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Beati F, Persano G, De Pasquale MD, Martucci C, Madafferi S, Miele E, Stracuzzi A, Di Paolo PL, Natali GL, Alaggio R, Crocoli A, Inserra A. Growing teratoma syndrome in children and adolescents: Prevalence and surgical outcome. Pediatr Blood Cancer 2024; 71:e31126. [PMID: 38837659 DOI: 10.1002/pbc.31126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 05/15/2024] [Accepted: 05/19/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Patients affected by metastatic germ cell tumors may occasionally experience enlargement of masses with concurrent normalization of tumor markers during or after chemotherapy. This phenomenon is described as growing teratoma syndrome (GTS). The aim of the pre sent study is to assess the prevalence of GTS in the pediatric population and its implications in terms of surgical outcome. PATIENTS AND METHODS The clinical notes of patients diagnosed with stage III and IV malignant germ cell tumors from January 2010 until December 2020 at our Institution were retrospectively reviewed. The prevalence of GTS, treatment strategies, survival, and outcome were analyzed. RESULTS Thirty-three patients with high-stage malignant germ cell tumors were diagnosed in our institution in the analyzed period. Nine patients (28%) had radiologic evidence of enlargement of persistent masses with normal markers after chemotherapy; these patients were classified as GTS patients. All nine patients underwent resection of metastatic lymph nodes, and six had surgery on visceral metastases. In six patients, radical excision of all metastatic sites was achieved; five patients are alive and in complete remission, while one died because of peri-operative complications. Out of the three patients who could not achieve radical excision of the metastases, two died of progressive disease, and one is alive with progressive disease. CONCLUSIONS Patients affected by GTS have a risk of progression of chemotherapy-resistant disease and death. Radical surgical excision is essential to achieve disease control and long-term survival.
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Affiliation(s)
- Federico Beati
- General and Thoracic Surgery Unit, Department of Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Giorgio Persano
- Surgical Oncology - General and Thoracic Surgery Unit, Department of Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maria Debora De Pasquale
- Onco-Hematology Unit, Department of Onco-Hematology and Gene Therapy, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Cristina Martucci
- General and Thoracic Surgery Unit, Department of Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Silvia Madafferi
- Surgical Oncology - General and Thoracic Surgery Unit, Department of Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Evelina Miele
- Onco-Hematology Unit, Department of Onco-Hematology and Gene Therapy, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Alessandra Stracuzzi
- Pathology Unit, Department of Laboratories, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Pier Luigi Di Paolo
- Radiology Unit, Department of Diagnostic Imaging, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Gian Luigi Natali
- Radiology Unit, Department of Diagnostic Imaging, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Rita Alaggio
- Pathology Unit, Department of Laboratories, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Alessandro Crocoli
- Surgical Oncology - General and Thoracic Surgery Unit, Department of Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Alessandro Inserra
- General and Thoracic Surgery Unit, Department of Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
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Yuen KL, Pandit K, Puri D, Yodkhunnatham N, Bagrodia A. Testicular cancer with small metastatic burden: optimal approach in 2024. Curr Opin Urol 2024; 34:204-209. [PMID: 38305430 DOI: 10.1097/mou.0000000000001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
PURPOSE OF REVIEW Recent advancements in the management of clinical stage II (CS II) testicular cancer have transformed it into a predominantly curable condition. This success in treatment advancements has markedly extended patient survival. However, these treatments carry risks and morbidities, which is important to consider given the disease's impact on young men and the emerging understanding of long-term treatment consequences. RECENT FINDINGS Emerging data support primary retroperitoneal lymph node dissection (RPLND) for select CS II seminoma patients, with similar short-term outcomes to chemotherapy but less treatment intensity. Recent studies have also challenged the reflexive use of adjuvant chemotherapy for pathologic node-positive disease, as growing evidence shows low relapse rates regardless of nodal stage. Furthermore, novel biomarkers like circulating serum microRNA-371a-3p levels can help predict the presence of viable germ cell tumor at time of RPLND. SUMMARY Advances in risk stratification and therapy enable personalized de-escalation approaches for oligometastatic testicular cancer, optimizing survivorship. Upfront RPLND, reassessing adjuvant systemic therapy for RPLND pN+ disease, and novel biomarkers will shape precision treatment to achieve high cure rates with excellent quality of life. Ongoing trials of reduced-intensity regimens, accurate prognostic models, improved surgical strategy, and emerging biomarkers represent the next frontier in tailored curative therapy.
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Affiliation(s)
- Kit L Yuen
- Department of Urology, University of California San Diego, La Jolla, CA, USA
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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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Nestler T, Schoch J, Belge G, Dieckmann KP. MicroRNA-371a-3p-The Novel Serum Biomarker in Testicular Germ Cell Tumors. Cancers (Basel) 2023; 15:3944. [PMID: 37568759 PMCID: PMC10417034 DOI: 10.3390/cancers15153944] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 07/30/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
INTRODUCTION Testicular germ cell tumors (TGCTs) are a paradigm for the use of serum tumor markers in clinical management. However, conventional markers such as alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) have quite limited sensitivities and specificities. Within the last decade, the microRNA-371a-3p (miR371) emerged as a possible new biomarker with promising features. AREAS COVERED This review covers the typical features as well as possible clinical applications of miR371 in TGCT patients, such as initial diagnosis, therapy monitoring, and follow-up. Additionally, technical issues are discussed. EXPERT OPINION With a sensitivity of around 90% and specificity >90%, miR371 clearly outperforms the classical serum tumor markers in TGCTs. The unique features of the test involve the potential of modifying recent standards of care in TGCT. In particular, miR371 is expected to aid clinical decision-making in scenarios such as discriminating small testicular TGCT masses from benign ones prior to surgery, assessing equivocal lymphadenopathies, and monitoring chemotherapy results. Likewise, it is expected to make follow-up easier by reducing the intensity of examinations and by sparing imaging procedures. Overall, the data presently available are promising, but further prospective studies are required before the test can be implemented in standard clinical care.
