Postchemotherapy surgery for germ cell tumors--what have we learned in 35 years?

Role of 18F-Fluorodeoxyglucose Positron Emission Tomography in Children With Germ Cell Tumor After Chemotherapy

BACKGROUND/AIM

18F-fluoro-2-deoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is a diagnostic tool widely used in adult oncology and some pediatric oncological settings. There are no established recommendations for the use of this imaging modality in pediatric malignant germ cell tumors (mGCT), however. Our aim is to evaluate the role of 18F-FDG PET/CT in the restaging of mGCT after chemotherapy in children and adolescents.

METHODS

We retrospectively reviewed patients with mGCT treated in Associazione Italiana Ematologia Oncologia Pediatrica (AIEOP) centers who underwent 18F-FDG PET/CT between 2011 and 2021.

RESULTS

Seventeen patients (median age 13 y) were included in the study. In 14 patients, 18F-FDG PET/CT was performed at diagnosis; 12 showed pathologic uptake. The 2 18F-FDG PET/CT negative cases were histologically defined as yolk sac tumor (YST) and mixed (chorioncarcinoma, YST). Nine of the 12 patients who had pathologic 18F-FDG PET/CT at diagnosis repeated the examination after neoadjuvant chemotherapy, before, second look surgery. In 5 cases, no pathologic uptake was evident. Histology showed necrosis alone in 4 cases and necrosis and mature teratoma in 1. In 3 of the 6 cases with pathologic uptake (2 of 6 patients did not perform the examination at diagnosis), histology showed persistence of malignant component, whereas in the remaining 3 cases, necrosis and mature teratoma were present.

CONCLUSION

In our review of a series of children with mGCT, 18F-FDG PET/CT after neoadjuvant chemotherapy showed 1 of 5 false negatives and was unable to discriminate between residual malignant component and mature teratoma.

Unilateral Post-Chemotherapy Robot-Assisted Retroperitoneal Lymph Node Dissection for Stage II Non-Seminomatous Germ Cell Tumors: Sexual and Reproductive Outcomes

We aimed to report sexual and reproductive outcomes following post-chemotherapy robot-assisted retroperitoneal unilateral lymph node dissection (PC-rRPLND) for non-seminomatous germ cell tumors (NSGCTs) at a high-volume cancer center. We collected records regarding sexual and reproductive outcomes of patients undergoing unilateral PC-rRPLND for stage II NSGCTs from January 2018 to November 2021. Preoperative and postoperative (at 12 months) ejaculatory function as well as erectile function, based on the International Index of Erectile Function-5 (IIEF-5) and Erection Hardness Score (EHS), were assessed. Only patients with a pre-operative IIEF-5 of ≥22 and EHS of ≥3 were included in this analysis. Overall, 22 patients undergoing unilateral PC-rRPLND met the inclusion criteria. Of these, seven (31.8%) patients presented an andrological disorder of any type after PC-rRPLND. Specifically, retrograde ejaculation was present in three (13.6%) patients and hypospermia was present in one (4.5%) patient. Moreover, three (13.6%) patients yielded erectile dysfunction (IIEF-5 < 22 and/or EHS < 3). Lastly, two (9.1%) succeeded in naturally conceiving a child after PC-rRPLND. Retrograde ejaculation is confirmed to be one of the most common complications of PC-rRPLND. Moreover, a non-negligible number of patients experience erectile dysfunction.

Robot-Assisted Laparoscopic Radical Prostatectomy for Prostatic Metastatic Recurrence from Testicular Cancer

Introduction

Treatment evidence for malignancies metastatic to the prostate in young patients is scarce. Herein, we present a case of prostatic metastasis from testicular cancer treated with induction chemotherapy followed by robot-assisted radical prostatectomy. Case Presentation. The patient is a 34-year-old male who underwent radical orchiectomy for a left testicular tumor two years ago and was diagnosed with a mixed germ cell tumor. He was followed up without adjuvant therapy, but symptoms of dysuria lead to suspicion of a prostate tumor, which was diagnosed by prostate biopsy as seminoma of the prostate. After four cycles of chemotherapy, normalization of tumor markers, and tumor shrinkage on imaging, he underwent robot-assisted radical prostatectomy. No recurrence has been observed nine months after treatment.

