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Kardoust Parizi M, Margulis V, Bagrodia A, Bekku K, Klemm J, Matsukawa A, Alimohammadi A, Motlagh RS, Mostafaei H, Laukhtina E, Shariat SF. Primary retroperitoneal lymph node dissection for clinical stage II seminoma: A systematic review and meta-analysis of safety and oncological effectiveness. Urol Oncol 2024; 42:102-109. [PMID: 38360519 DOI: 10.1016/j.urolonc.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/21/2023] [Accepted: 01/08/2024] [Indexed: 02/17/2024]
Abstract
To evaluate the oncological outcomes and safety of primary retroperitoneal lymph node dissection (RPLND) in patients with clinical stage (CS) II seminomatous testicular germ cell tumor (TGCT). A literature search using PubMed, Scopus, and Cochrane Library was conducted on July 2023 to identify relevant studies according to the Preferred Reporting Items for Systematic Review and Meta Analysis (PRISMA) guidelines. The pooled recurrence rate and treatment-related complications were calculated using a random effects model. Overall 8 studies published between 1997 and 2023 including a total of 355 patients were selected for systematic review and meta-analysis with the overall median follow-up of 38 months. The overall and infield recurrence rate were 0.14 (95% CI: 0.08-0.22) and 0.04 (95% CI: 0.00-0.11), respectively. The overall pooled rate of ≥ Clavien Dindo grade III complications was 0.04 (95% CI: 0.01-0.10); there was no significant heterogeneity (I^2 = 35.10%, P = 0.19). Antegrade ejaculation was preserved with the overall pooled rate of 0.98 (95% CI: 0.95-1.00); there was no significant heterogeneity on Chi-square and I2 tests (I^2 = 0.00%, P = 0.58). Primary RPLND is a safe and effective treatment option for patients with CS II seminomatous TGCT resulting highly promising cure rates combined with low treatment-associated adverse events, at medium-term follow-up. However, owing to the lack of comparative studies to the current standard of care and the limited follow-up, individual decision must be made with the informed patient in a shared decision process together with a multidisciplinary team.
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Affiliation(s)
- Mehdi Kardoust Parizi
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Aditya Bagrodia
- Department of Urology, University of California San Diego, San Diego, CA
| | - Kensuke Bekku
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Jakob Klemm
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Akihiro Matsukawa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Jikei University School of Medicine, Tokyo, Japan
| | - Arman Alimohammadi
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Reza Sari Motlagh
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Hadi Mostafaei
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Department of Urology, Second Faculty of Medicine, Charles University, Prag, Czech Republic; Departments of Urology, Weill Cornell Medical College, New York, NY; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan.
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Heidenreich A, Paffenholz P, Hartmann F, Seelemeyer F, Pfister D. Retroperitoneal Lymph Node Dissection in Clinical Stage IIA/B Metastatic Seminoma: Results of the COlogne Trial of Retroperitoneal Lymphadenectomy In Metastatic Seminoma (COTRIMS). Eur Urol Oncol 2024; 7:122-127. [PMID: 37438222 DOI: 10.1016/j.euo.2023.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/06/2023] [Accepted: 06/23/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Radiation therapy and systemic chemotherapy are recommended treatment options in marker-negative clinical stage (CS) IIA/B seminoma. Despite high cure rates of 82-94%, both therapeutic options are associated with significant long-term toxicities. OBJECTIVE To evaluate the feasibility, oncological efficacy, and treatment-associated morbidity of primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) in CS IIA/B seminoma. DESIGN, SETTING, AND PARTICIPANTS A prospective, single-arm, clinical phase 2 trial including CS IIA/B seminoma patients was conducted. INTERVENTION Primary nerve-sparing retroperitoneal lymphadenectomy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Relapse-free and overall survival, surgery-associated complications according to the Clavien-Dindo classification, and Kaplan-Meier methods for survival calculation were assessed. RESULTS AND LIMITATIONS Thirty patients at a mean age of 39.1 (34-52) yr with marker-negative CS IIA and IIB seminomas were recruited. The median follow-up was 22 (8-30) mo. Nineteen (63%) and 11 (36%) patients were diagnosed with stages IIA and B, respectively, at the time of primary diagnosis. Fourteen (47%) and 16 (53%) patients were diagnosed with CS IIA and IIB, respectively, at the time of nsRPLND. Twenty-seven and three patients underwent open and robot-assisted nsRPLND, respectively. The median operating room time was 125 (115-145) min, median blood loss was <150 ml, and median time of hospitalization was 4.5 (3-9) d. Four (13%) patients experienced Clavien-Dindo grade 3a complications. Lymph node histology revealed seminoma in 25 (80%) patients; two and three patients demonstrated embryonal carcinoma and benign disease, respectively. Sixteen patients underwent a serum analysis of miR371 preoperatively, which predicted metastatic disease in 12/13 and benign histology in 3/3 patients. Three of 30 (10%) patients developed an outfield relapse 4, 6, and 9 mo postoperatively and were salvaged by systemic chemotherapy. Limitations are the low patient number and length of follow-up. CONCLUSIONS The nsRPLND approach results in a high cure rate at midterm follow-up and is associated with a low frequency of treatment-associated morbidities, making this approach a feasible alternative to radiation therapy or systemic chemotherapy. PATIENT SUMMARY The standard treatment of clinical stage IIA/B seminomas is radiation therapy or chemotherapy, which results in a significantly increased frequency of long-term toxicity and secondary neoplasms. In this trial, we demonstrate that nerve-sparing retroperitoneal lymph node dissection is a feasible therapeutic approach with low morbidity and high oncological efficacy.