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Affiliation(s)
- Tim Nestler
- Department of Urology, Federal Armed Forces Hospital Koblenz, 56072 Koblenz, Germany
| | - Justine Schoch
- Department of Urology, Federal Armed Forces Hospital Koblenz, 56072 Koblenz, Germany
| | - Gazanfer Belge
- Department of Tumour Genetics, University Bremen, 28359 Bremen, Germany
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Fanni SC, Febi M, Colligiani L, Volpi F, Ambrosini I, Tumminello L, Aghakhanyan G, Aringhieri G, Cioni D, Neri E. A first look into radiomics application in testicular imaging: A systematic review. FRONTIERS IN RADIOLOGY 2023; 3:1141499. [PMID: 37492385 PMCID: PMC10365019 DOI: 10.3389/fradi.2023.1141499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/27/2023] [Indexed: 07/27/2023]
Abstract
The aim of this systematic review was to evaluate the state of the art of radiomics in testicular imaging by assessing the quality of radiomic workflow using the Radiomics Quality Score (RQS) and the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). A systematic literature search was performed to find potentially relevant articles on the applications of radiomics in testicular imaging, and 6 final articles were extracted. The mean RQS was 11,33 ± 3,88 resulting in a percentage of 31,48% ± 10,78%. Regarding QUADAS-2 criteria, no relevant biases were found in the included papers in the patient selection, index test, reference standard criteria and flow-and-timing domain. In conclusion, despite the publication of promising studies, radiomic research on testicular imaging is in its very beginning and still hindered by methodological limitations, and the potential applications of radiomics for this field are still largely unexplored.
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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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Kordan Y, Köseoğlu E, Esen B, Özkan A, Kiremit MC, Kılıç M, Esen T. Postchemotherapy robotic retroperitoneal lymph node dissection for non-seminomatous germ cell tumors in the lateral decubitus position: oncological and functional outcomes. World J Urol 2023; 41:1101-1107. [PMID: 36806014 DOI: 10.1007/s00345-023-04329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/05/2023] [Indexed: 02/23/2023] Open
Abstract
PURPOSE Retroperitoneal lymph node dissection (RPLND) is recommended for residual masses following chemotherapy for non-seminomatous germ cell tumors (NSGCT). Recently, aberrant recurrence patterns were reported in patients who underwent robotic RPLND. We aimed to evaluate perioperative safety in addition to functional and early oncological outcomes of postchemotherapy robotic RPLND (pcR-RPLND) for NSGCT. METHODS A total of 25 patients with NSGCT who underwent a pcR-RPLND between January 2011 and June 2022 were evaluated retrospectively. Descriptive statistics were provided for demographics, clinical characteristics, intraoperative and postoperative parameters. Functional and oncological outcomes were recorded. RESULTS The median patient age was 28.9 years (IQR 21.5-32.4). The median retroperitoneal tumor size was 2.6 cm (IQR 1.5-3.5). Intraoperative complications occurred in only one case and the open conversion rate was 12%. There were seven cases with postoperative complications (Clavien grade II: 5 and IIIa: 2). Patients were followed for a median of 33.2 months (IQR 14.8-43.0). Antegrade ejaculation was preserved in 85.7% of the patients. Two patients (8%) relapsed and both had out-of-field recurrences at unusual sites (perinephric fat and omentum). Of those, one patient died (4%) of testicular cancer. CONCLUSION pcR-RPLND is a feasible and technically reproducible procedure with favorable perioperative morbidity, low rate of complications, and acceptable postoperative ejaculatory function. Although the recurrence rate was low (8%), recurrences were observed at unusual sites. Further studies are required to investigate any association between the robotic approach and aberrant recurrence patterns.
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Affiliation(s)
- Yakup Kordan
- School of Medicine, Department of Urology, Koç University, Istanbul, 34010, Turkey
| | - Ersin Köseoğlu
- School of Medicine, Department of Urology, Koç University, Istanbul, 34010, Turkey
| | - Barış Esen
- School of Medicine, Department of Urology, Koç University, Istanbul, 34010, Turkey.
| | - Arif Özkan
- School of Medicine, Department of Urology, Koç University, Istanbul, 34010, Turkey
| | - Murat Can Kiremit
- School of Medicine, Department of Urology, Koç University, Istanbul, 34010, Turkey
| | - Mert Kılıç
- Department of Urology, VKF American Hospital, Istanbul, Turkey
| | - Tarık Esen
- School of Medicine, Department of Urology, Koç University, Istanbul, 34010, Turkey
- Department of Urology, VKF American Hospital, Istanbul, Turkey
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Parkin CJ, Sharma A, Winter M. How to do an open midline extraperitoneal bilateral retroperitoneal lymph node dissection for non-seminomatous germ cell tumour. ANZ J Surg 2023; 93:337-338. [PMID: 36448646 DOI: 10.1111/ans.18182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022]
Abstract
Retroperitoneal lymph node dissection, remains a crucial step in the management of patients with non-seminomatous germ cell tumours who have undergone chemotherapy. It is a technically challenging operation with a number of techniques that have been advocated. We outline the midline, extraperitoneal approach to perform a bilateral template lymph node dissection.
