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Ghosh A, Sirinukunwattana K, Khalid Alham N, Browning L, Colling R, Protheroe A, Protheroe E, Jones S, Aberdeen A, Rittscher J, Verrill C. The Potential of Artificial Intelligence to Detect Lymphovascular Invasion in Testicular Cancer. Cancers (Basel) 2021; 13:cancers13061325. [PMID: 33809521 PMCID: PMC7998792 DOI: 10.3390/cancers13061325] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/08/2021] [Accepted: 03/12/2021] [Indexed: 11/16/2022] Open
Abstract
Testicular cancer is the most common cancer in men aged from 15 to 34 years. Lymphovascular invasion refers to the presence of tumours within endothelial-lined lymphatic or vascular channels, and has been shown to have prognostic significance in testicular germ cell tumours. In non-seminomatous tumours, lymphovascular invasion is the most powerful prognostic factor for stage 1 disease. For the pathologist, searching multiple slides for lymphovascular invasion can be highly time-consuming. The aim of this retrospective study was to develop and assess an artificial intelligence algorithm that can identify areas suspicious for lymphovascular invasion in histological digital whole slide images. Areas of possible lymphovascular invasion were annotated in a total of 184 whole slide images of haematoxylin and eosin (H&E) stained tissue from 19 patients with testicular germ cell tumours, including a mixture of seminoma and non-seminomatous cases. Following consensus review by specialist uropathologists, we trained a deep learning classifier for automatic segmentation of areas suspicious for lymphovascular invasion. The classifier identified 34 areas within a validation set of 118 whole slide images from 10 patients, each of which was reviewed by three expert pathologists to form a majority consensus. The precision was 0.68 for areas which were considered to be appropriate to flag, and 0.56 for areas considered to be definite lymphovascular invasion. An artificial intelligence tool which highlights areas of possible lymphovascular invasion to reporting pathologists, who then make a final judgement on its presence or absence, has been demonstrated as feasible in this proof-of-concept study. Further development is required before clinical deployment.
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Affiliation(s)
- Abhisek Ghosh
- Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK; (L.B.); (R.C.); (C.V.)
- Nuffield Department of Clinical and Laboratory Sciences, Oxford University, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Correspondence:
| | - Korsuk Sirinukunwattana
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7LF, UK; (K.S.); (N.K.A.); (J.R.)
- Oxford NIHR Biomedical Research Centre, Oxford University, Oxford OX3 9DU, UK
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford OX3 7DQ, UK
- Ground Truth Labs, Oxford OX4 2HN, UK;
| | - Nasullah Khalid Alham
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7LF, UK; (K.S.); (N.K.A.); (J.R.)
- Oxford NIHR Biomedical Research Centre, Oxford University, Oxford OX3 9DU, UK
| | - Lisa Browning
- Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK; (L.B.); (R.C.); (C.V.)
- Oxford NIHR Biomedical Research Centre, Oxford University, Oxford OX3 9DU, UK
| | - Richard Colling
- Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK; (L.B.); (R.C.); (C.V.)
- Nuffield Department of Surgical Sciences, Oxford University, Oxford OX3 9DU, UK;
| | - Andrew Protheroe
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK; (A.P.); (E.P.)
| | - Emily Protheroe
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK; (A.P.); (E.P.)
| | - Stephanie Jones
- Nuffield Department of Surgical Sciences, Oxford University, Oxford OX3 9DU, UK;
| | | | - Jens Rittscher
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7LF, UK; (K.S.); (N.K.A.); (J.R.)
- Oxford NIHR Biomedical Research Centre, Oxford University, Oxford OX3 9DU, UK
| | - Clare Verrill
- Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK; (L.B.); (R.C.); (C.V.)
