in patients with nonseminomatous testicular cancer. Clinics (Sao Paulo) 2024; 79:100338. [PMID: 38359698 PMCID: PMC10877677 DOI: 10.1016/j.clinsp.2024.100338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Almost 20 % of patients with Non-Seminomatous Germinative Cell Tumors (NSGCT) will require intrathoracic metastasectomy after chemotherapy. The authors aim to determine their long-term survival rates. METHODS Retrospective study including patients with NSGCT and intrathoracic metastasis after systemic therapy from January 2011 to June 2022. Treatment outcomes and overall survival were analyzed with the Kaplan-Meier method. RESULTS Thirty-seven male patients were included with a median age of 31.8 years. Six presented with synchronous mediastinum and lung metastasis, nine had only lung, and 22 had mediastinal metastasis. Over half had retroperitoneal lymph node metastasis. Twenty-two had dissimilar pathologies, with a discordance rate of 62 %. Teratoma and embryonal carcinoma were the prevalent primary tumor types, 40.5 % each, while teratoma was predominant (70.3 %) in the metastasis group. Thoracotomy was the main surgical approach (39.2 %) followed by VATS (37.2 %), cervico-sternotomy (9.8 %), sternotomy (5.8 %), and clamshell (3.9 %). Lung resection was performed in 40.5 % of cases. Overall, 10-year survival rates were 94.3 % with no surgical-related mortality. CONCLUSION Multimodality treatment with systemic therapy followed by radical surgery offers a high cure rate to patients with intrathoracic metastatic testicular germ cell tumors.
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Affiliation(s)
- Jaqueline Schaparini Fonini
- Thoracic Surgery Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Pedro Henrique Xavier Nabuco de Araujo
- Thoracic Surgical Oncology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Thoracic Surgical Oncology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Paula Duarte D'Ambrosio
- Thoracic Surgery Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | | | - Pedro Prosperi Desenzi Ciaralo
- Thoracic Surgery Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Ricardo Mingarini Terra
- Thoracic Surgery Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Thoracic Surgery Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Paulo Manuel Pêgo-Fernandes
- Thoracic Surgery Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
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Saltzman AF, Hensley P, Ross J, Woo L, Billmire D, Rescorla F, Puri D, Patel S, Pierorazio P, Bagrodia A, Cary C, Cost NG. Critical elements of pediatric testicular germ cell tumors surgery. Semin Pediatr Surg 2023; 32:151343. [PMID: 38006835 DOI: 10.1016/j.sempedsurg.2023.151343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
Children, adolescents and young adults with testicular germ cell tumors require appropriate surgical care to insure excellent outcomes. This article presents the most critical elements, and their basis in evidence, for surgery in this population. Specifically, the importance of inguinal radical orchiectomy for malignant tumors, partial orchiectomy for prepubertal tumors and normal serum tumor markers, and the appropriate use of post-chemotherapy retroperitoneal lymph node dissection in those with residual retroperitoneal masses.
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Affiliation(s)
| | - Patrick Hensley
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | - Jonathan Ross
- Department of Urology, Rush University, Chicago, IL, USA
| | - Lynn Woo
- Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Deborah Billmire
- Department of Pediatric Surgery, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Frederick Rescorla
- Department of Pediatric Surgery, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Dhruv Puri
- Department of Urology, University of California San Diego, La Jolla, CA, USA
| | - Sunil Patel
- Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Aditya Bagrodia
- Department of Urology, University of California San Diego, La Jolla, CA, USA
| | - Clint Cary
- Department of Urology, Indiana University, Indianapolis, IN, USA
| | - Nicholas G Cost
- Division of Urology, Department of Surgery at the University of Colorado School of Medicine, Aurora, CO, USA; The Surgical Oncology Program, Children's Hospital Colorado, Aurora, CO, USA.
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Patrikidou A, Cazzaniga W, Berney D, Boormans J, de Angst I, Di Nardo D, Fankhauser C, Fischer S, Gravina C, Gremmels H, Heidenreich A, Janisch F, Leão R, Nicolai N, Oing C, Oldenburg J, Shepherd R, Tandstad T, Nicol D. European Association of Urology Guidelines on Testicular Cancer: 2023 Update. Eur Urol 2023; 84:289-301. [PMID: 37183161 DOI: 10.1016/j.eururo.2023.04.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023]
Abstract
CONTEXT Each year the European Association of Urology (EAU) produce a document based on the most recent evidence on the diagnosis, therapy, and follow-up of testicular cancer (TC). OBJECTIVE To represent a summarised version of the EAU guidelines on TC for 2023 with a focus on key changes in the 2023 update. EVIDENCE ACQUISITION A multidisciplinary panel of TC experts, comprising urologists, medical and radiation oncologists, and pathologists, reviewed the results from a structured literature search to compile the guidelines document. Each recommendation in the guidelines was assigned a strength rating. EVIDENCE SYNTHESIS For the 2023 EAU guidelines on TC, a review and restructure were undertaken. The key changes incorporated in the 2023 update include: new supporting text regarding venous thromboembolism prophylaxis in males with metastatic germ cell tumours receiving chemotherapy; quality of life after treatment; an update of the histological classifications and inclusion of the World Health Organization 2022 pathological classification; inclusion of the revalidation of the 1997 International Germ Cell Cancer Collaborative Group prognostic risk factors; and a new section covering oncology treatment protocols. CONCLUSIONS The 2023 version of the EAU guidelines on TC include the highest available scientific evidence to standardise the management of TC. Better stratification and optimisation of treatment modalities will continue to improve the high survival rates for patients with TC. PATIENT SUMMARY This article presents a summary of the European Association of Urology guidelines on testicular cancer published in 2023 and includes the latest recommendations for management of this disease. The guidelines are a valuable resource that may help patients in understanding treatment recommendations.
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Affiliation(s)
- Anna Patrikidou
- Department of Oncology, Institut Gustave Roussy, Villejuif, France
| | - Walter Cazzaniga
- Department of Urology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Daniel Berney
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Joost Boormans
- Department of Urology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Isabel de Angst
- Department of Urology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Domenico Di Nardo
- Patient Representative, European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | | | - Stefanie Fischer
- Department of Medical Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Carmen Gravina
- Department of Urology, Sant'Andrea Hospital-Sapienza University, Rome, Italy
| | - Hendrik Gremmels
- Patient Representative, European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | | | - Florian Janisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ricardo Leão
- Department of Urology, Faculty of Medicine, University of Coimbra, Clinical Academic Center of Coimbra, Coimbra, Portugal
| | - Nicola Nicolai
- Department of Surgery, Urology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Christoph Oing
- Department of Oncology, Freeman Hospital NHS Foundation Trust, London, UK
| | - Jan Oldenburg
- Department of Oncology, Akershus University Hospital, Lorenskog, Norway
| | - Robert Shepherd
- Department of Urology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Torgrim Tandstad
- Department of Oncology, The Cancer Clinic, St. Olav's University Hospital, Trondheim, Norway
| | - David Nicol
- Department of Urology, The Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer research, London, UK.
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Gerdtsson A, Torisson G, Thor A, Grenabo Bergdahl A, Almås B, Håkansson U, Törnblom M, Negaard HFS, Glimelius I, Halvorsen D, Karlsdóttir Á, Haugnes HS, Larsen SM, Holmberg G, Wahlqvist R, Tandstad T, Cohn-Cedermark G, Ståhl O, Kjellman A. Validation of a prediction model for post-chemotherapy fibrosis in nonseminoma patients. BJU Int 2023; 132:329-336. [PMID: 37129962 DOI: 10.1111/bju.16040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVE To validate Vergouwe's prediction model using the Swedish and Norwegian Testicular Cancer Group (SWENOTECA) RETROP database and to define its clinical utility. MATERIALS AND METHODS Vergouwe's prediction model for benign histopathology in post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) uses the following variables: presence of teratoma in orchiectomy specimen; pre-chemotherapy level of alpha-fetoprotein; β-Human chorionic gonadotropin and lactate dehydrogenase; and lymph node size pre- and post-chemotherapy. Our validation cohort consisted of patients included in RETROP, a prospective population-based database of patients in Sweden and Norway with metastatic nonseminoma, who underwent PC-RPLND in the period 2007-2014. Discrimination and calibration analyses were used to validate Vergouwe's prediction model results. Calibration plots were created and a Hosmer-Lemeshow test was calculated. Clinical utility, expressed as opt-out net benefit (NBopt-out ), was analysed using decision curve analysis. RESULTS Overall, 284 patients were included in the analysis, of whom 130 (46%) had benign histology after PC-RPLND. Discrimination analysis showed good reproducibility, with an area under the receiver-operating characteristic curve (AUC) of 0.82 (95% confidence interval 0.77-0.87) compared to Vergouwe's prediction model (AUC between 0.77 and 0.84). Calibration was acceptable with no recalibration. Using a prediction threshold of 70% for benign histopathology, NBopt-out was 0.098. Using the model and this threshold, 61 patients would have been spared surgery. However, only 51 of 61 were correctly classified as benign. CONCLUSIONS The model was externally validated with good reproducibility. In a clinical setting, the model may identify patients with a high chance of benign histopathology, thereby sparing patients of surgery. However, meticulous follow-up is required.
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Affiliation(s)
- Axel Gerdtsson
- Division of Urology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Gustav Torisson
- Department of Translational Medicine, Lund University, Lund, Sweden
| | - Anna Thor
- Division of Urology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Urology, Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Grenabo Bergdahl
- Department of Urology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Urology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenborg, Sweden
| | - Bjarte Almås
- Department of Urology, Haukeland University Hospital, Bergen, Norway
| | | | - Magnus Törnblom
- Section of Urology, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- Department of Surgery, Visby County Hospital, Visby, Sweden
| | | | - Ingrid Glimelius
- Department of Immunology, Genetics and Pathology, Cancer Precision Medicine, Uppsala University, Uppsala, Sweden
| | - Dag Halvorsen
- Department of Urology, St. Olavs University Hospital, Trondheim, Norway
| | - Ása Karlsdóttir
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Hege Sagstuen Haugnes
- Department of Oncology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UIT-The Arctic University of Norway, Tromsø, Norway
| | | | - Göran Holmberg
- Department of Urology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenborg, Sweden
| | - Rolf Wahlqvist
- Department of Urology, Oslo University Hospital, Oslo, Norway
| | - Torgrim Tandstad
- The Cancer Clinic, St. Olavs University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, The Norwegian University of Science and Technology, Trondheim, Norway
| | - Gabriella Cohn-Cedermark
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Genitourinary Oncology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Olof Ståhl
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Anders Kjellman
- Division of Urology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Urology, Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
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7
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Gilligan TD. Resection of Residual Masses After Chemotherapy for Metastatic Nonseminomatous Germ Cell Tumors in Adolescents and Adults. J Clin Oncol 2023; 41:3899-3904. [PMID: 37410968 DOI: 10.1200/jco.23.00654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/05/2023] [Accepted: 05/30/2023] [Indexed: 07/08/2023] Open
Abstract
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.
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8
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Antonelli L, Ardizzone D, Ravi P, Bagrodia A, Mego M, Daneshmand S, Nicolai N, Nazzani S, Giannatempo P, Franza A, Heidenreich A, Paffenholz P, Saoud R, Eggener S, Ho M, Oswald N, Olson K, Tryakin A, Fedyanin M, Naoun N, Javaud C, Fizazi K, King JM, Adra N, Douglawi A, Cary C, Sweeney C, Fankhauser CD. Risk of residual cancer after complete response following first-line chemotherapy in men with metastatic non-seminomatous germ cell tumour and International Germ Cell Cancer Cooperative Group intermediate/poor prognosis: A multi-institutional retrospective cohort study. Eur J Cancer 2023; 182:144-154. [PMID: 36787661 DOI: 10.1016/j.ejca.2022.12.032] [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] [Received: 12/03/2022] [Revised: 12/18/2022] [Accepted: 12/23/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Current guidelines recommend surveillance in metastatic non-seminomatous germ cell tumour patients treated with first-line-chemotherapy and a complete clinical response (normalisation of serum tumour markers and residual masses <1 cm). However, this recommendation is based on a series including patients with good prognosis according to International Germ Cell Cancer Cooperative Group prognostic group (IGCCCG-PG). The aim of this study was to analyse the proportion of residual teratoma and survival among patients with intermediate/poor IGCCCG-PG and a complete clinical response after first-line-chemotherapy. MATERIAL & METHODS This is a retrospective study of men with intermediate/poor IGCCCG-PG, who had a complete clinical response after first-line chemotherapy. Patients were either followed by surveillance or treated with post-chemotherapy retroperitoneal lymph node dissection (pcRPLND). RESULTS Between 2009 and 2018, 143 men with intermediate (n = 83) or poor (n = 60) IGCCCG-PG were treated at 11 international centres. Among 33 patients treated with pcRPLND, the specimen showed teratoma and viable cancer in 16 (48%) and 4 (12%). During a median a 7-year follow-up, 20/110 (18%) patients managed with surveillance relapsed, of whom seven (6%) had a retroperitoneal-only relapse versus 2/33 patients managed with pcRPLND relapsed. No difference was observed regarding overall survival (OS) among men treated with pcRPLND or surveillance (5-year OS, 93% and 89%, p-value = 0.35). The median time-to-recurrence among men on surveillance was 1.3 years (range: 0.3-9.1), and the most common sites of relapses included retroperitoneum (11%), chest (5%), and bones (4%). CONCLUSIONS While most men with intermediate/poor IGCCCG-PG harbour teratoma/cancer in the retroperitoneum despite a complete response to first-line-chemotherapy, only 6% managed with surveillance relapsed in the retroperitoneum. There was no significant difference in OS between the two groups.