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Affiliation(s)
- Axel Heidenreich
- Department of Urology, Uro-Oncology, Robot-Assisted and Specialized Urologic Surgery, University Hospital Cologne, Cologne, Germany; Department of Urology, Medical University Vienna, Vienna, Austria.
| | - Pia Paffenholz
- Department of Urology, Uro-Oncology, Robot-Assisted and Specialized Urologic Surgery, University Hospital Cologne, Cologne, Germany
| | - Florian Hartmann
- Department of Urology, Uro-Oncology, Robot-Assisted and Specialized Urologic Surgery, University Hospital Cologne, Cologne, Germany
| | - Felix Seelemeyer
- Department of Urology, Uro-Oncology, Robot-Assisted and Specialized Urologic Surgery, University Hospital Cologne, Cologne, Germany
| | - David Pfister
- Department of Urology, Uro-Oncology, Robot-Assisted and Specialized Urologic Surgery, University Hospital Cologne, Cologne, Germany
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Farkouh A, Shete K, Cheng KW, Buell MI, Hu B. A systematic review of pN0 testicular seminoma: a new clinical entity and future directions. Urol Oncol 2023; 41:476-482. [PMID: 37968167 DOI: 10.1016/j.urolonc.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/07/2023] [Accepted: 10/17/2023] [Indexed: 11/17/2023]
Abstract
Retroperitoneal lymph node dissection (RPLND) for testicular seminoma with enlarged retroperitoneal lymph nodes has received increased consideration and exposed a new clinical entity: pN0 disease. Enlarged, nonmetastatic retroperitoneal lymph nodes provide insight into the natural history of seminoma while offering a benchmark for improving the accuracy of staging. The purpose of this systematic review was to report the pN0 rates, describe risk factors associated with it, and discuss emerging research that may reduce its incidence. We performed a systemic review of published literature on PubMed, Embase, Web of Science, as well as oncology meeting abstracts evaluating histology of lymph nodes in patients with testicular seminoma treated primarily with retroperitoneal lymph node dissection. Studies were excluded if histology was not reported. A total of 15 publications and abstracts were included. Although study designs were heterogeneous, there was a minimal risk of bias. Overall, the reported pN0 rates were 0% to 22%. In prospective clinical trials it was 9% to 16%. The presence of pN0 was associated with preoperative smaller lymph nodes, a solitary enlarged lymph node, or negative serum miRNA-371. The incidence of pN0 seminoma is concerning as it points to a potential historical overtreatment; however, it also represents an important inflection for testicular cancer research as quantifiable improvements in clinical staging will translate to clear benefits to patients.
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Affiliation(s)
- Ala'a Farkouh
- Department of Urology, Loma Linda University Health, Loma Linda, CA
| | - Kanha Shete
- Department of Urology, Loma Linda University Health, Loma Linda, CA
| | - Kai Wen Cheng
- Department of Urology, Loma Linda University Health, Loma Linda, CA
| | - Matthew I Buell
- Department of Urology, Loma Linda University Health, Loma Linda, CA
| | - Brian Hu
- Department of Urology, Loma Linda University Health, Loma Linda, CA.