Conclusion

In men with a history of testicular cancer presenting with lower urinary tract symptoms, it is important to consider recurrent prostate metastases.

Advances in diagnosis and treatment of testicular cancer

Testicular cancer is a curable cancer. The success of physicians in curing the disease is underpinned by multidisciplinary advances. Cisplatin-based combination chemotherapy and the refinement of post-chemotherapy surgical procedures and diagnostic strategies have greatly improved long term survival in most patients. Despite such excellent outcomes, several controversial dilemmas exist in the approaches to clinical stage I disease, salvage chemotherapy, post-chemotherapy surgical procedures, and implementing innovative imaging studies. Relapse after salvage chemotherapy has a poor prognosis and the optimal treatment is not apparent. Recent research has provided insight into the molecular mechanisms underlying cisplatin resistance. Phase 2 studies with targeted agents have failed to show adequate efficacy; however, our understanding of cisplatin resistant disease is rapidly expanding. This review summarizes recent advances and discusses relevant issues in the biology and management of testicular cancer.

Survival Outcomes of Patients With Primary Mediastinal Germ Cell Tumors: A Retrospective Single-institutional Experience

BACKGROUND/AIM

Primary mediastinal non-seminomatous germ cell tumors (PMNSGCTs) are occasionally complicated by a hematologic malignancy, as with somatic-type malignant tumors called germ cell tumors with somatic-type malignancy (GCTSTM) and are known to have a poor prognosis.

PATIENTS AND METHODS

Data obtained between September 1997 and February 2020 for patients with mediastinal germ cell tumor at our institution were retrospectively analyzed. Key outcome measures included survival rates and the clinical features of non-seminoma cases.

RESULTS

Of 16 patients, 9 had pure seminoma, and 7 had non-seminoma. At the median follow-up of 56.2 months, the 5-year survival rate was significantly higher in patients with seminoma (100%) than in those with non-seminoma (37%) (log-rank test, p=0.0153). Regarding PMNSGCT, two patients evolved into GCTSTM and three had concomitant hematological malignancies.

CONCLUSION

Patients with PMNSGCTs, GCTSTM complications, and hematologic malignancies showed poor survival, suggesting the need for the development of treatment strategies.

Outcome of Postchemotherapy Residual Disease in Extracranial Germ Cell Tumor in Children: Experience of a Tertiary Care Center

OBJECTIVES

The aim was to review outcome with residual disease at the end of first line chemotherapy in patients with extracranial germ cell tumor (GCT) in our resource limited setting.

METHODS

A retrospective analysis of 196 patients with GCT recruited at Shaukat Khanum Memorial Cancer Hospital (SKMCH) from January 2008 to December 2016. Data fields included site, histopathology, stage, risk groups, baseline alpha fetoprotein, beta human chorionic gonadotropin levels, residuum after primary treatment, completeness of surgical excision and outcomes. Data analysis involved quantitative analysis, mean and median calculations, event free survival (EFS) and overall survival (OS) calculations using Kaplan-Meier curves.

RESULTS

In 196 included patients, M:F ratio was 1. There were 81 (41.3%) adolescents. Alpha fetoprotein was >10,000 IU/L in 56 (28.6%) patients. Sixty-two (31.6%) patients had extragonadal disease. Most patients (n=137, 69.9%) presented with advanced stage (III/IV). Seventy-six patients had postchemotherapy residual disease (n=59 [78%] with partial response (PR) and 17 [22%] with no response [NR]). Five-year OS was 83% and EFS was 67%. Five-year EFS of patients with complete remission after primary chemotherapy was 85% versus 70% in patients with PR and 6% in those with NR (P=0.001). OS in patients with complete remission, PR and NR was 94%, 87%, and 46%, respectively. All patients with NR progressed or relapsed and 8/17 died. Four patients with normalized tumor marker response were found to have active tumor on resection of postchemotherapy residuum.

CONCLUSION

Patients with postchemotherapy residual disease in pediatric extracranial GCTs, fare better if their residuum is resected compared with those who do not undergo resection.