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Affiliation(s)
- Luca Antonelli
- Department of Urology, Luzerner Kantonsspital, University of Lucerne, Switzerland; Department of Urology, Policlinico Umberto I, Rome, Italy
| | | | - Praful Ravi
- Department of Medicine, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Aditya Bagrodia
- Department of Urology, The University of Texas Southwestern, Dallas, TX, USA
| | - Michal Mego
- Department of Oncology, Comenius University, National Cancer Institute, Bratislava, Slovak Republic
| | - Siamak Daneshmand
- Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Nicola Nicolai
- Urologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sebastiano Nazzani
- Urologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Patrizia Giannatempo
- Urologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Andrea Franza
- Urologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Axel Heidenreich
- Department of Urology, Uro-Oncology, Robot Assisted and Reconstructive Urologic Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany; Department of Urology, Medical University, Vienna, Austria
| | - Pia Paffenholz
- Department of Urology, Uro-Oncology, Robot Assisted and Reconstructive Urologic Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Ragheed Saoud
- Section of Urology, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Scott Eggener
- Section of Urology, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Matthew Ho
- Section of Urology, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | | | | | - Alexey Tryakin
- N.N. Blokhin Russian Cancer Research Center, Moscow, Russian Federation
| | - Mikhail Fedyanin
- N.N. Blokhin Russian Cancer Research Center, Moscow, Russian Federation
| | | | | | - Karim Fizazi
- Institut Gustave Roussy, Villejuif Cedex, France
| | - Jennifer M King
- Division of Medical Oncology, Indiana University School of Medicine, Indianapolis, USA
| | - Nabil Adra
- Division of Medical Oncology, Indiana University School of Medicine, Indianapolis, USA
| | - Antoin Douglawi
- Division of Medical Oncology, Indiana University School of Medicine, Indianapolis, USA
| | - Clint Cary
- Division of Medical Oncology, Indiana University School of Medicine, Indianapolis, USA
| | - Christopher Sweeney
- Department of Medicine, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Christian D Fankhauser
- Department of Urology, Luzerner Kantonsspital, University of Lucerne, Switzerland; University of Zurich, Zurich, Switzerland.
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Abstract
Testicular cancer is a curable cancer. The success of physicians in curing the disease is underpinned by multidisciplinary advances. Cisplatin-based combination chemotherapy and the refinement of post-chemotherapy surgical procedures and diagnostic strategies have greatly improved long term survival in most patients. Despite such excellent outcomes, several controversial dilemmas exist in the approaches to clinical stage I disease, salvage chemotherapy, post-chemotherapy surgical procedures, and implementing innovative imaging studies. Relapse after salvage chemotherapy has a poor prognosis and the optimal treatment is not apparent. Recent research has provided insight into the molecular mechanisms underlying cisplatin resistance. Phase 2 studies with targeted agents have failed to show adequate efficacy; however, our understanding of cisplatin resistant disease is rapidly expanding. This review summarizes recent advances and discusses relevant issues in the biology and management of testicular cancer.
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Affiliation(s)
- Michal Chovanec
- 2nd Department of Oncology, Faculty of Medicine, Comenius University, National Cancer Institute, Bratislava, Slovakia
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School of Brown University, Lifespan Academic Medical Center, Providence, RI, USA
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10
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Conduit C, Hong W, Martin F, Thomas B, Lawrentschuk N, Goad J, Grimison P, Ahmadi N, Tran B, Lewin J. A meta-analysis of clinicopathologic features that predict necrosis or fibrosis at post-chemotherapy retroperitoneal lymph node dissection in individuals receiving treatment for non-seminoma germ cell tumours. Front Oncol 2022; 12:931509. [PMID: 36059636 PMCID: PMC9428700 DOI: 10.3389/fonc.2022.931509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Post-chemotherapy retroperitoneal lymph node dissection (pcRPLND) for residual nodal masses is a critical component of care in metastatic testicular germ cell tumour (GCT). However, the procedure is not of therapeutic value in up to 50% of individuals in whom histopathology demonstrates post-treatment necrosis or fibrosis alone. Improved diagnostic tools and clinicopathologic features are needed to separate individuals who benefit from pcRPLND and avoid surgery in those who do not. Methods A prospectively registered meta-analysis of studies reporting clinicopathologic features associated with teratoma, GCT and/or necrosis/fibrosis at pcRPLND for metastatic non-seminoma GCT (NSGCT) was undertaken. We examined the effect of various clinicopathologic factors on the finding of necrosis/fibrosis at pcRPLND. The log odds ratios (ORs) of each association were pooled using random-effects models. Results Using the initial search strategy, 4,178 potentially eligible abstracts were identified. We included studies providing OR relating to clinicopathologic factors predicting pcRPLND histopathology, or where individual patient-level data were available to permit the calculation of OR. A total of 31 studies evaluating pcRPLND histopathology in 3,390 patients were eligible for inclusion, including two identified through hand-searching the reference lists of eligible studies. The following were associated with the presence of necrosis/fibrosis at pcRPLND: absence of teratomatous elements in orchidectomy (OR 3.45, 95% confidence interval [CI] 2.94-4.17); presence of seminomatous elements at orchidectomy (OR 2.71, 95% CI 1.37-5.37); normal pre-chemotherapy serum bHCG (OR 1.96, 95% CI 1.62-2.36); normal AFP (OR 3.22, 95% CI 2.49–4.15); elevated LDH (OR 1.72, 95% CI 1.37-2.17); >50% change in mass during chemotherapy (OR 4.84, 95% CI 3.94-5.94); and smaller residual mass size (<2 cm versus >2 cm: OR 3.93, 95% CI 3.23-4.77; <5 cm versus >5 cm: OR 4.13, 95% CI 3.26-5.23). Conclusions In this meta-analysis, clinicopathologic features helped predict the presence of pcRPLND necrosis/fibrosis. Collaboration between centres that provide individual patient-level data is required to develop and validate clinical models and inform routine care to direct pcRPLND to individuals most likely to derive benefits. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD42021279699
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Affiliation(s)
- Ciara Conduit
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
- Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Wei Hong
- Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Department of Medical Oncology, St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Felicity Martin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Benjamin Thomas
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Nathan Lawrentschuk
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jeremy Goad
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Peter Grimison
- Department of Medical Oncology, Chris O’Brien Lifehouse, Camperdown, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Nariman Ahmadi
- Department of Urology, Chris O’Brien Lifehouse, Camperdown, NSW, Australia
| | - Ben Tran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
- Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Jeremy Lewin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
- ONTrac at Peter Mac, Victorian Adolescence and Young Adult Cancer Service, Melbourne, VIC, Australia
- *Correspondence: Jeremy Lewin,
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11
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Zor M, Yilmaz S, Topuz B, Kaya E, Yalcin S, Coguplugil AE, Ince ME, Gurdal M. Post-chemotherapy modified template retroperitoneal lymph node dissection in patients with nonseminomatous germ cell tumours. Aktuelle Urol 2022; 53:325-330. [PMID: 34734394 DOI: 10.1055/a-1469-6892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Murat Zor
- Department of Urology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Sercan Yilmaz
- Department of Urology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Bahadir Topuz
- Department of Urology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Engin Kaya
- Department of Urology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Serdar Yalcin
- Department of Urology, Gulhane Research and Training Hospital, Ankara, Turkey
| | | | - Mehmet Emin Ince
- Department of Urology, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Mesut Gurdal
- Department of Urology, Gulhane Research and Training Hospital, Ankara, Turkey
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12
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Moore JA, Lehner MJ, Anfossi S, Datar S, Tidwell RS, Campbell M, Shah AY, Ward JF, Karam JA, Wood CG, Pisters LL, Calin GA, Tu S. Predictive capacity of a miRNA panel in identifying teratoma in post-chemotherapy consolidation surgeries. BJUI COMPASS 2022; 4:81-87. [PMID: 36569509 PMCID: PMC9766861 DOI: 10.1002/bco2.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/15/2021] [Accepted: 02/18/2022] [Indexed: 12/27/2022] Open
Abstract
Objectives To investigate the utility of a novel serum miRNA biomarker panel to distinguish teratoma from nonmalignant necrotic/fibrotic tissues or nonviable tumours in patients with NSGCT undergoing post-chemotherapy consolidation surgery. Patients and methods We prospectively collected pre-surgical serum samples from 22 consecutive testicular NSGCT patients with residual NSGCT after chemotherapy undergoing post-chemotherapy consolidation surgery. We measured serum miRNA expression of four microRNAs (miRNA-375, miRNA-200a-3p, miRNA-200a-5p and miRNA-200b-3p) and compared with pathologic findings at time of surgery. Receiver operating characteristic (ROC) curves were performed to assess the ability of these miRNA to differentiate between teratoma and necrosis or viable malignancy. Results Twenty-two patients with NSGCT were split into two groups based on pathology at time of post-chemotherapy consolidation surgery (teratoma group vs. necrosis/fibrosis/viable tumour group, i.e., NFVT). Patients with teratoma were older at diagnosis compared with those patients with NFVT (median age 28.7 vs. 23.9). Patients with NFVT were more likely to have embryonal carcinoma in their primary tumour (81.8% vs. 27.3%; p = 0.01). The majority of patients in both groups were stage III (63.6% vs. 72.7%). In this analysis, none of the miRNAs had good sensitivity or specificity to predict teratoma. There was no significant association between the expression levels of the miRNAs and the presence of teratoma. There was no statistically significant correlation between any of the miRNAs and teratoma size. Conclusion This novel miRNA panel (miRNA-375, miRNA-200a-3p, miRNA-200a-5p and miRNA-200b-3p) did not distinguish teratoma from nonmalignant necrotic/fibrotic tissues or nonviable tumours in patients with NSGCT undergoing post-chemotherapy consolidation surgery.