- Oxford NIHR Biomedical Research Centre, Oxford University, Oxford OX3 9DU, UK
- Nuffield Department of Surgical Sciences, Oxford University, Oxford OX3 9DU, UK;
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5
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McHugh DJ, Funt SA, Silber D, Knezevic A, Patil S, O’Donnell D, Tsai S, Reuter VE, Sheinfeld J, Carver BS, Motzer RJ, Bajorin DF, Bosl GJ, Feldman DR. Adjuvant Chemotherapy With Etoposide Plus Cisplatin for Patients With Pathologic Stage II Nonseminomatous Germ Cell Tumors. J Clin Oncol 2020; 38:1332-1337. [PMID: 32109195 PMCID: PMC7164484 DOI: 10.1200/jco.19.02712] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The relapse rate after primary retroperitoneal lymph node dissection (RPLND) for patients with pathologic stage (PS) IIA nonseminomatous germ cell tumors (NSGCTs) is 10%-20% but increases to ≥ 50% for PS IIB disease. We report our experience with 2 cycles of adjuvant etoposide plus cisplatin (EP×2) after therapeutic primary RPLND. PATIENTS AND METHODS All patients with PS II NSGCT seen at Memorial Sloan Kettering Cancer Center from March 1989 to April 2016 and who were planned to receive EP×2 were included. Each cycle consisted of cisplatin 20 mg/m2 and etoposide 100 mg/m2 on days 1 through 5 at 21-day intervals. Demographic characteristics, histopathologic features, therapeutic and survival outcomes were recorded. RESULTS Of 156 patients, 30 (19%) had pathologic N1, 122 (78%) had pathologic N2 (pN2), and 4 (3%) had pathologic N3 (pN3) disease. The median number of involved lymph nodes was 3 (range, 1-37 nodes), and the median size of the largest involved node was 2.0 cm (range, 0.4-7.0 cm); extranodal extension was present in 69 patients (45%). Embryonal carcinoma was the most frequent RPLND histology, present in 143 patients (92%). One hundred fifty patients (96%) received EP×2, five received EP×1 and one received EP×4. With a median follow-up of 9 years, 2 patients (1.3%; 1 patient each with pN2 and pN3 disease) experienced relapse; both patients remain continuously disease free at more than 5 and 22 years after salvage chemotherapy. Three patients died, all unrelated to NSGCT, yielding 10-year disease-specific, relapse-free, and overall survival rates of 100%, 98%, and 99%, respectively. CONCLUSION Adjuvant EP×2 for PS II NSGCT is highly effective, has acceptable toxicity, and incurs less drug cost than 2 cycles of bleomycin, etoposide, and cisplatin. Inclusion of bleomycin in this setting is not necessary.
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Affiliation(s)
- Deaglan J. McHugh
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Medical College of Cornell University, New York, NY
| | - Samuel A. Funt
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Medical College of Cornell University, New York, NY
| | - Deborah Silber
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrea Knezevic
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Devon O’Donnell
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stephanie Tsai
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Victor E. Reuter
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joel Sheinfeld
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brett S. Carver
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert J. Motzer
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Medical College of Cornell University, New York, NY
| | - Dean F. Bajorin
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Medical College of Cornell University, New York, NY
| | - George J. Bosl
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Medical College of Cornell University, New York, NY
| | - Darren R. Feldman
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Medical College of Cornell University, New York, NY
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6
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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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7
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Hamilton RJ, Nayan M, Anson-Cartwright L, Atenafu EG, Bedard PL, Hansen A, Chung P, Warde P, Sweet J, O'Malley M, Sturgeon J, Jewett MAS. Treatment of Relapse of Clinical Stage I Nonseminomatous Germ Cell Tumors on Surveillance. J Clin Oncol 2019; 37:1919-1926. [PMID: 30802156 DOI: 10.1200/jco.18.01250] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Active surveillance (AS) for testicular nonseminomatous germ cell tumors (NSGCT) is widely used. Although there is no consensus for optimal treatment at relapse on surveillance, globally patients typically receive chemotherapy. We describe treatment of relapses in our non-risk-adapted NSGCT AS cohort and highlight selective use of primary retroperitoneal lymph node dissection (RPLND). METHODS From December 1980 to December 2015, 580 patients with clinical stage I NSGCT were treated with AS, and 162 subsequently relapsed. First-line treatment was based on relapse site and extent. Logistic regression was used to explore factors associated with need for multimodal therapy on AS relapse. RESULTS Median time to relapse was 7.4 months. The majority of relapses were confined to the retroperitoneum (66%). After relapse, first-line treatment was chemotherapy for 95 (58.6%) and RPLND for 62 (38.3%), and five patients (3.1%) underwent other therapy. In 103 (65.6%), only one modality of treatment was required: chemotherapy only in 58 of 95 (61%) and RPLND only in 45 of 62 (73%). Factors associated with multimodal relapse therapy were larger node size (odds ratio, 2.68; P = .045) in patients undergoing chemotherapy and elevated tumor markers (odds ratio, 6.05; P = .008) in patients undergoing RPLND. When RPLND was performed with normal markers, 82% required no further treatment. Second relapse occurred in 30 of 162 patients (18.5%). With median follow-up of 7.6 years, there were five deaths (3.1% of AS relapses, but 0.8% of whole AS cohort) from NSGCT or treatment complications. CONCLUSION The retroperitoneum is the most common site of relapse in clinical stage I NSGCT on AS. Most are cured by single-modality treatment. RPLND should be considered for relapsed patients, especially those with disease limited to the retroperitoneum and normal markers, as an option to avoid chemotherapy.
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Affiliation(s)
- Robert J Hamilton
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,2The University of Toronto, Toronto, Ontario, Canada
| | - Madhur Nayan
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,2The University of Toronto, Toronto, Ontario, Canada
| | - Lynn Anson-Cartwright
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,2The University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Philippe L Bedard
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Aaron Hansen
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Peter Chung
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Padraig Warde
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Joan Sweet
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Martin O'Malley
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeremy Sturgeon
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Michael A S Jewett
- 1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,2The University of Toronto, Toronto, Ontario, Canada
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