Successful treatment of radiotherapy and apatinib in patient with mediastinal mixed non-seminomatous germ cell tumor: A case report

RATIONALE

Mediastinal non-seminomatous germ cell tumors (MNSGCTs) are rare malignancies. Chemotherapy followed by surgical resection has been regarded as the standard management, but treatment options for chemotherapy-refractory patients or those with unresectable tumors are limited, resulting in a very poor prognosis.

PATIENT CONCERNS

An 18-year-old female presented with symptoms of cough, chest tightness, and shortness of breath for 2 months, and the symptoms gradually worsened.

DIAGNOSIS

Computed tomography (CT) revealed a large mediastinal mass invading the pericardium and great blood vessels. Serum human chorionic gonadotropin (HCG) and α-fetoprotein (AFP) levels were normal. Histopathological examination of biopsy specimens revealed mixed MNSGCT with embryonal carcinoma and immature teratoma components.

INTERVENTIONS

The patient achieved complete remission (CR) and long-term survival after multimodal therapy comprising chemotherapy, positron emission tomography/CT (PET/CT)-guided volumetric-modulated arc therapy (VMAT), and anti-angiogenic targeted therapy.

OUTCOMES

The patient was followed up for more than 4 years without recurrence, metastasis, or treatment-related adverse effects.

LESSONS

The case presented here highlights the importance of multidisciplinary diagnosis and treatment, providing evidence that radiotherapy and anti-angiogenic therapy may play an important role in unresectable or residual tumors after failure of conventional treatments of MNSGCT. Percutaneous biopsy is necessary for diagnosis if the tumor is unresectable, and serum AFP and HCG levels are normal. Additionally, PET/CT is an effective method for evaluation of efficacy and radiotherapy guidance for patients with MNSGCTs.

Pathologic concordance of resected metastatic nonseminomatous germ cell tumors in the chest

OBJECTIVE

Men with metastatic nonseminomatous germ cell tumors (NSGCTs) often present with residual chest tumors after chemotherapy. We examined the pathologic concordance of intrathoracic disease and outcomes based on the worst pathology of disease resected at first thoracic surgery.

METHODS

A retrospective analysis was performed of consecutive patients undergoing thoracic resection for metastatic NSGCT in our institution between 2005 and 2018.

RESULTS

Eighty-nine patients (all men) were included. The median age was 29 years (interquartile range [IQR], 23-35 years). Primary sites were testis (n = 84; 94.4%) and retroperitoneum (n = 5; 5.6%). Eighty-seven patients received chemotherapy before undergoing surgery. Nineteen patients (21.3%; group 1) had malignancy resected at first surgery (OR1), and the other 70 patients had benign disease at OR1 (78.7%; group 2). Concordant pathology between lungs was 85.2% in group 1 and 91% in group 2, and between lung and mediastinum was 50% in group 1 and 72.7% in group 2. Despite no teratoma at OR1, 3 patients (15.8%) in group 2 had resection of teratoma (n = 2) or malignancy (n = 1) at future surgery. After a mean follow-up of 65.5 months (IQR, 23.1-89.2 months) for group 1 and 47.7 months (IQR, 13.0-75.1 months) for group 2, overall survival was significantly worse for group 1 (68.4% vs 92.9%; P = .03).

CONCLUSIONS

The wide range of pathology resected in patients with intrathoracic NSGCT metastases requires careful decision making regarding treatment. Pathologic concordance between lungs is better than that between lung and mediastinum in patients with intrathoracic NSGCT metastases. Aggressive surgical management should be considered for all residual disease due to the low concordance between sites and the potential for excellent long-term survival even in patients with chemotherapy-refractory disease.

Surgical Management of Genitourinary Cancer Liver Metastases

Genitourinary cancers are common. Liver metastases from genitourinary cancers are uncommon; isolated liver metastasis is rare. Liver resection in select patients with metastatic renal cell carcinoma can lead to prolonged survival. Patients with metachronous and low-burden disease are most likely to benefit. Chemotherapy is first-line treatment of metastatic germ cell tumors. Liver resection is dependent on germ cell lineage and initial response to chemotherapy. Prognosis with liver metastases from prostate cancer is poor; liver-only lesions are rare. Liver resection generally is not indicated. Cumulative experience with liver resection for metastatic bladder cancer is limited. Liver metastases are poor prognostic indicators for metastasectomy.