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Affiliation(s)
- Joseph A. Moore
- Department of Genitourinary Medical OncologyDivision of Cancer Medicine, University of Texas MD Anderson Cancer CenterHoustonTX
| | - Michael J. Lehner
- Department of Internal MedicineUniversity of Texas Health Science Center at HoustonHoustonTXUSA
| | - Simone Anfossi
- Department of Translational Molecular PathologyDivision of Pathology/Lab Medicine, University of Texas MD Anderson Cancer CenterHoustonTX
| | - Saumil Datar
- Department of Internal MedicineUniversity of Texas Health Science Center at HoustonHoustonTXUSA
| | - Rebecca S. Tidwell
- Department of BiostatisticsUniversity of Texas MD Anderson Cancer CenterTXHoustonTX
| | - Matthew Campbell
- Department of Genitourinary Medical OncologyDivision of Cancer Medicine, University of Texas MD Anderson Cancer CenterHoustonTX
| | - Amishi Y. Shah
- Department of Genitourinary Medical OncologyDivision of Cancer Medicine, University of Texas MD Anderson Cancer CenterHoustonTX
| | - John F. Ward
- Department of UrologyDivision of Surgery, University of Texas MD Anderson Cancer CenterHoustonTX
| | - Jose A. Karam
- Department of UrologyDivision of Surgery, University of Texas MD Anderson Cancer CenterHoustonTX
| | - Christopher G. Wood
- Department of UrologyDivision of Surgery, University of Texas MD Anderson Cancer CenterHoustonTX
| | - Lois L. Pisters
- Department of UrologyDivision of Surgery, University of Texas MD Anderson Cancer CenterHoustonTX
| | - George A. Calin
- Department of Translational Molecular PathologyDivision of Pathology/Lab Medicine, University of Texas MD Anderson Cancer CenterHoustonTX
| | - Shi‐Ming Tu
- Department of Genitourinary Medical OncologyDivision of Cancer Medicine, University of Texas MD Anderson Cancer CenterHoustonTX
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13
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Abu-Salha YM, Ahlschlager L, Milowsky MI, Saunders K, Rose TL, Wobker SE, Bjurlin MA. Vigilance is key: Metastatic teratoma in an enlarging retroperitoneal mass after treatment of advanced seminoma – a case report. JOURNAL OF CLINICAL UROLOGY 2022. [DOI: 10.1177/20514158221075411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We present the case of a patient with pure seminoma in the orchiectomy specimen with retroperitoneal mass and a minimally elevated alpha fetoprotein (AFP). The patient received chemotherapy with positron emission tomography (PET) imaging demonstrating minimal fluorodeoxyglucose (FDG) uptake consistent with no viable tumour. Subsequent imaging revealed slow growth in the residual mass with a mildly elevated fluctuating AFP. A robotic-assisted laparoscopic retroperitoneal lymph node dissection was performed revealing metastatic teratoma. This case illustrates the potential for a missed or ‘burned out’ occult NSGCT in a patient with pure seminoma and the importance of post-treatment surveillance. In advanced seminoma, PET may be used to distinguish viable tumour from necrosis in post-chemotherapy residual masses. However, it is unable to distinguish between teratoma and necrosis in non-seminomatous germ cell tumours (NSGCT). Minimally elevated AFP could be a normal variant or signify a component of NSGCT in such cases. Level of evidence: 4
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Affiliation(s)
- Yousef M Abu-Salha
- Department of Urology, The University of North Carolina at Chapel Hill (UNC), USA
| | - Lauren Ahlschlager
- Department of Urology, The University of North Carolina at Chapel Hill (UNC), USA
- UNC School of Medicine, The University of North Carolina at Chapel Hill (UNC), USA
| | - Matthew I Milowsky
- Division of Oncology, The University of North Carolina at Chapel Hill (UNC), USA
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill (UNC), USA
| | - Katherine Saunders
- Department of Pathology and Laboratory Medicine, The University of North Carolina at Chapel Hill (UNC), USA
| | - Tracy L Rose
- Division of Oncology, The University of North Carolina at Chapel Hill (UNC), USA
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill (UNC), USA
| | - Sara E Wobker
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill (UNC), USA
- Department of Pathology and Laboratory Medicine, The University of North Carolina at Chapel Hill (UNC), USA
| | - Marc A Bjurlin
- Department of Urology, The University of North Carolina at Chapel Hill (UNC), USA
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill (UNC), USA
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14
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Moore JA, Slack RS, Lehner MJ, Campbell MT, Shah AY, Zhang M, Guo CC, Ward JF, Karam JA, Wood CG, Pisters LL, Tu SM. Very Late Recurrence in Germ Cell Tumor of the Testis: Lessons and Implications. Cancers (Basel) 2022; 14:cancers14051127. [PMID: 35267435 PMCID: PMC8909729 DOI: 10.3390/cancers14051127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/01/2022] [Accepted: 02/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background. Very late recurrence (LR), i.e., >5 years after initial presentation, occurs in about 1% of patients with germ cell tumors of the testis (TGCT) and is associated with poor prognosis. Methods. We retrospectively reviewed the records of patients at the M. D. Anderson Cancer Center who developed LR > 5 years after their initial diagnosis of TGCT. Results. We identified 25 patients who developed LR between July 2007 and August 2020. The median age at the time of LR was 46 years (range, 29−61). Pathology of LR: somatic transformation to carcinoma or sarcoma—11, nonseminoma with yolk sac tumor or teratoma—11, nonseminoma without yolk sac tumor or teratoma—2, not available—1. With a median follow-up of 3.5 years, 68% of patients are alive 3 years after LR. Patients with prior post-chemotherapy consolidation surgery do not have statistically significant longer survival compared to patients who did not receive post-chemotherapy consolidation surgery, 83.3% vs. 60.8% at 3 years, respectively, p = 0.50. Conclusions. Patients with LR > 5 years tend to harbor nonseminoma (with yolk sac tumor and or teratoma). Among these patients, a majority who did not undergo surgery to remove residual disease after chemotherapy developed somatic transformation and succumbed to their LR.
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Affiliation(s)
- Joseph A. Moore
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Rebecca S. Slack
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Michael J. Lehner
- Department of Internal Medicine, University of Texas Health Science Center, Houston, TX 77030, USA;
| | - Matthew T. Campbell
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.T.C.); (A.Y.S.)
| | - Amishi Y. Shah
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.T.C.); (A.Y.S.)
| | - Miao Zhang
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.Z.); (C.C.G.)
| | - Charles C. Guo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.Z.); (C.C.G.)
| | - John F. Ward
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.F.W.); (J.A.K.); (C.G.W.); (L.L.P.)
| | - Jose A. Karam
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.F.W.); (J.A.K.); (C.G.W.); (L.L.P.)
| | - Christopher G. Wood
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.F.W.); (J.A.K.); (C.G.W.); (L.L.P.)
| | - Louis L. Pisters
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.F.W.); (J.A.K.); (C.G.W.); (L.L.P.)
| | - Shi-Ming Tu
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.T.C.); (A.Y.S.)
- Correspondence:
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15
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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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16
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Tiwari S, Agrawal S. Consolidative radiation in partial responders/unresectable/recurrent disease after first-line/salvage chemotherapy in poor-risk nonseminomatous germ cell tumor prolongs survival: A new paradigm? J Cancer Res Ther 2022. [DOI: 10.4103/jcrt.jcrt_1859_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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17
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Green DB, Rosa FGL, Craig PG, Khani F, Lam ET. Metastatic Mature Teratoma and Growing Teratoma Syndrome in Patients with Testicular Non-Seminomatous Germ Cell Tumors. Korean J Radiol 2021; 22:1650-1657. [PMID: 34402242 PMCID: PMC8484155 DOI: 10.3348/kjr.2020.1391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/14/2021] [Accepted: 05/10/2021] [Indexed: 11/17/2022] Open
Abstract
Metastatic mature teratoma is a common radiologic and histopathologic finding after chemotherapy for metastatic non-seminomatous germ cell tumors. The leading theory for these residual tumors is the selective chemotherapy resistance of teratomas versus the high chemotherapy sensitivity of the embryonal components. Growing teratoma syndrome is a relatively rare phenomenon defined as an enlarging residual mass histologically proven to be a mature teratoma in the setting of normal serum tumor markers. Metastatic mature teratomas should be resected because of their malignant potential and occasional progression to growing teratoma syndrome with the invasion of the surrounding structures. CT is the preferred imaging modality for post-chemotherapy surveillance and should cover all sites of potential metastatic disease. This article reviews the clinical, pathologic, and multimodality imaging features of metastatic mature teratomas in patients with primary testicular non-seminomatous germ cell tumors.
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Affiliation(s)
- Daniel B Green
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA.
| | - Francisco G La Rosa
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Paul G Craig
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Francesca Khani
- Department of Pathology & Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Elaine T Lam
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, UCHealth Tony Grampsas Urologic Cancer Care Clinic, Anschutz Medical Campus, Aurora, CO, USA
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18
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Funt SA, McHugh DJ, Tsai S, Knezevic A, O'Donnell D, Patil S, Silber D, Bromberg M, Carousso M, Reuter VE, Carver BS, Sheinfeld J, Motzer RJ, Bajorin DF, Bosl GJ, Feldman DR. Four Cycles of Etoposide plus Cisplatin for Patients with Good-Risk Advanced Germ Cell Tumors. Oncologist 2021; 26:483-491. [PMID: 33586274 PMCID: PMC8176973 DOI: 10.1002/onco.13719] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/05/2021] [Indexed: 01/08/2023] Open
Abstract
Background The National Comprehensive Cancer Network recommends either three cycles of bleomycin, etoposide, and cisplatin or four cycles of etoposide and cisplatin (EPx4) as initial chemotherapy for the treatment of good‐risk germ cell tumors (GCTs). To assess the response, toxicity, and survival outcomes of EPx4, we analyzed our experience. Material and Methods Response and survival outcomes, selected toxicities, and adherence to chemotherapy dose and schedule were assessed in patients with good‐risk GCT who received EPx4 at Memorial Sloan Kettering Cancer Center between 1982 and 2016. The results were compared with our past results and published data. Results Between 1982 and 2016, 944 patients with GCT were treated with EPx4, 289 who were previously reported plus 655 treated between January 2000 and August 2016. A favorable response was achieved in 928 of 944 patients (98.3%). Five‐year progression‐free, disease‐specific, and overall survival rates were 93.9%, 98.6%, and 97.9%, respectively. Median follow‐up was 7.3 years (range, 2.8 months to 35.5 years). Viable, nonteratomatous malignant GCT was present in 3.5% of 432 postchemotherapy retroperitoneal lymph node dissection specimens from patients with nonseminomatous GCT. Febrile neutropenia and thromboembolic events occurred in 16.0% and 8.9%, respectively, with one treatment‐related death. In the more recent 655‐patient cohort, full‐dose EPx4 was administered to 631 (96.3%), with deviations from planned treatment driven mainly by vascular (n = 13), hematologic (n = 11), renal (n = 7), or infectious (n = 5) events. Conclusion EPx4 is highly effective and well tolerated in patients with good‐risk GCTs and remains a standard of care. Implications for Practice Four cycles of etoposide and cisplatin (EPx4) is a standard‐of‐care regimen for all patients with good‐risk germ cell tumors with a favorable response rate and disease‐specific survival of 98%. Full‐dose administration of etoposide and cisplatin and complete resection of residual disease lead to optimal outcomes. EPx4 should be the recommended regimen in active smokers, patients with reduced or borderline kidney function, and patients aged 50 years or older, which are patient groups at increased risk for bleomycin pulmonary toxicity. Because of a risk of acquired severe pulmonary illness, EPx4 may also be favored for patients who vape or use e‐cigarettes and during ongoing transmission of severe acute respiratory syndrome coronavirus 2. The NCCN recommends either three cycles of bleomycin, etoposide, and cisplatin (BEPx3) or four cycles of etoposide and cisplatin (EPx4) as initial chemotherapy for the treatment of good‐risk germ cell tumors. This article assesses outcomes specific to EPx4 treatment.
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Affiliation(s)
- Samuel A Funt
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA.,Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Deaglan J McHugh
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA.,Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Stephanie Tsai
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Andrea Knezevic
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Devon O'Donnell
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Deborah Silber
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Maria Bromberg
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Maryann Carousso
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Victor E Reuter
- Department of Pathology, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Brett S Carver
- Department of Urology, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Joel Sheinfeld
- Department of Urology, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Robert J Motzer
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA.,Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Dean F Bajorin
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA.,Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - George J Bosl
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA.,Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
| | - Darren R Feldman
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA.,Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York, USA
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Torres L, Ramos JG, Varela R, Godoy F, Orrego PA, Mosquera A, Vecino SVP. Factores asociados a la histología de masa residual retroperitoneal post quimioterapia en tumor testicular de células germinales. Rev Urol 2020. [DOI: 10.1055/s-0040-1721357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Resumen
Objetivo El objetivo de este estudio es describir las características y factores relacionados con la histología de la masa residual postquimioterapia en pacientes con tumor de células germinales de origen testicular sometidos a linfadenectomía retroperitoneal durante 12 años de seguimiento.
Métodos Retrospectivamente se recolectaron datos clínicos, quirúrgicos y patológicos de la historia clínica de los pacientes en un centro de referencia de manejo de cáncer durante un periodo de 12 años. Se estimó la asociación entre los datos recolectados con la histología del tumor residual post quimioterapia.
Resultados Se incluyeron 64 pacientes, la edad promedio fue 28.1 años, el tamaño promedio de masa residual fue de 6.7 cm. La histología de la masa residual fue teratoma en 60.9%, necrosis 26.5% y tumor viable 12.5%. El grupo pronóstico tiene asociación con la histología de la masa retroperitoneal. Las masas con histología de necrosis tuvieron menor tamaño con media 6.5 cm mientras que otras histologías tuvieron tamaño promedio de la masa residual de 10.4 cm.
Conclusiones La LNDRP-PC es el estándar de tratamiento en masas residuales retroperitoneales después de quimioterapia y puede generar sobre-tratamiento hasta en 50% de los casos. El teratoma en la histología testicular está relacionado mayor tamaño de la masa residual retroperitoneal. Las características histológicas de la masa residual son comparables con otras series.