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Affiliation(s)
- Cameron James Parkin
- Department of Urology, Royal North Shore Hospital, Northern Sydney Local Health District, New South Wales, Australia.,North Shore Urology Research Group, Royal North Shore Hospital, New South Wales, Australia.,Department of Surgery, University of Notre Dame, Sydney, New South Wales, Australia
| | - Aditya Sharma
- Department of Urology, Royal North Shore Hospital, Northern Sydney Local Health District, New South Wales, Australia.,North Shore Urology Research Group, Royal North Shore Hospital, New South Wales, Australia
| | - Matthew Winter
- Department of Urology, Royal North Shore Hospital, Northern Sydney Local Health District, New South Wales, Australia.,North Shore Urology Research Group, Royal North Shore Hospital, New South Wales, Australia
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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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Masterson TA, Tagawa ST. A 25-year review of advances in testicular cancer: Perspectives on evaluation, treatment, and future directions/challenges. Urol Oncol 2021; 39:561-568. [PMID: 33853746 DOI: 10.1016/j.urolonc.2021.02.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 10/21/2022]
Abstract
The year 2020 will be remembered for a number of different events, both good and bad. For the journal Urologic Oncology, Seminars and Original Investigations, this year represents the 25th anniversary of its inception and 1st publication. Under the encouragement of Editor-in-Chief Dr. Michael Droller, the collective editorial board has put together a reflection of the progresses made among the spectrum of genitourinary cancers across the entirety of therapeutic disciplines. In this review, we discuss the advances achieved in our knowledge and understanding of testicular germ cell tumors since 1995, and the challenges that lie ahead.
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Affiliation(s)
- Timothy A Masterson
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN.
| | - Scott T Tagawa
- Division of Medical Oncology, Department of Medicine and Department of Urology, Weill Cornell University Medicine, New York, NY
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11
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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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12
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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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13
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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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14
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Abstract
PURPOSE OF REVIEW Although testicular cancer remains a highly curable malignancy, challenges and uncertainty still remain in certain aspects of management. Residual disease after chemotherapy in patients with germ cell tumors (GCT) remains one of these challenges. We aim to highlight the recent literature on the management of residual disease after chemotherapy in GCT and the emerging innovations that may provide further guidance into this area. RECENT FINDINGS A subset of patients with GCT will have residual disease after chemotherapy, and management of these patients involves highly skilled multidisciplinary experts including medical oncologists, surgeons, radiologists, and pathologists. Management options depend on histologic subtype, either seminoma or nonseminoma, and involve size criteria, possible further imaging modalities, and tumor markers. Even with these tools at highly specialized expert centers, uncertainty in management remains, and recent literature has explored the use of newer biomarkers to aid in these cases. SUMMARY Postchemotherapy residual masses in GCT can prove to be complicated cases to manage. Balancing survival with quality of life outcomes is important and requires a multidisciplinary team experienced in treating GCT.
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15
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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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16
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Nason GJ, Rendon RA, Wood L, Huddart RA, Albers P, Einhorn LH, Nichols CR, Kollmannsberger C, Anson-Cartwright L, Warde P, Jewett MAS, Chung P, Bedard PL, Hansen AR, Hamilton RJ. Clinical dilemmas in local and regional testis cancer. Can Urol Assoc J 2020; 15:E58-E64. [PMID: 33007187 DOI: 10.5489/cuaj.6913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
At the Canadian Testis Cancer Workshop, the multidisciplinary management of testis cancer care was discussed. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician's assistants, residents, fellows, nurses, patients, and patient advocacy group members.This review summarizes the discussion regarding clinical dilemmas in local and regional testis cancer. We present cases that highlight the need for a coordinated approach to individualize care. Overarching themes include the importance of a multidisciplinary approach to testis cancer, willingness to involve a high-volume experienced center, and given that the oncological outcomes are excellent, a reminder that clinical decisions need to prioritize selecting a strategy with the least treatment-related morbidity when safe.
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Affiliation(s)
- Gregory J Nason
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Ricardo A Rendon
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Lori Wood
- Division of Medical Oncology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Robert A Huddart
- The Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Peter Albers
- Department of Urology, Heinrich-Heine University, Medical Faculty, Düsseldorf, Germany
| | - Lawrence H Einhorn
- Department of Oncology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Craig R Nichols
- Testicular Cancer Multidisciplinary Clinic, Virginia Mason Medical Center, Seattle, WA, United States
| | - Christian Kollmannsberger
- British Columbia Cancer Agency Vancouver Cancer Centre, University of British Columbia, Vancouver, BC, Canada
| | - Lynn Anson-Cartwright
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Padraig Warde
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
| | - Michael A S Jewett
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Peter Chung
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
| | - Philippe L Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Aaron R Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
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17
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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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18
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Gilligan T, Lin DW, Aggarwal R, Chism D, Cost N, Derweesh IH, Emamekhoo H, Feldman DR, Geynisman DM, Hancock SL, LaGrange C, Levine EG, Longo T, Lowrance W, McGregor B, Monk P, Picus J, Pierorazio P, Rais-Bahrami S, Saylor P, Sircar K, Smith DC, Tzou K, Vaena D, Vaughn D, Yamoah K, Yamzon J, Johnson-Chilla A, Keller J, Pluchino LA. Testicular Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 17:1529-1554. [PMID: 31805523 DOI: 10.6004/jnccn.2019.0058] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Testicular cancer is relatively uncommon and accounts for <1% of all male tumors. However, it is the most common solid tumor in men between the ages of 20 and 34 years, and the global incidence has been steadily rising over the past several decades. Several risk factors for testicular cancer have been identified, including personal or family history of testicular cancer and cryptorchidism. Testicular germ cell tumors (GCTs) comprise 95% of malignant tumors arising in the testes and are categorized into 2 main histologic subtypes: seminoma and nonseminoma. Although nonseminoma is the more clinically aggressive tumor subtype, 5-year survival rates exceed 70% with current treatment options, even in patients with advanced or metastatic disease. Radical inguinal orchiectomy is the primary treatment for most patients with testicular GCTs. Postorchiectomy management is dictated by stage, histology, and risk classification; treatment options for nonseminoma include surveillance, systemic therapy, and nerve-sparing retroperitoneal lymph node dissection. Although rarely occurring, prognosis for patients with brain metastases remains poor, with >50% of patients dying within 1 year of diagnosis. This selection from the NCCN Guidelines for Testicular Cancer focuses on recommendations for the management of adult patients with nonseminomatous GCTs.