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

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

Differences in PD-L1-Expressing Macrophages and Immune Microenvironment in Testicular Germ Cell Tumors

OBJECTIVES

To characterize the tumor microenvironment of testicular germ cell tumors (GCTs) using immunohistochemical markers.

METHODS

Seventy-seven orchiectomies, including 36 nonmetastatic (NM) seminomas, 15 metastatic (M) seminomas, 13 nonmetastatic nonseminomatous germ cell tumors (NSGCTs), and 13 metastatic NSGCTs, were studied with PD-1, PD-L1, FOXP3, CD68, CD163, and mismatch repair (MMR) immunohistochemistry. FOXP3+ and PD-1+ tumor-infiltrating lymphocytes (TILs) and tumor-associated macrophages (TAMs) expressing CD68 and CD163 were enumerated. PDL-1 expression was evaluated on tumor cells and macrophages.

RESULTS

GCTs primarily express PD-L1 on TAMs, except choriocarcinoma, where true tumor cell positivity was noted. Seminomas reveal increased intratumoral PD-L1+ TAMs compared with NSGCTs (P < .05). Activated TILs are increased in NM-seminomas compared with M-seminomas (P < .05). All GCTs retained MMR expression.

CONCLUSIONS

Robust PD-L1+ TAMs are significantly expanded in seminomas compared with NSGCTs. Among all GCTs, only choriocarcinoma cells reveal true positivity for PD-L1. These findings expand the realm of potentially targeted treatments for GCTs.

Limited post-chemotherapy retroperitoneal resection of residual tumour in non-seminomatous testicular cancer: complications, outcome and quality of life

BACKGROUND

Resection of residual masses after chemotherapy plays a crucial role in management of patients with germ cell tumours (GCTs). The extent of surgery is controversial and we present the experiences from Aarhus University Hospital over a 20-year period. The aim was to evaluate survival, complications, working ability and quality of life (QOL) following a limited surgical procedure performed to resect residual masses in non-seminomatous testicular cancer patients after chemotherapy.

MATERIAL AND METHODS

A consecutive patient cohort of 109 patients having surgery between 1993 and 2013 was investigated. Hospital records were reviewed and complications were graded according to the Clavien-Dindo classification. QOL data were assessed in a cross-sectional analysis using the European Organisation for Research and Treatment of Cancer (EORTC), QLQ-C30 version 3.0. Patients were matched 1:1 with controls to evaluate the influence of surgical resection on the QOL.

RESULTS

With a median follow-up of 10.3 years, 11 relapses in retroperitoneum were recorded in 10 patients (9%), and four patients (5%) died of disease progression. The majority of relapses in patients considered having no evidence of disease (NED) after primary retroperitoneal surgery occurred 10 + years after treatment and was outside the field of the elective lymph node dissection. Twenty-seven (44%) grade I, 15 (24%) grade II, 7 (11%) grade IIIa and 13 (21%) grade IIIb complications were recorded. No grade IV and V complications were observed. Twenty-three patients (20%) reported loss of antegrade ejaculation. We found no significant differences between patients and controls regarding QOL.

CONCLUSION

The survival outcome and complication rate are favourable and are comparable to studies involving full and modified template lymph node dissection. We find that limited resection constitutes an applicable and safe procedure. Limited surgical resection did not influence the patients' long-term QOL. Longer follow-up might be considered.

Validation of a prediction model for avoiding post-chemotherapy retroperitoneal lymphadenectomy in patients with metastatic nonseminomatous germ cell cancer

INTRODUCTION

Post-chemotherapy residual masses (PCRMs) may contain persistent cancer or teratoma in more than 50% of patients with metastatic non-seminomatous germ cell tumours (mNSGCTs). Retroperitoneal lymph node dissection (RPLND) is curative, but controversy exists about selection criteria for surgery. A validated prediction model by Vergouwe et al (2007) based on over 1000 patients was evaluated at our centre.

METHODS

mNSGCT patients treated with RPLND for PCRMs were identified from an electronic database. Typographical errors in the model were identified and corrected using their 2003 publication, but retaining the 2007 coefficients. Six clinical variables were included in the model and the calculated probability of benign tissue was compared with pathology. "Benign tissue only" was considered a positive test outcome in patients with a predicted probability of "benign tissue only" greater than 70%.