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Affiliation(s)
- Lynda Torres
- Médica Uróloga. Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Jose Gustavo Ramos
- Médico Urólogo, Urología Oncológica, Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Rodolfo Varela
- Médico Urólogo, Urología Oncológica, Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Fabian Godoy
- Médico Urólogo, Urología Oncológica, Instituto Nacional de Cancerología, Bogotá, Colombia
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20
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Cotner CE, Hilton S, Mamtani R, Guzzo T, Vaughn DJ. Surveillance of postchemotherapy subcentimeter residual retroperitoneal mass in metastatic nonseminomatous germ cell tumor: Does how you measure matter? Urol Oncol 2020; 39:136.e11-136.e17. [PMID: 33308971 DOI: 10.1016/j.urolonc.2020.11.026] [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: 07/01/2020] [Revised: 11/08/2020] [Accepted: 11/15/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Approximately 70% to 80% of patients with metastatic nonseminomatous germ cell tumor (NSGCT) treated with cisplatin-based chemotherapy achieve a complete response, defined as normalization of serum tumor markers and either no residual retroperitoneal mass (RRM) or an RRM <1.0 cm. While there is universal agreement that patients with an RRM ≥1.0 cm should undergo retroperitoneal lymph node dissection (RPLND), many institutions including ours recommend surveillance for patients who achieve a complete response. However, studies have not defined which axis of the RRM should be considered when deciding between surveillance and RPLND. PATIENTS AND METHODS Good-risk metastatic NSGCT patients treated with cisplatin-based chemotherapy who achieved a complete response and underwent surveillance were identified using our institution's electronic medical records. A post-hoc review was performed by a blinded radiologist. The RRM dimensions in the transaxial short axis (TSA), transaxial long axis (TLA), and craniocaudal axis (CCA) were recorded. Differences in the frequency of recurrence between groups with an RRM <1.0 cm and ≥1.0 cm in the TLA and CCA were assessed using the Fisher exact test. RESULTS Thirty-nine patients who met study criteria were included. At a median follow-up of 63.8 months, 2 patients (5.1%) recurred. Both were successfully treated with salvage chemotherapy and RPLND. Thirteen (33%) and 27 (69%) patients had an RRM ≥1.0 cm in the TLA and CCA, respectively. There were no statistically significant differences in the risk of recurrence between patients with an RRM <1.0 cm and ≥1.0 cm in the TLA (P = 0.54) or CCA (P = 0.53). CONCLUSIONS Surveillance is an effective strategy in good-risk NSGCT patients with a postchemotherapy RRM <1.0 cm in the TSA. Our study suggests referencing the TSA and not the TLA or CCA may avoid unnecessary postchemotherapy RPLNDs.
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Affiliation(s)
- Cody E Cotner
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Susan Hilton
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Ronac Mamtani
- Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA
| | - Thomas Guzzo
- Division of Urology, University of Pennsylvania, Philadelphia, PA
| | - David J Vaughn
- Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA.
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21
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Kozakova K, Mego M, Cheng L, Chovanec M. Promising novel therapies for relapsed and refractory testicular germ cell tumors. Expert Rev Anticancer Ther 2020; 21:53-69. [PMID: 33138660 DOI: 10.1080/14737140.2021.1838279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Germ cell tumors (GCTs) are the most common solid malignancies in young men. The overall cure rate of GCT patients in metastatic stage is excellent, however; patients with relapsed or refractory disease have poor prognosis. Attempts to treat refractory disease with novel effective treatment to improve prognosis have been historically dismal and the ability to predict prognosis and treatment response in GCTs did not sufficiently improve in the last three decades. AREAS COVERED We performed a comprehensive literature search of PubMed/MEDLINE to identify original and review articles (years 1964-2020) reporting on current improvement salvage treatment in GCTs and novel treatment options including molecularly targeted therapy and epigenetic approach. Review articles were further searched for additional original articles. EXPERT OPINION Despite multimodal treatment approaches the treatment of relapsed or platinum-refractory GCTs remains a challenge. High-dose chemotherapy (HDCT) regimens with autologous stem-cell transplant (ASCT) from peripheral blood showed promising results in larger retrospective studies. Promising results from in vitro studies raised high expectations in molecular targets. So far, the lacking efficacy in small and unselected trials do not shed a light on targeted therapy. Currently, wide inclusion of patients into clinical trials is highly advised.
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Affiliation(s)
- Kristyna Kozakova
- Department of Anesthesiology and Intensive Care Medicine, National Cancer Institute , Bratislava, Slovakia.,2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute , Bratislava, Slovakia
| | - Michal Mego
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute , Bratislava, Slovakia.,Division of Hematology Oncology, Indiana University Simon Cancer Center , Indianapolis, IN, USA
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine , Indianapolis, IN, USA.,Department of Urology, Indiana University School of Medicine , Indianapolis, IN, USA
| | - Michal Chovanec
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute , Bratislava, Slovakia.,Division of Hematology Oncology, Indiana University Simon Cancer Center , Indianapolis, IN, USA
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22
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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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23
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Nason GJ, Jewett MAS, Bostrom PJ, Goldberg H, Hansen AR, Bedard PL, Sturgeon J, Warde P, Chung P, Anson-Cartwright L, Sweet J, Atenafu EG, O'Malley M, Hamilton RJ. Long-term Surveillance of Patients with Complete Response Following Chemotherapy for Metastatic Nonseminomatous Germ Cell Tumor. Eur Urol Oncol 2020; 4:289-296. [PMID: 32907779 DOI: 10.1016/j.euo.2020.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 07/13/2020] [Accepted: 08/18/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is controversy regarding the management of patients with normal markers and residual masses (≤1 cm) after chemotherapy for nonseminomatous germ cell tumors (NSGCTs). OBJECTIVE To determine long-term outcomes of a surveillance strategy in such patients. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of our multidisciplinary testicular cancer database was performed. All patients who underwent primary chemotherapy for metastatic NSGCTs were identified between 1981 and 2016. A complete response (CR) was defined as normalization of serum tumor markers and a ≤1 cm residual mass in the largest axial dimension following chemotherapy. All such patients were surveilled. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Outcome variables of interest were time to death, time to cancer-specific survival, and time to relapse. Overall survival and relapse-free survival were calculated using the Kaplan-Meier method, and the cumulative incidence of cause-specific survival rates was calculated using competing risk analysis. The impact of risk group and chemotherapy regimen on relapse-free survival was assessed using log-rank test. RESULTS AND LIMITATIONS During the study period, 1429 metastatic germ cell tumor patients were treated with primary chemotherapy. CR was achieved in 191 (18.5%) NSGCT patients. The median age at diagnosis was 27.4 yr, with a median follow-up of 81.1 mo. The majority had American Joint Committee on Cancer stage II at diagnosis (I: 23.8%; II: 49.2%; III: 27%) and International Germ Cell Cancer Collaborative Group good-risk disease (good: 78%; intermediate: 17.8%; poor: 4.2%). Of the 191 patients with a CR, 175 (91.6%) never relapsed and remain disease free. Sixteen (8.4%) patients relapsed after a median of 11.3 mo (range 1-332 mo), with over half (nine patients; 4.7%) relapsing in the retroperitoneum only and salvaged successfully with postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) alone. Of these nine patients, only two (1%) had viable disease in the PC-RPLND specimen. The remaining seven patients had relapses outside the retroperitoneum and received salvage chemotherapy ± postchemotherapy resection. Overall, nine (4.7%) patients have died, but only four (2.1%) from testis cancer. CONCLUSIONS Our data, the largest series to date, confirm that surveillance is safe and effective for men who achieve a CR following chemotherapy for metastatic NSGCTs. PATIENT SUMMARY Surveillance is a safe strategy for patients who achieve a complete response following chemotherapy for metastatic testis cancer.
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Affiliation(s)
- Gregory J Nason
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Michael A S Jewett
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Peter J Bostrom
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Hanan Goldberg
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, 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
| | - Jeremy Sturgeon
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Padraig Warde
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Peter Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Lynn Anson-Cartwright
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Joan Sweet
- Department of Pathology and Lab Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Martin O'Malley
- Division of Abdominal Imaging, Joint Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada.
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24
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John P, Albers P, Hiester A, Heidenreich A. [Retroperitoneal lymph node dissection in testicular germ cell tumours: indications, complications and special cases]. Aktuelle Urol 2020; 51:475-481. [PMID: 32557448 DOI: 10.1055/a-1176-9796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
ZusammenfassungDie retroperitoneale Lymphadenektomie ist integraler Bestandteil der stadienadaptierten Therapie von testikulären Keimzelltumoren. Verschiedene Ansätze der retroperitonealen Lymphadenektomie werden auf Basis unterschiedlicher Indikationen durchgeführt.Die nervschonende retroperitoneale Lymphadenektomie als primäre Therapieoption bei nicht seminomatösen Keimzelltumoren im klinischen Stadium I sollte risikoadaptiert erfolgen. Geringfügige perioperative Komplikationen wie Wundinfekte, Lymphozelen und paralytischer Ileus treten bei in etwa 14 % der Patienten auf. Schwerwiegendere Komplikationen wie chylärer Aszites und Lungenarterienembolien treten bei ca. 5,4 % der Patienten auf. Die häufigste Langzeitkomplikation ist hierbei das Auftreten einer Retrograden Ejakulation. Der Erhalt der antegraden Ejakulation kann jedoch bei weit über 90 % der Patienten erreicht werden.Die postchemotherapeutische retroperitoneale Lymphadenektomie ist integraler Bestandteil der multimodalen Therapie bei retroperitonealen Residualbefunden. Bei residuellen Befunden > 3 cm beim fortgeschrittenen Seminom dient das FDG PET als zuverlässige Entscheidungshilfe zur Durchführung einer retroperitonealen Lymphadenektomie.Bei ca. 30 % der Patienten mit nicht seminomatösen Keimzelltumoren finden sich residuelle retroperitoneale Tumorbefunde. Diese sollten unabhängig von der Größe der Befunde bei negativen Serumtumormarkern oder Serumtumormarkern im Plateau komplett reseziert werden. Die postchemotherapeutische retroperitoneale Lymphadenektomie stellt einen herausfordernden Eingriff dar und sollte primär an ausgewiesenen Zentren durchgeführt werden. Bei bis zu 25 % der Patienten ist im Rahmen der postchemotherapeutischen retroperitonealen Lymphadenektomie die Resektion umgebender Strukturen indiziert. Eine Beteiligung der aorta abdominalis liegt in 6 – 10 % der Fälle vor, eine Beteiligung der vena cava in ca. 2 % der Fälle. Komplikationsraten liegen bei der postchemotherapeutischen retroperitonealen Lymphadenektomie höher als bei der primären nervschonenenden Lymphadenektomie mit signifikant höherem intraoperativen Blutverlust und signifikant höherer Transfusionsrate. Mit einer Wahrscheinlichkeit von 2 – 7 % tritt chylärer Aszites nach postchemotherapeutischer retroperitonealer Lymphadenektomie häufiger auf. Jedoch kann auch im Rahmen der postchemotherapeutischen Lymphadenektomie bei bis zu 85 % der Erhalt der antegraden Ejakulation erreicht werden. Entscheidend für den Erhalt der antegraden Ejakulation und einer Verbesserung der Morbidität insgesamt ist auch hier das nach Möglichkeit das Anstreben eines nervsparenden Vorgehens durch Anpassung der Felder.
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25
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Grenn EE, Anderson CD, Earl TM, Orr WS. Malignant Somatic Transformation of a Teratoma 15 Years Following Completion Therapy for a Germ Cell Tumor. Am Surg 2020; 86:527-528. [PMID: 32684045 DOI: 10.1177/0003134820919738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Emily E Grenn
- 21693 Department of Surgery, University of Mississippi Medical Center School of Medicine, Jackson, MS, USA
| | - Christopher D Anderson
- 21693 Department of Surgery, University of Mississippi Medical Center School of Medicine, Jackson, MS, USA
| | - T Mark Earl
- 21693 Department of Surgery, University of Mississippi Medical Center School of Medicine, Jackson, MS, USA
| | - W Shannon Orr
- 21693 Department of Surgery, University of Mississippi Medical Center School of Medicine, Jackson, MS, USA
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26
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Öztürk Ç, Hoekstra HJ, Hemmer PHJ, Gietema JA, Kruijff S. Posterior retroperitoneoscopic resection of recurrent nonseminomatous tumor mass: a case report of the surgical procedure. J Surg Case Rep 2020; 2020:rjaa122. [PMID: 32665838 PMCID: PMC7342175 DOI: 10.1093/jscr/rjaa122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/22/2020] [Indexed: 11/14/2022] Open
Abstract
Treatment of stage II-IV nonseminomatous testicular germ cell tumors (NSTGCTs) consists of cisplatin-based combination chemotherapy and, when present, resection of residual retroperitoneal tumor mass (RRTM) by conventional laparotomy or laparoscopy. In case of a retroperitoneal recurrence, a second conventional or laparoscopic procedure may be challenging. A case of late relapse after prior conventional resection of a RRTM and tailor-made surgical management with a posterior retroperitoneoscopic resection (PRR) is reported. A posterior retroperitoneoscopic RRTM resection was performed in a 26-year-old male with a history of stage IIC NSTGCT, presenting with a late left-sided retroperitoneal relapse, 6 years after initial treatment. Postoperative course was uneventful and at 1-year follow-up the patient had no evidence of disease. Reoperative surgery by a minimal invasive retroperitoneoscopic approach should be considered as an alternative for patients with a recurrent retroperitoneal tumor mass of a NSTGCT.