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Affiliation(s)
- Timothy Gilligan
- 1Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Daniel W Lin
- 2University of Washington/Seattle Cancer Care Alliance
| | | | | | | | | | | | | | | | | | | | | | | | - Will Lowrance
- 14Huntsman Cancer Institute at the University of Utah
| | | | - Paul Monk
- 16The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Joel Picus
- 17Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | | | | | - Daniel Vaena
- 24St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - David Vaughn
- 25Abramson Cancer Center at the University of Pennsylvania
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19
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King J, Kawakami J, Heng D, Gan CL. Post-chemotherapy retroperitoneal lymph node dissection for non-seminomatous germ cell tumors: A single-surgeon, Canadian experience. Can Urol Assoc J 2020; 14:E407-E411. [PMID: 32223881 DOI: 10.5489/cuaj.6219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Post-chemotherapy retroperitoneal lymph node dissection (PCRPLND) has a well-established role in the management of residual retroperitoneal masses >1 cm in patients with advanced non-seminomatous germ cell tumor (NSGCT). Herein, we report our single-surgeon surgical experience in a Canadian tertiary hospital. METHODS We identified 57 patients with NSGCT who received primary chemotherapy and PCRPLND from 2010-2016. Surgical complication rate was graded with Clavien-Dindo classification. Chi-squared testing was used in testing for differences in proportion of PCRPLND tumor histology vs. the historical cohorts. Chi-squared testing was also used to analyze the association between primary orchiectomy tumor histology and post-chemotherapy residual mass (PCRM) tumor histology. RESULTS The overall complication rate was 23% (n=13), of which four were Clavien-Dindo grade IIIb and one was grade IVa. Fourteen percent of patients required additional procedure for resection of adjacent organs intraoperatively. There was a statistically significant difference in the distribution of PCRPLND tumor histologies (Chi-squared p=0.0187), with a lower rate of viable tumor (7%) and higher rate of teratoma (63%) compared to historical cohorts. The absence of teratoma in the primary orchiectomy specimen was associated with the findings of fibrotic/necrotic tissue in the PCRM (Chi-squared p=0.0005). CONCLUSIONS Our series demonstrated that the rate of viable tumor in PCRM appears lower than published historical series, and this possibly reflects the improvement in chemotherapy delivery in a contemporary series. The high rate of teratoma in the PCRM calls for ongoing need for PCRPLND. Grade III and IV surgical complications are considered rare in our series.
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Affiliation(s)
- Joshua King
- Biological Sciences, University of Lethbridge, Lethbridge, AB, Canada
| | - Jun Kawakami
- Division of Urology, Department of Surgery, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Daniel Heng
- Division of Medical Oncology, Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Chun Loo Gan
- Division of Medical Oncology, Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
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20
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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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21
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Nason GJ, Donahoe L, de Perrot M, Aditya I, Jewett MAS, Bedard PL, Hansen AR, Chung P, Warde P, Anson-Cartwright L, Sweet J, O'Malley M, Atenafu EG, Hamilton RJ. Simultaneous Vs Sequential Retroperitoneal, Thoracic and Cervical Resection of Post Chemotherapy Residual Masses in Patients With Metastatic Nonseminomatous Germ Cell Tumors of the Testis. Urology 2020; 138:69-76. [PMID: 32004556 DOI: 10.1016/j.urology.2019.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare a simultaneous vs sequential approach to residual post chemotherapy mass resections in metastatic testis cancer. METHODS A retrospective review was performed of patients who underwent retroperitoneal and thoracic/cervical resection of post chemotherapy residual masses between 2002 and 2018. Group 1: "Simultaneous" (Combined Retroperitoneal and Thoracic/Cervical resections on the same date); Group 2: "Sequential" (Retroperitoneal and Thoracic/Cervical resections at separate dates). RESULTS During the study period, 35 simultaneous and 17 sequential resections were performed. The median age at surgery was 28 years (Range 16-61). The median follow-up from last surgical procedure was 62.7 months (Range 0.4-194). Histology revealed teratoma in 38 (73.1%) patients, necrosis in 8 (15.4%) and viable tumor in 6 (11.5%). Discordant pathology findings between thoracic/cervical and abdominal resections were noted in 16 (30.8%) patients. No differences were observed between the simultaneous vs sequential groups in median operating time (585 minutes vs 545 minutes, P = .64), blood loss (1300 vs 1300 mls, P = .42), or length of stay (9 vs 11 days, P = .14). There was no difference between the 5-year (65.7% vs 68.6%) relapse-free survival between the 2 groups (P = .84) or the 5-year (88.6% vs 100%) overall and disease-specific survival (P = .25). CONCLUSION Simultaneous resection of retroperitoneal and thoracic/cervical post chemotherapy metastases is a feasible in some patients. It requires multidisciplinary collaboration and a longer primary procedure.
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Affiliation(s)
- Gregory J Nason
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Ishan Aditya
- 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
| | - Philip L Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Aaron R Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Padraig Warde
- 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
| | - Martin O'Malley
- Division of Abdominal Imaging, Joint Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada.
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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: 198] [Impact Index Per Article: 39.6] [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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24
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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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26
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European Association of Urology Guidelines on Testis Cancer: Important Take Home Messages. Eur Urol Focus 2019; 5:742-744. [DOI: 10.1016/j.euf.2019.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/01/2019] [Indexed: 11/20/2022]
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Abstract
There are several treatment approaches for stage II germ cell tumors (GCTs), and a thorough understanding of the staging classification and histologic differences in tumor biology and therapeutic responsiveness is critical to determine an effective, multimodal management strategy that involves urologists, medical oncologists, and radiation oncologists. This article discusses contemporary management strategies for stage II GCTs, including chemotherapy, radiotherapy, retroperitoneal lymph node dissection (RPLND), and surveillance. Patient selection, histology, and extent of lymphadenopathy drive management, and, as both treatment and detection strategies continue to emerge and be refined, the management of patients with stage II GCT continues to evolve.