RESULTS

Fifty-two (52) mNSGCT patients between 1980 and 2014 were evaluable. Median age was 32 years (range 17-52) and International Germ Cell Consensus Classification (IGCCC) prognostic stages were: good 46.2%, intermediate 32.7%, and poor 21.2%. Most patients received bleomycin/etoposide/cisplatin (BEP) chemotherapy and full bilateral RPLND. Pathology showed residual cancer or teratoma in 31 patients (59.6%) and benign findings in 21 patients (40.6%). Positive and negative predictive values and accuracy were 100%, 69%, and 73%, respectively.

CONCLUSIONS

"Benign tissue only" was found in 100% of patients in whom this was predicted using our pre-determined criteria. This study involved a limited number of patients, but confirms the potential value of the Vergouwe et al model. Routine use of this prediction model in clinical practice should be tested for mNSGCT patients with PCRMs.

Do retroperitoneal extragonadal germ cell tumours exist?

INTRODUCTION

Extragonadal germ cell tumours (GCTs) have been described arising in midline structures. Although primary retroperitoneal extragonadal GCTs (RPGCTs) comprise 30% to 40% of these, their existence as a genuine disease has been questioned. Our study evaluated clinicopathological findings to examine this question in RPGCT patients at our centre.

METHODS

Data from 414 men between 1980 and 2014 treated at London Health Sciences Centre with chemotherapy for testicular GCTs were reviewed retrospectively. Primary RPGCT was defined as pathologically diagnosed GCT with no evidence of GCT in the testes by physical exam or ultrasound. Patients thought to have primary RPGCT at the time of initial diagnosis were identified from an electronic database and data were extracted.

RESULTS

In total, 18 men with a diagnosis of metastatic RPGCT were identified. Four were excluded due to ultrasound reports that were incomplete or suggested malignancy. The remaining 14 patients had negative or non-specific ultrasounds, and all received platinum-based combination chemotherapy. Ten patients (71%) underwent post-chemotherapy RP lymph node dissections; of those 8 (57%) who underwent orchiectomy, none had corresponding pathologically normal testicular tissue.

CONCLUSION

RPGCT patients present with more advanced disease stage. Our study sample size is limited, but the findings are consistent with existing literature suggesting that primary RPGCTs may not exist as a unique disease, but instead may represent metastatic disease from a clinically occult testicular primary. By corollary, viable malignant germ cells may be present in testes of patients with presumed primary RPGCT, and may persist as a site of residual malignant disease after chemotherapy.

Aggressive multimodal therapy may prolong disease-free survival in recurrent primary retroperitoneal embryonal carcinoma

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5% of extragonadal germ cell tumours are currently considered to be of primary retroperitoneal origin.

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Retroperitoneal EGGCTs are assumed to a poor prognosis group even if they fulfill the IGCCCG criteria for good, or intermediate prognosis.

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The combination of radical surgery and chemotherapy may prolong disease-free survival even in a second- or third-line treatment.

Introduction

Primary retroperitoneal extragonadal tumours relapsing after initial chemotherapy have a poor prognosis.

Presentation of the case

We report a case of primary retroperitoneal embryonal carcinoma in a patient with negative open testes biopsy. After the first line of chemotherapy (4 cycles BEP) secondary surgery with extirpation of a retroperitoneal residual mass was performed. The residuum proved histologically to be a mature teratoma, and no adjuvant treatment was given according to current recommendations. The patient had regular follow-up. 3.5 years later, patient developed recurrence in the ipsilateral adrenal gland, which was treated with surgery and 4 cycles of salvage VeIP chemotherapy. Seven months after the second surgical intervention the patient underwent multivisceral “desperation surgery” for early metastatic disease progression followed by 2 cycles of salvage TIP chemotherapy. The patient is currently disease-free at 34 months.

Conclusion

Initial postchemotherapy retroperitoneal lymph node dissection is crucial for local retroperitoneal disease control. Aggressively treated metastatic recurrent disease does not preclude prolonged survival. Despite a generally poor prognosis, repeated complex oncosurgical therapy for retroperitoneal extragonadal tumours may be worthwhile.