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Affiliation(s)
- Çiğdem Öztürk
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Harald J Hoekstra
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Patrick H J Hemmer
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Jourik A Gietema
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Schelto Kruijff
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
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27
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Malik K, Raja A, Radhakrishnan V, Kathiresan N. A retrospective analysis of patients undergoing postchemotherapy retroperitoneal lymph node dissection and metastasectomy in advanced nonseminomatous germ cell tumors. Indian J Urol 2020; 36:112-116. [PMID: 32549662 PMCID: PMC7279107 DOI: 10.4103/iju.iju_301_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 01/21/2020] [Accepted: 02/02/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction: Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) and metastasectomy play an important role in the management of advanced-stage nonseminomatous germ cell tumors (NSGCT). We aimed to analyze preoperative parameters that could predict postoperative histology. Materials and Methods: We analyzed the data of 72 patients who underwent PC-RPLND and 14 patients who underwent metastasectomy after receiving cisplatin- or carboplatin-based chemotherapy for advanced stage NSGCT at our institute from 1994 to 2015. Clinical and pathological parameters such as the histology of orchidectomy, RPLND and metastasectomy, serum tumor markers, and the pre and post chemotherapy retroperitoneal lymph node size were recorded. Results: Seventy-two patients with a mean age of 28 years underwent PC-RPLND. Of the various variables evaluated, only percentage change in nodal size was found to be statistically significant in predicting necrosis (P = 0.004). A decrease of 75% was found to predict the necrosis with a specificity of 100%. There was 84.6% concordance between the histology of RPLND and that of metastasectomy. Conclusion: A 75% reduction in tumor size is highly predictive of absence of viable tumor or teratoma, however larger series are required to confirm these findings. RPLND histopathologies have a high concordance with metastasectomy histology and thus can be used as a guide to tailor further management.
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Affiliation(s)
- Kanuj Malik
- Department of Surgical, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | - Anand Raja
- Department of Surgical, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | | | - N Kathiresan
- Department of Surgical Oncology, Apollo Specialty Hospital, Chennai, Tamil Nadu, India
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28
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Nome RV, Cvancarova Småstuen M, Bjøro T, Kiserud CE, Fosså SD. Longitudinal kidney function outcome in aging testicular cancer survivors. Acta Oncol 2020; 59:467-474. [PMID: 32043400 DOI: 10.1080/0284186x.2020.1724328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Purpose: Testicular cancer survivors (TCSs) have increased risk of reduced kidney function related to treatment burden, but longitudinal studies of renal outcome in aging TCSs have been lacking. This longitudinal study describes age- and treatment-related kidney function changes in TCSs compared to a comparison group from the general population.Patients and methods: Estimated glomerular filtration rate (eGFR) was determined in blood samples from Norwegian TCSs (diagnosed 1980-1994) and surveyed median 11, 19 and 26 years since diagnosis (Survey1 [N = 1273], 2 [N = 849] and 3 [N = 670]) defining four treatment groups; Surgery only, Radiotherapy (RT) only, Cisplatin-based chemotherapy (CBCT) ≤850 mg and High CBCT/RT >850 mg cisplatin or any combination of CBCT with RT. A comparison group was constructed from similarly aged men who participated in a population-based health survey. By multiple linear regressions and generalized mixed models for repeated measurements, we studied difference in eGFR between TCSs and the comparison group for all TCSs combined and stratified by treatment modality.Results: At Survey 1, the kidney function for the youngest TCSs combined versus the comparison group was significantly reduced by mean six units (mL/min/1.73 m2) with further decline to mean 12 units at Survey 3. The kidney function was significantly reduced in all treatment groups with the largest differences emerging for TCSs from the High CBCT/RT Group, thus indicating a deteriorating impact of high cumulative doses of cisplatin.Conclusion: Collated to the comparison group, the kidney function in TCSs became increasingly impaired during nearly three post-treatment decades, related to the treatment modality. Early detection and intervention of kidney dysfunction is important to reduce the risk of TCSs' long-term morbidity and mortality related to nephrotoxicity, such as cardio-vascular diseases.
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Affiliation(s)
- Ragnhild V. Nome
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Milada Cvancarova Småstuen
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway
| | - Trine Bjøro
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Sophie D. Fosså
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
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Clinical outcome of post-chemotherapy retroperitoneal lymph node dissection in metastatic nonseminomatous germ cell tumour: A systematic review. Eur J Surg Oncol 2020; 46:999-1005. [PMID: 32173176 DOI: 10.1016/j.ejso.2020.02.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/24/2020] [Accepted: 02/22/2020] [Indexed: 01/11/2023] Open
Abstract
Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is an important element of the management of patients with residual tumour after chemotherapy for disseminated nonseminomatous germ cell tumour (NSGCT). This is a challenging procedure and the outcome varies widely between institutions. There is much debate concerning the anatomical extent of the dissection and the literature is conflicting regarding the outcome of this procedure. In this systematic review we aim to summarise the literature on the relapse rate of PC-RPLND. We performed a search of the literature of the PubMed/MEDLINE and Embase databases, in accordance with the PRISMA guidelines. Studies reporting on the relapse rate of PC-RPLND in NSGCT patients with residual tumour were eligible for inclusion. We calculated the weighted average relapse rates of included studies and assessed the risk of bias using the Newcastle-Ottawa scale. A total of 33 studies, reporting on 2,379 patients undergoing open PC-RPLND (O-RPLND) and 463 patients undergoing minimally invasive PC-RPLND (MI-RPLND) were included. The weighted average relapse rates were 11.4% for O-RPLND, and 3.0% for MI-RPLND. The rates of retroperitoneal relapse were 4.6% and 1.7% after O-RPLND and MI-RPLND, respectively. For O-RPLND specifically, the average retroperitoneal relapse rate was 3.1% after modified dissection and 6.1% after bilateral dissection. We conclude that modified template dissection is oncologically safe in carefully selected patients. Minimally invasive procedures are feasible but long-term data on the oncological outcome are still lacking. PC-RPLND is a complex and challenging procedure, and patients should be treated at high-volume expert centres.
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Tsunezuka H, Nakamura T, Fujikawa K, Shimomura M, Okada S, Shimada J, Teramukai S, Ukimura O, Inoue M. Prediction models for the viability of pulmonary metastatic lesions after chemotherapy in nonseminomatous germ cell tumors. Int J Urol 2020; 27:206-212. [PMID: 31916319 DOI: 10.1111/iju.14162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 11/10/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To analyze predictors associated with viable cells in pulmonary residual lesions after chemotherapy for metastatic testicular nonseminomatous germ cell tumors and to develop models to prioritize pulmonary resection. METHODS Between 2008 and 2017, 40 patients underwent pulmonary metastasectomy after chemotherapy for nonseminomatous germ cell tumors. We evaluated these patients, and 326 pulmonary residual lesions were confirmed using computed tomography and pathological evaluations. Relationships with outcomes were analyzed using logistic regression analyses. Risk prediction models were developed, and predictive probabilities for the risk of viable cells were estimated. RESULTS Histological examinations showed that 73 (22%) pulmonary residual lesions contained viable cells: teratomas, 46 (14%); and cancer cells, 37 (11%). Multivariate analyses showed that the predictors associated with cancer cells in the residual lesions were elevated tumor marker levels, multiregimen chemotherapy, increased tumor size 6 months before surgery and the histological composition of the primary lesion, including yolk sac tumors. Additional predictors associated with teratomas were aspect ratio and histological composition of the primary lesion, including teratomas. CONCLUSIONS Intratumoral heterogeneity contributes to nonseminomatous germ cell tumor chemoresistance, and primary lesion site yolk sac tumors and teratomas are associated with greater risks of viable cells. Increased residual lesion size during chemotherapy could also be a predictor. Our simple model can predict the presence of viable cells in residual lesions after chemotherapy, and it might assist in decision-making and prioritizing pulmonary residual lesion resection.
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Affiliation(s)
- Hiroaki Tsunezuka
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Terukazu Nakamura
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Urology, Saiseikai Suita Hospital, Suita, Japan
| | - Kei Fujikawa
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masanori Shimomura
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoru Okada
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Junichi Shimada
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Osamu Ukimura
- Department of Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masayoshi Inoue
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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31
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Cheriyan SK, Nicholson M, Aydin AM, Azizi M, Peyton CC, Sexton WJ, Gilbert SM. Current management and management controversies in early- and intermediate-stage of nonseminoma germ cell tumors. Transl Androl Urol 2020; 9:S45-S55. [PMID: 32055485 DOI: 10.21037/tau.2019.05.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Early stage nonseminomatous germ cell tumor (NSGCT) remains a treatable disease, with stage I cancer specific survival exceeding 95%. Using a risk-adapted approach; active surveillance (AS), adjuvant chemotherapy, and retroperitoneal lymph node dissection (RPLND) all options for treatment; with surveillance being increasingly used. With persistently elevated markers (stage IS), chemotherapy remains the hallmark of treatment. Management of stage II NSGCT varies based on status of tumor markers. With negative markers, both induction chemotherapy and upfront RPLND remain options. Management of a residual mass <1 cm after chemotherapy remains controversial, with AS and nerve-sparing RPLND considered options. The development of miR-371a-3p microRNA shows promise a novel biomarker for testicular cancer (GCT). Despite controversies in management, cures for NSGCT are achievable in 95-99% of patients.
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Affiliation(s)
- Salim K Cheriyan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Marilin Nicholson
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Ahmet M Aydin
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Mounsif Azizi
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Charles C Peyton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Honecker F, Aparicio J, Berney D, Beyer J, Bokemeyer C, Cathomas R, Clarke N, Cohn-Cedermark G, Daugaard G, Dieckmann KP, Fizazi K, Fosså S, Germa-Lluch JR, Giannatempo P, Gietema JA, Gillessen S, Haugnes HS, Heidenreich A, Hemminki K, Huddart R, Jewett MAS, Joly F, Lauritsen J, Lorch A, Necchi A, Nicolai N, Oing C, Oldenburg J, Ondruš D, Papachristofilou A, Powles T, Sohaib A, Ståhl O, Tandstad T, Toner G, Horwich A. ESMO Consensus Conference on testicular germ cell cancer: diagnosis, treatment and follow-up. Ann Oncol 2019; 29:1658-1686. [PMID: 30113631 DOI: 10.1093/annonc/mdy217] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The European Society for Medical Oncology (ESMO) consensus conference on testicular cancer was held on 3-5 November 2016 in Paris, France. The conference included a multidisciplinary panel of 36 leading experts in the diagnosis and treatment of testicular cancer (34 panel members attended the conference; an additional two panel members [CB and K-PD] participated in all preparatory work and subsequent manuscript development). The aim of the conference was to develop detailed recommendations on topics relating to testicular cancer that are not covered in detail in the current ESMO Clinical Practice Guidelines (CPGs) and where the available level of evidence is insufficient. The main topics identified for discussion related to: (1) diagnostic work-up and patient assessment; (2) stage I disease; (3) stage II-III disease; (4) post-chemotherapy surgery, salvage chemotherapy, salvage and desperation surgery and special topics; and (5) survivorship and follow-up schemes. The experts addressed questions relating to one of the five topics within five working groups. Relevant scientific literature was reviewed in advance. Recommendations were developed by the working groups and then presented to the entire panel. A consensus vote was obtained following whole-panel discussions, and the consensus recommendations were then further developed in post-meeting discussions in written form. This manuscript presents the results of the expert panel discussions, including the consensus recommendations and a summary of evidence supporting each recommendation. All participants approved the final manuscript.
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Affiliation(s)
- F Honecker
- Tumor and Breast Center ZeTuP, St. Gallen, Switzerland; Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald Tumorzentrum, University Medical Center, Hamburg, Germany.