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Affiliation(s)
- Rashed A Ghandour
- Department of Urology, University of Texas Southwestern Medical Center, 2001 Inwood Road, 4th Floor, Dallas, TX 75390-9110, USA
| | - Nirmish Singla
- Department of Urology, University of Texas Southwestern Medical Center, 2001 Inwood Road, 4th Floor, Dallas, TX 75390-9110, USA
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern Medical Center, 2001 Inwood Road, 4th Floor, Dallas, TX 75390-9110, USA.
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28
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Thomas LJ, Brooks MA, Stephenson AJ. The Role of Imaging in the Diagnosis, Staging, Response to Treatment, and Surveillance of Patients with Germ Cell Tumors of the Testis. Urol Clin North Am 2019; 46:315-331. [DOI: 10.1016/j.ucl.2019.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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29
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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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Funt SA, Patil S, Feldman DR, Motzer RJ, Bajorin DF, Sheinfeld J, Tickoo SK, Reuter VE, Bosl GJ. Impact of Teratoma on the Cumulative Incidence of Disease-Related Death in Patients With Advanced Germ Cell Tumors. J Clin Oncol 2019; 37:2329-2337. [PMID: 31233353 DOI: 10.1200/jco.18.01608] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE In men with metastatic germ cell tumors (GCTs), risk-directed treatment is determined, in part, by a distinction between seminoma and nonseminomatous GCT (NSGCT). The importance of NSGCT cell type is uncertain. We evaluated the long-term impact of teratoma on survival in patients with NSGCT. METHODS Prechemotherapy, primary tumors from patients who received platinum-based chemotherapy were studied, and the histology was confirmed by a genitourinary pathologist. The cumulative incidence of disease-related death (CIDD) was the primary end point, and a competing-risk analysis was performed. RESULTS Tumors were available from 232 patients, including 193 with NSGCT. An element of teratoma was present in 82 NSGCT primary tumors (42%). With a median follow-up of 17 years (range, 0.3 to 35 years), 58 patients with NSGCT died, 47 as a result of GCT and 11 as a result of other causes. Most GCT deaths occurred within the first 5 years and were associated with pretreatment risk status (P < .001). Death as a result of other causes rose steadily after 15 years and was not associated with risk status (P = .66). A higher CIDD was observed in patients who had NSGCT with teratoma than those with NSGCT without teratoma and seminoma (5-year CIDD rate, 27.4%, 17.4%, and 10.3%, respectively; P = .03). A higher CIDD was observed in patients who had NSGCT with mature teratoma compared with those with either NSGCT with immature teratoma or NSGCT without teratoma (5-year CIDD rate, 38.1%, 19.9%, and 17.4%, respectively; P = .01). CONCLUSION The presence of teratoma, particularly mature teratoma, in an NSGCT primary tumor is associated with a higher CIDD, consistent with the hypothesis that differentiation is associated with adverse outcomes. Death as a result of non-GCT causes is not associated with risk status and must be separated from GCT death when evaluating long-term survival.
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Affiliation(s)
- Samuel A Funt
- Memorial Sloan Kettering Cancer Center, New York, NY and Weill Cornell Medical College, New York, NY
| | - Sujata Patil
- Memorial Sloan Kettering Cancer Center, New York, NY and Weill Cornell Medical College, New York, NY
| | - Darren R Feldman
- Memorial Sloan Kettering Cancer Center, New York, NY and Weill Cornell Medical College, New York, NY
| | - Robert J Motzer
- Memorial Sloan Kettering Cancer Center, New York, NY and Weill Cornell Medical College, New York, NY
| | - Dean F Bajorin
- Memorial Sloan Kettering Cancer Center, New York, NY and Weill Cornell Medical College, New York, NY
| | - Joel Sheinfeld
- Memorial Sloan Kettering Cancer Center, New York, NY and Weill Cornell Medical College, New York, NY
| | - Satish K Tickoo
- Memorial Sloan Kettering Cancer Center, New York, NY and Weill Cornell Medical College, New York, NY
| | - Victor E Reuter
- Memorial Sloan Kettering Cancer Center, New York, NY and Weill Cornell Medical College, New York, NY
| | - George J Bosl
- Memorial Sloan Kettering Cancer Center, New York, NY and Weill Cornell Medical College, New York, NY
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Ghodoussipour S, Daneshmand S. Postchemotherapy Resection of Residual Mass in Nonseminomatous Germ Cell Tumor. Urol Clin North Am 2019; 46:389-398. [PMID: 31277733 DOI: 10.1016/j.ucl.2019.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The introduction of cisplatin-based chemotherapy has revolutionized the care of patients with disseminated testicular germ cell tumors. Although a majority are cured with chemotherapy alone, surgical resection continues to play a role because one-third will have residual mass after chemotherapy. In this article, we review the current indications for postchemotherapy resection in nonseminomatous germ cell tumors, including masses greater than 1 cm, resection after salvage chemotherapy, with elevated markers, after late relapse, and for growing teratoma syndrome. We also highlight technical considerations of this often-challenging surgery, including the need for adjunctive procedures, extraretroperitoneal resections, and modern techniques to minimize morbidity.
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Affiliation(s)
- Saum Ghodoussipour
- Norris Comprehensive Cancer Center, USC Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90033, USA
| | - Siamak Daneshmand
- Norris Comprehensive Cancer Center, USC Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90033, USA.