| | - J Aparicio
- Department of Medical Oncology, Hospital Universitari i Politècnic la Fe, Valencia, Spain
| | - D Berney
- Department of Molecular Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - J Beyer
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - C Bokemeyer
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald Tumorzentrum, University Medical Center, Hamburg, Germany
| | - R Cathomas
- Department of Oncology and Hematology, Kantonsspital Graubünden, Chur, Switzerland
| | - N Clarke
- Department of Surgery, The Christie NHS Foundation Trust, Manchester, UK
| | - G Cohn-Cedermark
- Department of Oncology-Pathology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - G Daugaard
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - K-P Dieckmann
- Department of Urology, Asklepios Klinik Altona, Hamburg, Germany
| | - K Fizazi
- Department of Cancer Medicine, Gustave Roussy, University of Paris Sud, Villejuif, France
| | - S Fosså
- Department of Oncology, Oslo University Hospital Radiumhospitalet, Oslo, Norway
| | - J R Germa-Lluch
- Department of Medical Oncology, Catalan Institute of Oncology (ICO), Barcelona University, Barcelona, Spain
| | - P Giannatempo
- Department of Medical Oncology, Fondazione IRCCS Istituto dei Tumori, Milan, Italy
| | - J A Gietema
- Department of Medical Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - S Gillessen
- Department of Oncology and Hematology, Kantonsspital St. Gallen, St. Gallen; University of Bern, Bern, Switzerland
| | - H S Haugnes
- Department of Oncology, University Hospital of North Norway, Tromsø, Norway; Institute of Clinical Medicine, UIT - The Arctic University, Tromsø, Norway
| | - A Heidenreich
- Department of Urology, Uro-Oncology, Robot-assisted and Specialised Urologic Surgery, University of Cologne, Cologne, Germany
| | - K Hemminki
- Department of Molecular Genetic Epidemiology, German Cancer Research Center, Heidelberg, Germany
| | - R Huddart
- Department of Radiotherapy and Imaging, The Institute of Cancer Research, Royal Marsden Hospital, Sutton, UK
| | - M A S Jewett
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada
| | - F Joly
- Department of Urology-Gynaecology, Centre Francois Baclesse, Caen, France
| | - J Lauritsen
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - A Lorch
- Department of Urology, Genitourinary Medical Oncology, Heinrich-Heine University Hospital Düsseldorf, Düsseldorf, Germany
| | - A Necchi
- Department of Medical Oncology, Fondazione IRCCS Istituto dei Tumori, Milan, Italy
| | - N Nicolai
- Department of Surgery, Urology and Testis Surgery Unit, Fondazione IRCCS Istituto dei Tumori, Milan, Italy
| | - C Oing
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald Tumorzentrum, University Medical Center, Hamburg, Germany
| | - J Oldenburg
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
| | - D Ondruš
- 1st Department of Oncology, St. Elisabeth Cancer Institute, Comenius University Faculty of Medicine, Bratislava, Slovak Republic
| | - A Papachristofilou
- Department of Radiation Oncology, University Hospital Basel, Basel, Switzerland
| | - T Powles
- Department of Medical Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - A Sohaib
- Department of Radiology, Royal Marsden Hospital, Sutton, UK
| | - O Ståhl
- Department of Oncology, Skane University Hospital, Lund University, Lund, Sweden
| | - T Tandstad
- The Cancer Clinic, St. Olavs Hospital, Trondheim, Norway
| | - G Toner
- Department of Medical Oncology, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Australia
| | - A Horwich
- The Institute of Cancer Research, Royal Marsden Hospital, Sutton, UK
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Öztürk Ç, Been LB, van Ginkel RJ, Gietema JA, Hoekstra HJ. Laparoscopic Resection of Residual Retroperitoneal Tumor Mass in Advanced Nonseminomatous Testicular Germ Cell Tumors; a Feasible and Safe Oncological Procedure. Sci Rep 2019; 9:15837. [PMID: 31676840 PMCID: PMC6825184 DOI: 10.1038/s41598-019-52109-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 10/08/2019] [Indexed: 12/20/2022] Open
Abstract
Ten-year oncological experience of the University Medical Center Groningen with conventional laparotomy (C-RRRTM) and laparoscopy (L-RRRTM) is described concerning resection of residual retroperitoneal tumor masses (RRTM) in a large series of patients with advanced nonseminomatous testicular germ cell tumors (NSTGCT). 150 consecutive patients with disseminated NSTGCT required adjunctive surgery after combination chemotherapy. L-RRRTM was scheduled in 89 and C-RRRTM in 61 patients. Median residual tumor diameter was 20 mm in the L-RRRTM versus 42 mm in the C-RRRTM group (p < 0.001). Conversion rate was 15% in the L-RRRTM group. Perioperative complications occurred in 5 patients (6%) in the L-RRRTM and 7 (12%, NS) in the C-RRRTM group. Median duration of L-RRRTM was 156 minutes vs. 221 minutes for C-RRRTM (p < 0.001). 17/89 patients in the L-RRRTM group had postoperative complications versus 18/61 patients in the C-RRRTM group (NS). Median postoperative stay in the L-RRRTM group was 2 vs. 6 days in the C-RRRTM group (p < 0.001). During a median follow-up of 79 months, 27 patients had recurrences: 8 (9%) in the L-RRRTM group and 19 (31%) in the C-RRRTM group (p < 0.001). Laparoscopic resection of RRTM for advanced NSTGCT is feasible and an oncologically safe option in appropriately selected patients.
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Affiliation(s)
- Çiğdem Öztürk
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lukas B Been
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert J van Ginkel
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Jourik A Gietema
- Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Harald J Hoekstra
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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34
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Lewin J, Dufort P, Halankar J, O'Malley M, Jewett MAS, Hamilton RJ, Gupta A, Lorenzo A, Traubici J, Nayan M, Leão R, Warde P, Chung P, Anson Cartwright L, Sweet J, Hansen AR, Metser U, Bedard PL. Applying Radiomics to Predict Pathology of Postchemotherapy Retroperitoneal Nodal Masses in Germ Cell Tumors. JCO Clin Cancer Inform 2019; 2:1-12. [PMID: 30652572 PMCID: PMC6874033 DOI: 10.1200/cci.18.00004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose After chemotherapy, approximately 50% of patients with metastatic testicular germ cell tumors (GCTs) who undergo retroperitoneal lymph node dissections (RPNLDs) for residual masses have fibrosis. Radiomics uses image processing techniques to extract quantitative textures/features from regions of interest (ROIs) to train a classifier that predicts outcomes. We hypothesized that radiomics would identify patients with a high likelihood of fibrosis who may avoid RPLND. Patients and Methods Patients with GCT who had an RPLND for nodal masses > 1 cm after first-line platinum chemotherapy were included. Preoperative contrast-enhanced axial computed tomography images of retroperitoneal ROIs were manually contoured. Radiomics features (n = 153) were used to train a radial basis function support vector machine classifier to discriminate between viable GCT/mature teratoma versus fibrosis. A nested 10-fold cross-validation protocol was used to determine classifier accuracy. Clinical variables/restricted size criteria were used to optimize the classifier. Results Seventy-seven patients with 102 ROIs were analyzed (GCT, 21; teratoma, 41; fibrosis, 40). The discriminative accuracy of radiomics to identify GCT/teratoma versus fibrosis was 72 ± 2.2% (area under the curve [AUC], 0.74 ± 0.028); sensitivity was 56.2 ± 15.0%, and specificity was 81.9 ± 9.0% (P = .001). No major predictive differences were identified when data were restricted by varying maximal axial diameters (AUC range, 0.58 ± 0.05 to 0.74 ± 0.03). The prediction algorithm using clinical variables alone identified an AUC of 0.76. When these variables were added to the radiomics signature, the best performing classifier was identified when axial masses were limited to diameter < 2 cm (accuracy, 88.2 ± 4.4; AUC, 0.80 ± 0.05; P = .02). Conclusion A predictive radiomics algorithm had a discriminative accuracy of 72% that improved to 88% when combined with clinical predictors. Additional independent validation is required to assess whether radiomics allows patients with a high predicted likelihood of fibrosis to avoid RPLND.
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Affiliation(s)
- Jeremy Lewin
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Dufort
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jaydeep Halankar
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Martin O'Malley
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael A S Jewett
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robert J Hamilton
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Abha Gupta
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Armando Lorenzo
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeffrey Traubici
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Madhur Nayan
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ricardo Leão
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Padraig Warde
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter Chung
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lynn Anson Cartwright
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joan Sweet
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aaron R Hansen
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ur Metser
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Philippe L Bedard
- Jeremy Lewin, Padraig Warde, Peter Chung, Lynn Anson Cartwright, Joan Sweet, Aaron R. Hansen, and Philippe L. Bedard, Princess Margaret Cancer Centre; Michael A.S. Jewett, Robert J. Hamilton, Madhur Nayan, Ricardo Leão, Aaron R. Hansen, and Philippe L. Bedard, University of Toronto; Paul Dufort, Jaydeep Halankar, Martin O'Malley, and Ur Metser, University Health Network; and Abha Gupta, Armando Lorenzo, and Jeffrey Traubici, Hospital for Sick Children, Toronto, Ontario, Canada
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Paffenholz P, Nestler T, Hoier S, Pfister D, Hellmich M, Heidenreich A. External validation of 2 models to predict necrosis/fibrosis in postchemotherapy residual retroperitoneal masses of patients with advanced testicular cancer. Urol Oncol 2019; 37:809.e9-809.e18. [PMID: 31540832 DOI: 10.1016/j.urolonc.2019.07.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 07/12/2019] [Accepted: 07/25/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Nonseminomatous testicular germ cell tumors with residual retroperitoneal lesions >1 cm are treated with postchemotherapy retroperitoneal lymph node dissection (pcRPLND). However, up to 50% of patients are overtreated since the histology shows only residual necrosis/fibrosis. We aim to validate the 2 currently best performing prediction models (Vergouwe and Leao) for postchemotherapy residual mass histology. METHODS AND MATERIALS We performed a retrospective analysis including 402 patients who underwent a pcRPLND from 2008 to 2015. The study cohort was used to validate the 2 prediction models by Vergouwe and Leao using the published formulas and thresholds. RESULTS Using our validation cohort, the Vergouwe model reached a significantly better area under the curve compared to the Leao model (0.760 (confidence interval 0.713-0.807) vs. 0.692 (0.640-0.744), P = 0.002) in the prediction of benign histology. At a threshold of >70% for the predicted probability of benign disease, the Leao model revealed that pcRPLND would be avoided in 10.2% of patients with benign disease with an error rate of 3.8% for viable tumor, while the Vergouwe model would avoid pcRPLND in 27.4% of all patients with benign disease with an error rate of 10.1% for viable tumor and 2.9% for teratoma. Adjusting the models to our data had no significant improvement. Limitations include the retrospective design. CONCLUSIONS The discriminatory accuracy of both models is not sufficient to safely select patients for surveillance strategy instead of pcRPLND. Therefore, further studies including new biomarkers are needed to optimize the accuracy of potential prediction models and to minimize pcRPLND overtreatment.
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Affiliation(s)
- Pia Paffenholz
- Department of Urology, University Hospital Cologne, Cologne, Germany
| | - Tim Nestler
- Department of Urology, University Hospital Cologne, Cologne, Germany
| | - Simon Hoier
- Department of Urology, University Hospital Cologne, Cologne, Germany
| | - David Pfister
- Department of Urology, University Hospital Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - Axel Heidenreich
- Department of Urology, University Hospital Cologne, Cologne, Germany; Department of Urology, Medical University Vienna, Austria.
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Ghandour R, Ashbrook C, Freifeld Y, Singla N, El-Asmar JM, Lotan Y, Margulis V, Eggener S, Woldu S, Bagrodia A. Nationwide Patterns of Care for Stage II Nonseminomatous Germ Cell Tumor of the Testicle. Eur Urol Oncol 2019; 3:198-206. [PMID: 31272940 DOI: 10.1016/j.euo.2019.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/20/2019] [Accepted: 06/11/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Management strategies for advanced testicular cancer published from a few, high-volume clinical centers may not be generalizable. OBJECTIVE To discern treatment patterns for stage II nonseminomatous germ cell tumor (NSGCT) in a nationwide cancer registry. DESIGN, SETTING, AND PARTICIPANTS The National Cancer Database was queried for patients with a stage II NSGCT from 2004 to 2014. Patients were stratified by clinical nodal status: cN1/stage IIA, cN2/stage IIB, and cN3/stage IIIC. OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS Logistic regression was performed to determine factors independently associated with primary retroperitoneal lymph node dissection (RPLND), primary chemotherapy, and postchemotherapy RPLND (PC-RPLND). RESULTS AND LIMITATIONS A total of 2203 patients (stages IIA, n=1060; IIB, n=869; and IIC, n=274) met the inclusion criteria. Overall, 83% of patients underwent primary chemotherapy, while 17% underwent primary RPLND. Stratified by stage, use of primary chemotherapy was 78%, 88%, and 86% for stages IIA, IIB, and IIC, respectively. Overall, 24% of patients underwent PC-RPLND. Factors independently associated with a lower likelihood of undergoing primary RPLND were a more recent diagnosis and a higher clinical nodal stage. Conversely, patients treated at high-volume facilities were more likely to receive primary RPLND. Factors associated with a higher likelihood of undergoing PC-RPLND included a higher clinical nodal stage, treatment at a high-volume center, and a greater distance of patient travel. Associations based on serum tumor markers could not be assessed. CONCLUSIONS For clinical stage II NSGCT, nationwide utilization of primary chemotherapy is increasing compared with RPLND and is the preferred therapy for more advanced nodal disease. Primary RPLND may be underutilized in stage IIA disease. Utilization of PC-RPLND is driven by nodal stage as well as accessibility of a high-volume center. PATIENT SUMMARY The use of primary retroperitoneal lymph node dissection (RPLND) in early nodal disease is declining, while upfront chemotherapy is increasingly utilized. Primary RPLND may identify patients who are actually pN0 and would not benefit from systemic chemotherapy. Primary RPLND and postchemotherapy RPLND are performed more frequently at centers of excellence.
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Affiliation(s)
- Rashed Ghandour
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Caleb Ashbrook
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yuval Freifeld
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nirmish Singla
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jose M El-Asmar
- Division of Urology, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Scott Eggener
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Solomon Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Abstract
PURPOSE OF REVIEW We aim to give an overview of the epidemiology and treatment trends of testicular germ cell tumors (TGCTs), with an emphasis on recent trends. RECENT FINDINGS The incidence of TGCT appears to be increasing, particularly in developed countries, although the reasons are not well understood. There is evidence of racial differences in predisposition to TGCT, with white men having highest risk and men of African or Asian descent having lower risk. In the United States, the incidence of TGCT among Hispanics appears to be rising most quickly. A recent genomic analysis indicates there is no highly penetrant major TGCT susceptibility gene. Incorporation of multidisciplinary care has led to excellent long-term cure rates; however, access to care and insurance remains barriers in young men. Recent treatment trends have centered on maximizing oncologic outcomes while minimizing long-term morbidity. SUMMARY Emerging population-level data provide critical insight into the evolving demographics of TGCT, which may allow for elucidation of biologic and environmental determinants of TGCT. Further, identification of socioeconomic barriers to excellent clinical outcomes will allow for targeted interventions to patients with unique demographic and socioeconomic considerations. Treatment trend analyses suggest that the field is moving toward minimizing treatment-related morbidity.
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Wu Y, Meyers JP, Shi G, Jin Z, Xia J, Gu Y, Qian Q, Hong Y. A nomogram for predicting survival and retroperitoneal lymph node dissection treatment in patients with resected testicular germ cell tumors. J Surg Oncol 2019; 120:508-517. [PMID: 31140623 DOI: 10.1002/jso.25519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/10/2019] [Accepted: 05/13/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES To build nomogram incorporating potential prognostic factors for predicting survival outcomes of testicular germ cell tumors (TGCT) patients after resection of the primary tumor. METHODS Data of TGCT patients from the Surveillance, Epidemiology, and End Results database (2010-2016) who underwent resection of the primary tumor were collected. Overall survival (OS) and cancer-specific survival (CSS) were analyzed by using Cox regression models, nomogram, Kaplan-Meier method, and log-rank test. RESULTS We identified 7272 TGCT patients. Age at diagnosis, histology, tumor size, American Joint Committee on Cancer (AJCC) staging system, and number of metastases sites were independent prognostic factors and were integrated into nomograms. The nomograms had higher C-indexes for both OS and CSS compared with the AJCC 7th staging system (0.881 vs 0.831 and 0.895 vs 0.856, respectively). Moreover, the new stratification of risk groups based on the nomograms showed a more significant distinction between Kaplan-Meier curves for survival outcomes than the AJCC staging system. Retroperitoneal lymph node dissection was associated with statistically improved survival probability in the nomogram middle-risk group in resected TGCT patients. CONCLUSION The novel nomogram-based staging system could provide satisfactory risk stratification and survival prediction ability beyond traditional AJCC staging systems.
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Affiliation(s)
- Yougen Wu
- National Institute of Clinical Research, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China
| | - Jeffrey P Meyers
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Guowei Shi
- Department of Urology, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China
| | - Zhi Jin
- Department of Neurology, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China
| | - Ju Xia
- National Institute of Clinical Research, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China
| | - Yuting Gu
- National Institute of Clinical Research, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China
| | - Qingqing Qian
- National Institute of Clinical Research, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China.,Department of Pharmacy, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China
| | - Yang Hong
- National Institute of Clinical Research, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China.,Department of Osteology, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China
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Hiester A, Nini A, Fingerhut A, Große Siemer R, Winter C, Albers P, Lusch A. Preservation of Ejaculatory Function After Postchemotherapy Retroperitoneal Lymph Node Dissection (PC-RPLND) in Patients With Testicular Cancer: Template vs. Bilateral Resection. Front Surg 2019; 5:80. [PMID: 30705885 PMCID: PMC6345078 DOI: 10.3389/fsurg.2018.00080] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 12/20/2018] [Indexed: 01/04/2023] Open
Abstract
Background: Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays a crucial role in treatment of metastatic non-seminomatous germ cell cancer. Objective: To evaluate the functional outcome regarding the preservation of ejaculatory function comparing a bilateral vs. unilateral template resection in PC-RPLND patients. In addition, oncological safety and perioperative complications of the unilateral template resection was compared to the full bilateral one. Design/Setting/Participants: Between 2003 and 2018, 504 RPLNDs have been performed in 434 patients. The database of consecutive patients was queried to identify 171 patients with PC-RPLND after 1st line chemotherapy for a non-seminoma with or without bilateral template resection. Re-Do's, late relapse, salvage patients, and thoraco-abdominal approaches were excluded. Indication for a template resection was a unilateral residual mass mainly <5 cm as published (1). Outcome, Measurement, and Statistical Analysis: Descriptive statistics were used to report preoperative features, postoperative outcomes and patterns of recurrence, on the overall population and after stratification for the type of resection (bilateral vs. unilateral). Kaplan-Meier analyses were used to describe recurrence- and cancer-specific mortality-free survival rates at different time points. Results and Limitations: Overall, 90 and 81 patients underwent unilateral and bilateral radical resection, respectively. Median size of residual mass was 7 cm for bilateral and 4 cm for unilateral template resection. Clinical stage II and III were present in 31 and 69% of patients, respectively. Median follow-up was 14.5 months (IQR 3.3–37.6). The 1- and 2-year recurrence-free survival rates were 91 and 91%, and 77 and 72% for patients treated with unilateral template and bilateral resection, respectively (p = 0.0078). Median time to recurrence was 9.5 and 9 months in template and bilateral resection group, respectively. Adjunctive procedures were performed in 56 patients (33%) and were significantly more frequent in the bilateral resection group (43 vs. 23%, p = 0.006). The overall high-grade complication rate (Clavien-Dindo ≥ III) was 6, 3, and 9% in unilateral template and bilateral resection group, respectively (p = 0.6). The rate of preservation of antegrade ejaculation was significantly higher in the unilateral group. Conclusions: Antegrade ejaculation in patients undergoing unilateral template resection with a residual mass <5 cm can be preserved at a much higher rate. Moreover, this surgical procedure is oncologically safe in terms of mid-term recurrence and CSM-free survival rates. This data undermines the growing evidence of limited PC-RPLND being justifiable in strictly unilateral residual mass <5 cm. This data has to be confirmed with a longer follow-up regarding in-field and retroperitoneal recurrences.
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Affiliation(s)
- Andreas Hiester
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Alessandro Nini
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Anna Fingerhut
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Robert Große Siemer
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Christian Winter
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Peter Albers
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Achim Lusch
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
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Hale GR, Teplitsky S, Truong H, Gold SA, Bloom JB, Agarwal PK. Lymph node imaging in testicular cancer. Transl Androl Urol 2018; 7:864-874. [PMID: 30456189 PMCID: PMC6212624 DOI: 10.21037/tau.2018.07.18] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Testicular cancer is a rare malignancy mainly affecting young men. Survival for testicular cancer remains high due to the effectiveness of multimodal treatment options. Accurate imaging is imperative to both treatment and follow-up. Both computed tomography (CT) and magnetic resonance imaging (MRI) suffer from size cut-offs as the only distinguishing characteristic of benign vs. malignant lymph nodes and may miss up to 30% of micro-metastatic disease. While functional [positron emission tomography (PET)] imaging may rule out disease in patients with seminoma who have undergone chemotherapy, there is insufficient evidence to recommend its use in other settings. This review highlights the uses and pitfalls of conventional imaging during staging, active surveillance, and post-treatment phases of both seminomatous and non-seminomatous germ cell tumors (NSGCT).
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Affiliation(s)
- Graham R Hale
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Seth Teplitsky
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Hong Truong
- Department of Urology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Samuel A Gold
- SUNY Downstate College of Medicine, Downstate Medical Center, Brooklyn, NY, USA
| | - Jonathan B Bloom
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Piyush K Agarwal
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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41
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Woldu SL, Moore JA, Ci B, Freifeld Y, Clinton TN, Aydin AM, Singla N, Laura-Maria K, Hutchinson RC, Amatruda JF, Sagalowsky A, Lotan Y, Arriaga Y, Margulis V, Xie Y, Bagrodia A. Practice Patterns and Impact of Postchemotherapy Retroperitoneal Lymph Node Dissection on Testicular Cancer Outcomes. Eur Urol Oncol 2018; 1:242-251. [PMID: 31058267 PMCID: PMC6494089 DOI: 10.1016/j.euo.2018.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Owing to surgical complexity and controversy regarding indications, there are wide practice variations in the use of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). Objective To evaluate patterns of PC-RPLND use in the USA and evaluate the association between PC-RPLND and survival in advanced nonseminomatous germ cell tumors (NSGCTs). Design setting and participants A retrospective, observational study using National Cancer Data Base (NCDB) data from 2004-2014 for 5062 men diagnosed with stage II/III NSGCT. Outcome measurements and statistical analysis In a comparative analysis based on receipt of PC-RPLND, the primary outcome of interest was factors associated with omission of PC-RPLND as explored via logistic regression. As a secondary outcome, we evaluated the association between PC-RPLND and overall survival (OS) via multivariable Cox regression and propensity score matching (PSM). Results and limitations Patients undergoing PC-RPLND were more likely to be younger, white, privately insured, and reside in more educated/wealthier regions (p < 0.001). Insurance status was independently associated with receipt of PC-RPLND; compared to patients with private insurance, those without insurance were significantly less likely to receive PC-RPLND (odds ratio 0.49; p < 0.001). After multivariate adjustment, age, comorbidity, non-private insurance, distance from hospital, clinical stage, and risk group were independently associated with all-cause mortality. In addition, omission of PC-RPLND remained associated with all-cause mortality (hazard ratio 1.98; p < 0.001). After PSM, the 5-yr OS was significantly lower among those not undergoing PC-RPLND (72% vs 77%; p = 0.007). Conclusions PC-RPLND represents a critical part of the multidisciplinary management of NSGCT. Patients with non-private insurance are less likely to undergo PC-RPLND, and omission of PC-RPLND is associated with lower OS. Patient summary We evaluated the practice patterns for advanced testicular cancer management and found that patients who did not undergo a postchemotherapy retroperitoneal lymph node dissection were more likely to have worse survival outcomes. Patients with unfavorable insurance were less likely to receive this surgical treatment.
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Affiliation(s)
- Solomon L. Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Joseph A. Moore
- Department of Medicine, Division of Hematology/Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bo Ci
- Department of Clinical Science, Division of Biomedical Informatics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yuval Freifeld
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Timothy N. Clinton
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ahmet M. Aydin
- Department of Urology, Hacettepe University, Ankara, Turkey
| | - Nirmish Singla
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Krabbe Laura-Maria
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ryan C. Hutchinson
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James F. Amatruda
- Department of Medicine and Pediatrics, Division of Hematology/Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Arthur Sagalowsky
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yull Arriaga
- Department of Medicine, Division of Hematology/Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yang Xie
- Department of Clinical Science, Division of Biomedical Informatics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Abstract
The feasibility of laparoscopic retroperitoneal lymphadenectomy (RLA) for testicular cancer was shown >25 years ago. Initially the indication was clinical stage I (CS I) nonseminomatous germ cell tumor (NSGCT). Compared with that of open surgery, the morbidity was much decreased. However, in Europe, surgery for CS I is now replaced by chemotherapy. A relatively new indication is laparoscopic retroperitonal lymphadenectomy for small unilateral residual tumor after chemotherapy. The technique of unilateral lymphadenectomy for both indications is described in detail and with a video. The most recent development is bilateral laparoscopic RLA for residual tumors larger than 5 cm.
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Affiliation(s)
- Lukas Lusuardi
- Department of Urology, Paracelsus Medical University , Salzburg, Austria
| | - Thomas Kunit
- Department of Urology, Paracelsus Medical University , Salzburg, Austria
| | - Günter Janetschek
- Department of Urology, Paracelsus Medical University , Salzburg, Austria
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Heidenreich A, Paffenholz P, Nestler T, Pfister D. Primary and Postchemotherapy Retroperitoneal Lymphadenectomy for Testicular Cancer. Oncol Res Treat 2018; 41:370-378. [PMID: 29772568 DOI: 10.1159/000489508] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 04/23/2018] [Indexed: 11/19/2022]
Abstract
Clinical stage I (CS I) testicular non-seminomatous germ cell tumours (NSGCT) are highly curable. Following orchidectomy, a risk-adapted approach using active surveillance, nerve-sparing retroperitoneal lymph node dissection (RPLND) and primary chemotherapy is recommended by the current guidelines. CS I is defined as showing negative values for tumour markers (or values declining to their half-life following orchidectomy) and negative imaging studies of the chest, abdomen and retroperitoneum. Active surveillance can be performed in low- and high-risk NSGCT with an anticipated relapse rate of about 15% and 50%, respectively. The majority of patients will relapse with good and intermediate prognosis tumours, which have to be treated with 3 to 4 cycles of chemotherapy. About 25-30% of these patients will have to undergo postchemotherapy (PC) RPLND for residual masses. Primary chemotherapy with 1-2 cycles of cisplatin, etoposide, bleomycin (PEB) is a therapeutic option for high-risk CS I NSGCT associated with a recurrence rate of only 2-3% and a minimal acute and long-term toxicity rate. Nerve-sparing RPLND, if performed properly, will cure about 85% of all high-risk patients with CS I NSGCT without the need for chemotherapy. PC-RPLND plays an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours (TGCT). According to current guidelines and recommendations, PC-RPLND in advanced seminomas with residual tumours is only indicated if a positron emission tomography scan performed 6-8 weeks after chemotherapy is positive. In non-seminomatous TGCT, PC-RPLND is indicated for all residual radiographical lesions with negative or plateauing markers. Loss of antegrade ejaculation represents the most common long-term complication, which can be prevented by a nerve-sparing or modified template resection. The relapse rate after PC-RPLND is around 12%; however, it increases significantly to about 45% in cases with redo RPLND and late relapses. Patients with increasing markers should undergo salvage chemotherapy. Only select patients with elevated markers who are thought to be chemo-refractory might undergo desperation PC-RPLND if all radiographically visible lesions are completely resectable. PC-RPLND requires a complex surgical approach and should only be performed in experienced, tertiary referral centres.