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Heidenreich A, Paffenholz P, Nestler T, Pfister D. Management of residual masses in testicular germ cell tumors. Expert Rev Anticancer Ther 2019; 19:291-300. [PMID: 30793990 DOI: 10.1080/14737140.2019.1580146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION About 50% of all patients with advanced testicular cancer demonstrate residual retroperitoneal or extraretroperitoneal masses. About two thirds of the masses harbour necrosis/fibrosis only whereas as about 10% and 40% harbour vital cancer or teratoma. Appropriate therapy will result in a high cure rate if performed properly. Areas covered: This review article covers the indication, the surgical technique and the oncological outcome of PC-RPLND and resection of extraretroperitoneal residual masses following chemotherapy in patients with advanced testis cancer. Expert commentary: Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours. Patients with nonseminomas, residual masses < 1cm and good prognosis can undergo active surveillance. In all other cases, PC-RPLND with or without resection of adjacent organs needs to be performed for curative intent. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.
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Affiliation(s)
- Axel Heidenreich
- a Department of Urology, Urologic Oncology, Robot-assisted and Specialized Urologic Surgery , University Hospital Cologne , Köln , Germany
| | - Pia Paffenholz
- a Department of Urology, Urologic Oncology, Robot-assisted and Specialized Urologic Surgery , University Hospital Cologne , Köln , Germany
| | - Tim Nestler
- a Department of Urology, Urologic Oncology, Robot-assisted and Specialized Urologic Surgery , University Hospital Cologne , Köln , Germany
| | - David Pfister
- a Department of Urology, Urologic Oncology, Robot-assisted and Specialized Urologic Surgery , University Hospital Cologne , Köln , Germany
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Abstract
PURPOSE OF REVIEW The purpose of this review is to educate medical oncologists on the management of patients with residual germ cell tumors and the role of surgical resection after platinum-based chemotherapy. RECENT FINDINGS Patients with non-seminomatous testicular cancer and residual enlarged retroperitoneal lymph nodes > 1 cm following induction chemotherapy with normal tumor markers should undergo a post-chemotherapy retroperitoneal lymph node dissection. All patients with primary mediastinal non-seminoma should undergo surgical resection of the mediastinal mass post-chemotherapy. These are complex surgeries and require expert surgeons in high-volume centers. Patients with advanced testicular seminoma who have residual masses less than 3 cm after chemotherapy can be observed without further intervention. Patients with a residual mass > 3 cm should be evaluated with PET scan after 6 weeks of chemotherapy. Residual mass with negative PET scan can be followed by surveillance while a positive PET scan requires further work up to rule out active disease.
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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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Current controversies on the role of lymphadenectomy for testicular cancer for the journal: Urologic Oncology: Seminars and Original Investigations for the special seminars section on the role of lymphadenectomy for urologic cancers. Urol Oncol 2019; 39:698-703. [PMID: 30630731 DOI: 10.1016/j.urolonc.2018.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 12/04/2018] [Accepted: 12/22/2018] [Indexed: 11/22/2022]
Abstract
The role of surgery in the locoregional management of many solid tumors has long been established. For testicular cancer, the incorporation of lymphadenectomy has played an important part in generating long-term survival outcomes in excess of 90% for germ cell tumor patients. In this review, we address several clinical scenarios in which lymphadenectomy at times is underutilized, and others ill advised.
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36
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Pfister D, Heidenreich A. Management of Residual Tumor in Testicular Cancer. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42603-7_8-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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37
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Heidenreich A, Pfister D. Postchemotherapy Retroperitoneal Lymph Node Dissection in Advanced Germ Cell Tumors of the Testis. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42603-7_9-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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38
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Management of Residual Tumor in Testicular Cancer. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42623-5_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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39
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Heidenreich A, Pfister D. Postchemotherapy Retroperitoneal Lymph Node Dissection in Advanced Germ Cell Tumors of the Testis. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42623-5_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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40
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Handy JR, Bremner RM, Crocenzi TS, Detterbeck FC, Fernando HC, Fidias PM, Firestone S, Johnstone CA, Lanuti M, Litle VR, Kesler KA, Mitchell JD, Pass HI, Ross HJ, Varghese TK. Expert Consensus Document on Pulmonary Metastasectomy. Ann Thorac Surg 2018; 107:631-649. [PMID: 30476477 DOI: 10.1016/j.athoracsur.2018.10.028] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 10/09/2018] [Indexed: 12/17/2022]
Affiliation(s)
- John R Handy
- Thoracic Surgery, Providence Health & Services, Portland, Oregon.
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Todd S Crocenzi
- Medical Oncology, Providence Cancer Center, Providence Health & Services, Portland, Oregon
| | - Frank C Detterbeck
- Section of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Hiran C Fernando
- Inova Cardiac and Thoracic Surgery, Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Panos M Fidias
- Medical Oncology, Center for Cancer Care, Exeter Hospital, Exeter, New Hampshire
| | | | - Candice A Johnstone
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Lanuti
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Virginia R Litle
- Department of Surgery, Boston University Medical Center, Boston, Massachusetts
| | - Kenneth A Kesler
- Section of Thoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - John D Mitchell
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Harvey I Pass
- Department of Cardiothoracic Surgery, Langone Medical Center, New York University School of Medicine, New York, New York
| | - Helen J Ross
- Division of Hematology/Medical Oncology, Mayo Clinic, Phoenix, Arizona
| | - Thomas K Varghese
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
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41
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Mano R, Di Natale R, Sheinfeld J. Current controversies on the role of retroperitoneal lymphadenectomy for testicular cancer. Urol Oncol 2018; 37:209-218. [PMID: 30446455 DOI: 10.1016/j.urolonc.2018.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 08/13/2018] [Accepted: 09/12/2018] [Indexed: 01/13/2023]
Abstract
Retroperitoneal lymph node dissection (RPLND) is an important component of the multimodal treatment which cures most patients diagnosed with testicular germ cell tumors. Considering the high cure rates achieved, research focus in recent years has been directed toward improving quality of life and decreasing long-term treatment related sequelae. Consequently, the role of RPLND has evolved over the past 3 decades in both low-stage and advanced testicular cancer. The use of RPLND in clinically stage I and low volume stage II disease may offer the advantages of treating retroperitoneal teratoma which is present in 15% to 20% of patients, avoiding chemotherapy and reducing the need for frequent imaging during follow-up. Similarly, ongoing studies are evaluating the safety and effectiveness of RPLND for the treatment of early stage seminoma to avoid the long-term effects of chemotherapy and radiotherapy. RPLND is traditionally used for the treatment of residual masses >1 cm after completion of chemotherapy. Its role in subcentimeter residual masses remains somewhat controversial given the fact that 25% to 30% of these patients are found to harbor either teratoma or viable nonteratomatous germ cell tumors. The presence of teratoma increases the probability of teratoma in metastatic sites. Modified unilateral templates were developed based on early mapping studies with the aim of preserving antegrade ejaculation. Recent data suggests initial mapping studies underestimated the risk of contralateral retroperitoneal metastases which may reach 32%. Furthermore, antegrade ejaculation may be preserved in >95% of patients undergoing bilateral nerve sparing primary RPLND and >80% undergoing nerve-sparing PC-RPLND, which, in our view is the more prudent oncologic approach. Recently, multiple series have demonstrated the safety and short-term efficacy of minimally invasive RPLND; however, larger studies with prolonged follow-up are required to validate the long-term oncologic efficacy of newer techniques.