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Leão R, Nayan M, Punjani N, Jewett MAS, Fadaak K, Garisto J, Lewin J, Atenafu EG, Sweet J, Anson-Cartwright L, Boström P, Chung P, Warde P, Bedard PL, Bagrodia A, Freifeld Y, Power N, Winquist E, Hamilton RJ. A New Model to Predict Benign Histology in Residual Retroperitoneal Masses After Chemotherapy in Nonseminoma. Eur Urol Focus 2018; 4:995-1001. [PMID: 29428550 DOI: 10.1016/j.euf.2018.01.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/17/2018] [Accepted: 01/29/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Postchemotherapy retroperitoneal lymph node dissection (pcRPLND) is indicated in testicular cancer patients with normalised or plateaued serum tumour markers and residual retroperitoneal lesions >1cm. Challenges remain in predicting postchemotherapy residual mass (pcRM) histology, which may lead to unnecessary surgery. OBJECTIVE To develop an accurate model to predict pcRM histology in patients with nonseminomatous germ cell tumours (NSGCTs). DESIGN, SETTING, AND PARTICIPANTS A retrospective review of 335 patients undergoing pcRPLND for metastatic NSGCTs to develop a model to predict benign histology in retroperitoneal pcRM. Our model was compared with others and externally validated. INTERVENTION Chemotherapy and pcRPLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariable logistic regression to evaluate the presence of benign histology, and fractional polynomials to allow for a nonlinear association between continuous variables and the outcome. The final Princess Margaret model (PMM) was selected based on the number of variables used, reliability, and discriminative capacity to predict benign pcRM. RESULTS AND LIMITATIONS PMM included the presence of teratoma in the orchiectomy, prechemotherapy α-fetoprotein, prechemotherapy mass size, and change in mass size during chemotherapy. Model specificity was 99.3%. Compared with Vergouwe et al's model, PMM had significantly better accuracy (C statistic 0.843 vs 0.783). PMM appropriately identified a larger number of patients for whom pcRPLND can safely be avoided (13.9% vs 0%). Validated in external cohorts, the model retained high discrimination (C statistic 0.88 and 0.80). Larger and prospective studies are needed to further validate this model. CONCLUSIONS Our clinical model, externally validated, showed improved discriminative ability in predicting pcRM histology when compared with other models. The higher accuracy and reduced number of variables make this a novel and appealing model to use for patient counselling and treatment strategies. PATIENT SUMMARY Princess Margaret model accurately predicted postchemotherapy benign histology. These results might have clinical impact by avoiding unnecessary retroperitoneal lymph node dissection and consequently changing the paradigm of advanced testicular cancer treatment.
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Affiliation(s)
- Ricardo Leão
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Madhur Nayan
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nahid Punjani
- Division of Urology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Michael A S Jewett
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kamel Fadaak
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Juan Garisto
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jeremy Lewin
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Joan Sweet
- Department of Pathology, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada
| | - Lynn Anson-Cartwright
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Peter Boström
- Department of Urology, Turku University Hospital, Turku, Finland
| | - Peter Chung
- Department of Radiation Oncology, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada
| | - Padraig Warde
- Department of Radiation Oncology, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada
| | - Philippe L Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Aditya Bagrodia
- Division of Urology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Yuval Freifeld
- Division of Urology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nicholas Power
- Division of Medical Oncology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Eric Winquist
- Division of Urology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.
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Dowling CM, Assel M, Musser JE, Meeks JJ, Sjoberg DD, Bosl G, Motzer R, Bajorin D, Feldman D, Carver BS, Sheinfeld J. Clinical Outcome of Retroperitoneal Lymph Node Dissection after Chemotherapy in Patients with Pure Embryonal Carcinoma in the Orchiectomy Specimen. Urology 2018; 114:133-138. [PMID: 29410311 DOI: 10.1016/j.urology.2018.01.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/08/2018] [Accepted: 01/10/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the pathologic findings and clinical outcome of patients with pure embryonal carcinoma (EC) of the testis who were diagnosed with testis cancer from January 1989 to January 2013 who underwent an orchiectomy, cisplatin-based chemotherapy and a postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). METHODS We compared those patients with 100% EC with those with mixed nonseminomatous germ cell tumor pathology who underwent a PC-RPLND. RESULTS Of 1105 patients who underwent a PC-RPLND, 145 had pure EC. Twenty-six percent of patients presented with metastatic disease outside the retroperitoneum. Patients with mixed histologies tended to have worse International Germ Cell Cancer Collaborative Group risk compared to those with EC at orchiectomy (P = .037). Histology at PC-RPLND revealed fibrosis or necrosis in 76%, mature teratoma in 19% and viable cancer in 4%. Over one-third of the patients had a residual mass of <1 cm prior to RPLND; of whom 15% harbored mature teratoma in PC-RPLND histology. The Kaplan-Meier estimated probability of recurrence at 5 years of follow-up was 3.1% (95% CI 1.2%, 8.0%) for EC histology, 7.3% lower than mixed histology. For cancer-specific mortality, the Kaplan-Meier estimated probability at 5 years was 4.6% (95% CI 3.3%, 6.3%) and 1.7% (95% CI 0.4%, 6.8%) for mixed and pure EC histologies, respectively. CONCLUSION Approximately 20% of patients with pure EC had teratoma at PC-RPLND. We have shown that those with a maximum node size of <1 cm should not be precluded from RPLND.
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Affiliation(s)
- Catherine M Dowling
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY
| | - Melissa Assel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, NY
| | - John E Musser
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY
| | - Joshua J Meeks
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, NY
| | - George Bosl
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY
| | - Robert Motzer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY
| | - Dean Bajorin
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY
| | - Darren Feldman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY
| | - Brett S Carver
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY
| | - Joel Sheinfeld
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY.
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Cho JS, Kaimakliotis HZ, Cary C, Masterson TA, Beck S, Foster R. Modified retroperitoneal lymph node dissection for post-chemotherapy residual tumour: a long-term update. BJU Int 2017; 120:104-108. [DOI: 10.1111/bju.13844] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jane S. Cho
- Department of Urology; Indiana University School of Medicine; Indianapolis IN USA
| | | | - Clint Cary
- Department of Urology; Indiana University School of Medicine; Indianapolis IN USA
| | - Timothy A. Masterson
- Department of Urology; Indiana University School of Medicine; Indianapolis IN USA
| | - Stephen Beck
- Department of Urology; Southern Illinois University School of Medicine; Springfield IL USA
| | - Richard Foster
- Department of Urology; Indiana University School of Medicine; Indianapolis IN USA
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Retroperitoneal lymph node dissection: an update in testicular malignancies. Clin Transl Oncol 2017; 19:793-798. [PMID: 28150168 DOI: 10.1007/s12094-017-1622-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 01/23/2017] [Indexed: 10/20/2022]
Abstract
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.
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Öztürk Ç, Velleman T, Bongaerts AHH, Bergman LM, van Ginkel RJ, Gietema JA, Hoekstra HJ. Assessment of Volumetric versus Manual Measurement in Disseminated Testicular Cancer; No Difference in Assessment between Non-Radiologists and Genitourinary Radiologist. PLoS One 2017; 12:e0168977. [PMID: 28081195 PMCID: PMC5230761 DOI: 10.1371/journal.pone.0168977] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 12/11/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The aim of this study was to assess the feasibility and reproducibility of semi-automatic volumetric measurement of retroperitoneal lymph node metastases in testicular cancer (TC) patients treated with chemotherapy versus the standardized manual measurements based on RECIST criteria. METHODS 21 TC patients with retroperitoneal lymph node metastases of testicular cancer were studied with a CT scan of chest and abdomen before and after cisplatin based chemotherapy. Three readers, a surgical resident, a radiological technician and a radiologist, assessed tumor response independently using computerized volumetric analysis with Vitrea software® and manual measurement according to RECIST criteria (version 1.1). Intra- and inter-rater variability were evaluated with intra class correlations and Bland-Altman analysis. RESULTS Assessment of intra observer and inter observer variance proved non-significant in both measurement modalities. In particularly all intraclass correlation (ICC) values for the volumetric analysis were > .99 per observer and between observers. There was minimal bias in agreement for manual as well as volumetric analysis. CONCLUSION In this study volumetric measurement using Vitrea software® appears to be a reliable, reproducible method to measure initial tumor volume of retroperitoneal lymph node metastases of testicular cancer after chemotherapy. Both measurement methods can be performed by experienced non-radiologists as well.
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Affiliation(s)
- Çiğdem Öztürk
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ton Velleman
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Radiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Alphons H. H. Bongaerts
- Radiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - L. M. Bergman
- Radiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert J. van Ginkel
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jourik A. Gietema
- Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Harald J. Hoekstra
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Dusaud M, Malavaud B, Bayoud Y, Sebe P, Hoepffner JL, Salomon L, Houlgatte A, Pignot G, Rigaud J, Fléchon A, Pfister C, Rouprêt M, Soulié M, Méjean A, Durand X. Post-chemotherapy retroperitoneal teratoma in nonseminomatous germ cell tumors: Do predictive factors exist? Results from a national multicenter study. J Surg Oncol 2016; 114:992-996. [DOI: 10.1002/jso.24464] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 09/13/2016] [Indexed: 12/31/2022]
Affiliation(s)
- Marie Dusaud
- Department of Urology; Hopital d'Instruction des Armees Begin; Saint Mandé France
| | | | - Younes Bayoud
- Department of Urology; Hopital d'Instruction des Armees Begin; Saint Mandé France
| | | | | | | | - Alain Houlgatte
- Hopital d'Instruction des Armees du Val-de-Grace; Paris France
| | | | | | | | | | | | | | | | - Xavier Durand
- Department of Urology; Hopital d'Instruction des Armees Begin; Saint Mandé France
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Alanee SR, Carver BS, Feldman DR, Motzer RJ, Bosl GJ, Sheinfeld J. Pelvic Lymph Node Dissection in Patients Treated for Testis Cancer: The Memorial Sloan Kettering Cancer Center Experience. Urology 2016; 95:128-31. [PMID: 27235751 DOI: 10.1016/j.urology.2016.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/30/2016] [Accepted: 05/05/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To describe the pathologic findings and clinical outcome data for patients undergoing pelvic lymph node dissection (PLND) in the course of management of testicular germ cell tumors at Memorial Sloan Kettering Cancer Center (MSKCC). PATIENTS AND METHODS Following institutional review board approval, data on 2186 patients who underwent retroperitoneal lymph node dissection (RPLND) at MSKCC between 1989 and 2011 were retrospectively reviewed. Of these 2186 patients, we analyzed data for 44 patients (2%) who underwent PLND at the time of RPLND. RESULTS PLND was performed in 14/44 (31%) patients at time of primary RPLND (P-RPLND), and in 21/44(48%) patients at time of postchemotherapy RPLND (PC-RPLND), usually for suspicious radiologic or intraoperative findings, whereas 9/44 (21%) underwent PLND for treatment of relapse. Positive pelvic findings on imaging included pelvic disease ≤5 cm in 17/44 (39%) patients and >5 cm in 11/44 (25%) patients (median size = 4 cm). At the time of PC-RPLND, alpha-fetoprotein and beta human chorionic gonadotropin were elevated in 6/21 (29%) and 4/21 (19%) patients, respectively. Histology revealed teratoma in 15/44 (34%) and viable tumor in 5/44 (11%) patients. At a median follow-up of 46 months, 40/44 (91%) patients were living without disease, 3/44 (7%) were living with disease (1 after PC-RPLND and 2 after relapse), and 1/44 (2%) died of other causes. CONCLUSION PLND was performed infrequently in our series of patients who underwent RPLND for testis cancer. Teratoma was the dominant tumor histology in the resected tissue.
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Affiliation(s)
- Shaheen R Alanee
- Department of Surgery, Division of Urology, Southern Illinois University School of Medicine, Springfield, IL.
| | - Brett S Carver
- Urology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Darren R Feldman
- Genitourinary Oncology Services, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert J Motzer
- Genitourinary Oncology Services, Memorial Sloan Kettering Cancer Center, New York, NY
| | - George J Bosl
- Genitourinary Oncology Services, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joel Sheinfeld
- Urology, Memorial Sloan Kettering Cancer Center, New York, NY
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