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Affiliation(s)
- Roy Mano
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Renzo Di Natale
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joel Sheinfeld
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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42
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Leão R, Ahmad AE, Hamilton RJ. Testicular Cancer Biomarkers: A Role for Precision Medicine in Testicular Cancer. Clin Genitourin Cancer 2018; 17:e176-e183. [PMID: 30497810 DOI: 10.1016/j.clgc.2018.10.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/11/2018] [Accepted: 10/14/2018] [Indexed: 12/16/2022]
Abstract
Testicular germ cell tumors (TGCTs) represent the most common solid tumors among men aged 15 to 34 years. Fortunately, recent advances have made testicular cancer a highly curable disease. Despite the high cure rates, there are still several areas in testis cancer care where treatment decisions are controversial and guided only with clinical factors and historic serum tumor markers. Unfortunately, unlike other genitourinary malignancies, modern research techniques have not been widely tested or applied to germ cell tumors, perhaps as a result of excellent prognosis in this cohort of young men. Despite this, there remain numerous challenges and pitfalls in testis cancer care that need to be addressed. A reliable set of biomarkers could be extremely useful in helping risk-stratify patients, detect relapse early, guide surgical decision-making, and tailor follow-up. Current tumor markers (Alpha-fetoprotein, human chorionic gonadotrophin, and lactate dehydrogenase) have low accuracy and low sensitivity when used not only as diagnostic but also as prognostic and predictive markers. In twenty-first century medicine, there is a role for further prognostic stratification and the development of novel biomarkers that offer greater sensitivity and specificity for TGCTs. Despite the initial promising results, the majority of preclinical biomarkers do not, as yet have a proven validated role in clinical practice, and future prospective trials are needed to support and confirm the results of cohort studies. In this narrative review, we aimed to highlight the recent innovations in the development and implementation of novel testicular tumor markers and discuss their clinical applications and limitations in the management of this disease.
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Affiliation(s)
- Ricardo Leão
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Faculty of Medicine, University of Coimbra, Coimbra, Portugal; CUF Department of Urology, Lisbon, Portugal
| | - Ardalan E Ahmad
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Abstract
Testicular cancer is the most common malignancy among men between 14 and 44 years of age, and its incidence has risen over the past two decades in Western countries. Both genetic and environmental factors contribute to the development of testicular cancer, for which cryptorchidism is the most common risk factor. Progress has been made in our understanding of the disease since the initial description of carcinoma in situ of the testis in 1972 (now referred to as germ cell neoplasia in situ), which has led to improved treatment options. The combination of surgery and cisplatin-based chemotherapy has resulted in a cure rate of >90% in patients with testicular cancer, although some patients become refractory to chemotherapy or have a late relapse; an improved understanding of the molecular determinants underlying tumour sensitivity and resistance may lead to the development of novel therapies for these patients. This Primer provides an overview of the biology, epidemiology, diagnosis and current treatment guidelines for testicular cancer, with a focus on germ cell tumours. We also outline areas for future research and what to expect in the next decade for testicular cancer.
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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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Heidenreich A, Paffenholz P, Haidl F, Pfister D. [When is surgical resection of metastases in testicular germ cell tumors indicated and is there a scientific basis?]. Urologe A 2018; 56:627-636. [PMID: 28432399 DOI: 10.1007/s00120-017-0385-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Surgical resection of metastases represents an integral part of curative management in patients with testicular germ cell tumors (GCT). Primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) for low volume metastases in clinical stages I-IIB has to be differentiated from the more complex and more extensive postchemotherapeutic procedures. In Europe, primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) for clinical stage I nonseminomatous GCT (NSGCT) plays a subordinate. In clinical stage IIA/B, nsRPLND is indicated for patients with marker-negative metastases in whom cure rates of about 65% can be achieved with surgery alone. For clinical stage IIA/B seminomas, nsRPLND represents an individual, still experimental procedure with high cure rates. Postchemotherapy residual tumor resection (pRTR) for advanced seminomas is only indicated in the context of a FDG-PET/CT-positive residual mass >3 cm in diameter. For NSGCT, pRTR is indicated in patients with residual masses >1 cm and negative or plateauing tumor markers to resect persisting teratoma or vital cancer. Complete resection of all masses including resection of adjacent vascular, visceral or skeletal metastases is mandatory to achieving the highest cure rate possible. Due to the complexity and the lower rate of significant morbidity and mortality, these procedures should be done at tertiary referral centers.
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Affiliation(s)
- A Heidenreich
- Klinik für Urologie, Uro - Onkologie, Roboter-assistierte und Spezielle Urologische Chirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - P Paffenholz
- Klinik für Urologie, Uro - Onkologie, Roboter-assistierte und Spezielle Urologische Chirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - F Haidl
- Klinik für Urologie, Uro - Onkologie, Roboter-assistierte und Spezielle Urologische Chirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - D Pfister
- Klinik für Urologie, Uro - Onkologie, Roboter-assistierte und Spezielle Urologische Chirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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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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47
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Abstract
Residual tumor resection in patients with advanced testicular tumor plays a vital role in the multimodal treatment. Treatment indications for residual tumor resection have changed over the last two decades. While patients with advanced seminoma after chemotherapy or radiotherapy rarely need surgery, it is mandatory for most non-seminomatous tumor patients to undergo post-chemotherapy tumor resection. Due to adjunctive surgical procedures, the operation is surgically demanding and should be performed only in specialized high-volume referral centers. Additional surgical procedures such as nephrectomy, partial colectomy or vascular interventions including caval and aortic resection with grafting might be required. Consequently, several complications can be seen in the peri- and postoperative course. We aim to describe indications for residual tumor resection, operative technique, including adjunctive surgeries and the most common peri- and postoperative complications.
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48
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Nicolai N, Cattaneo F, Biasoni D, Catanzaro M, Torelli T, Zazzara M, Necchi A, Giannatempo P, Raggi D, Piva L, Colecchia M, Salvioni R, Stagni S. Laparoscopic Postchemotherapy Retroperitoneal Lymph-Node Dissection Can Be a Standard Option in Defined Nonseminomatous Germ Cell Tumor Patients. J Endourol 2016; 30:1112-1119. [DOI: 10.1089/end.2016.0458] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nicola Nicolai
- Testis Surgery Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | | | - Davide Biasoni
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Mario Catanzaro
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Tullio Torelli
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Michele Zazzara
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Andrea Necchi
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Patrizia Giannatempo
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Daniele Raggi
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Luigi Piva
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Maurizio Colecchia
- Department of Pathology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Roberto Salvioni
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Silvia Stagni
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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49
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Abstract
Testicular germ cell tumours are at the crossroads of developmental and neoplastic processes. Their cause has not been fully elucidated but differences in incidences suggest that a combination of genetic and environment factors are involved, with environmental factors predominating early in life. Substantial progress has been made in understanding genetic susceptibility in the past 5 years on the basis of the results of large genome-wide association studies. Testicular germ cell tumours are highly sensitive to radiotherapy and chemotherapy and hence have among the best outcomes of all tumours. Because the tumours occur mainly in young men, preservation of reproductive function, quality of life after treatment, and late effects are crucial concerns. In this Seminar, we provide an overview of advances in the understanding of the epidemiology, genetics, and biology of testicular germ cell tumours. We also summarise the consensus on how to treat testicular germ cell tumours and focus on a few controversies and improvements in the understanding of late effects of treatment and quality of life for survivors.
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Affiliation(s)
- Ewa Rajpert-De Meyts
- Department of Growth and Reproduction, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark; International Center for Research and Research Training in Endocrine Disrupting Effects on Male Reproduction and Child Health, Copenhagen, Denmark
| | - Katherine A McGlynn
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Keisei Okamoto
- Department of Urology, Shiga University of Medical Science, Tsukinowa, Seta, Shiga, Japan.
| | - Michael A S Jewett
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada
| | - Carsten Bokemeyer
- Department of Oncology, Haematology, Bone Marrow Transplantation with section Pneumology, Department of Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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50
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Alotaibi M, Saadeddin A, Bazarbashi S, Alkhateeb S, Alghamdi A, Alghamdi K, Murshid E, Abusamra A, Rabah D, Ahmad I, Al-Mansour M, Alsharm A. Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for testicular germ cell tumors. Urol Ann 2016; 8:141-5. [PMID: 27141181 PMCID: PMC4839228 DOI: 10.4103/0974-7796.179240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
This is an update to the previously published Saudi guidelines for the evaluation, medical, and surgical management of patients diagnosed with testicular germ cell tumors. It is categorized according to the stage of the disease using the tumor-node-metastasis staging system 7(th) edition. The guidelines are presented with supporting evidence level, they are based on comprehensive literature review, several internationally recognized guidelines, and the collective expertise of the guidelines committee members (authors) who were selected by the Saudi Oncology Society and Saudi Urological Association. Considerations to the local availability of drugs, technology and expertise have been regarded. These guidelines should serve as a roadmap for the urologists, oncologists, general physicians, support groups, and health care policy makers in the management of patients diagnosed with testicular germ cell tumors.
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Affiliation(s)
- Mohammed Alotaibi
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ahmad Saadeddin
- Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Shouki Bazarbashi
- Department of Oncology, Section of Medical Oncology, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Sultan Alkhateeb
- Department of Surgery, Division of Urology, King Abdulaziz Medical City and King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- Address for correspondence: Dr. Sultan Alkhateeb, Department of Surgery, Division of Urology, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, P.O. Box: 22490 (1446), Riyadh 11426, Saudi Arabia. E-mail:
| | - Abdullah Alghamdi
- Department of Urology, Prince Sultan Medical Military Center, Jeddah, Saudi Arabia
| | - Khalid Alghamdi
- Department of Surgery, Division of Urology, Security Forces Hospital, Jeddah, Saudi Arabia
| | - Esam Murshid
- Department of Oncology, Oncology Center, Prince Sultan Medical Military City, Jeddah, Saudi Arabia
| | - Ashraf Abusamra
- Department of Surgery, Urology Section, King Khalid Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Danny Rabah
- Department of Surgery, College of Medicine and Uro-oncology Research Chair, King Saud University, Jeddah, Saudi Arabia
| | - Imran Ahmad
- Department of Oncology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Mubarak Al-Mansour
- Department of Oncology, King Abdulaziz Medical City and King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Abdullah Alsharm
- Department of Medical Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
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