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Liu J, Thomas B, Lawrentschuk N. Re: Surgery in Early Metastatic Seminoma: A Phase II Trial of Retroperitoneal Lymph Node Dissection for Testicular Seminoma with Limited Retroperitoneal Lymphadenopathy. Eur Urol 2023; 84:438-439. [PMID: 37385842 DOI: 10.1016/j.eururo.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/22/2023] [Indexed: 07/01/2023]
Affiliation(s)
- Jianliang Liu
- E.J. Whitten Prostate Cancer Research Centre, Epworth Healthcare, Melbourne, Australia; Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Benjamin Thomas
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Nathan Lawrentschuk
- E.J. Whitten Prostate Cancer Research Centre, Epworth Healthcare, Melbourne, Australia; Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia; Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia.
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Sigg S, Fankhauser CD. The role of primary retroperitoneal lymph node dissection in the treatment of stage II seminoma. Curr Opin Urol 2023; 33:245-251. [PMID: 37144886 PMCID: PMC10256310 DOI: 10.1097/mou.0000000000001099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE OF REVIEW Stage II seminoma is responsive to chemo- or radiotherapy with a progression-free survival of 87-95% at 5 years but at the cost of short- and long-term toxicity. After evidence about these long-term morbidities emerged, four surgical cohorts investigating the role of retroperitoneal lymph node dissection (RPLND) as a treatment option for stage II disease were initiated. RECENT FINDINGS Currently, two RPLND series have been published as a complete report, while data from other series have only been published as congress abstracts. In series without adjuvant chemotherapy, recurrence rates ranged from 13% to 30% after follow-ups of 21-32 months. In those receiving RPLND and adjuvant chemotherapy, the recurrence rate was 6% after a mean follow-up of 51 months. Across all trials, recurrent disease was treated with systemic chemotherapy (22/25), surgery (2/25), and radiotherapy (1/25). The rate of pN0 disease after RPLND varied between 4% and 19%. Postoperative complications were reported in 2-12%, while antegrade ejaculation was maintained in 88-95% of patients. Median length of stay ranged from 1 to 6 days. SUMMARY In men with clinical stage II seminoma, RPLND is a safe and promising treatment option. Further research is needed to determine the risk of relapse and to personalize treatment options based on patient-specific risk factors.
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Affiliation(s)
- Silvan Sigg
- Department of Urology, Luzerner Kantonsspital, University of Lucerne, Lucerne
| | - Christian Daniel Fankhauser
- Department of Urology, Luzerner Kantonsspital, University of Lucerne, Lucerne
- University of Zurich, Zurich, Switzerland
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Wood GE, Chamberlain F, Tran B, Conduit C, Liow E, Nicol DL, Shamash J, Alifrangis C, Rajan P. Treatment de-escalation for stage II seminoma. Nat Rev Urol 2023:10.1038/s41585-023-00727-0. [PMID: 36882564 DOI: 10.1038/s41585-023-00727-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 03/09/2023]
Abstract
International Germ Cell Cancer Collaborative Group good-risk metastatic seminoma has cure rates of >95%. Within this risk group, patients with stage II disease exhibit the best oncological outcomes with the standard-of-care treatment strategies of radiotherapy or combination chemotherapy. However, these treatments can be associated with substantial early and late toxic effects. Therapy de-escalation aims to reduce treatment morbidity whilst preserving oncological outcomes. The evidence supporting such approaches is largely from non-randomized institutional data, and therefore this strategy is not recognized as standard of care. Current de-escalation approaches for stage II seminoma include single-agent chemotherapy, radiotherapy and surgery based on early data from clinical studies. Increased recognition of emerging data on treatment modification to reduce morbidity whilst maintaining cure rates and consideration of therapy de-escalation could improve patient survivorship outcomes.
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Affiliation(s)
- Georgina E Wood
- Department of Medical Oncology, University College London Hospitals NHS Foundation Trust, London, UK.,Department of Medical Oncology, Barts Health NHS Trust, London, UK
| | | | - Ben Tran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Personalized Medicine, Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - Ciara Conduit
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Personalized Medicine, Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - Elizabeth Liow
- Division of Personalized Medicine, Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - David L Nicol
- Department of Urology, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Jonathan Shamash
- Department of Medical Oncology, Barts Health NHS Trust, London, UK
| | - Constantine Alifrangis
- Department of Medical Oncology, University College London Hospitals NHS Foundation Trust, London, UK. .,National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK.
| | - Prabhakar Rajan
- Centre for Cancer Cell and Molecular Biology, Barts Cancer Institute, Queen Mary University of London, London, UK. .,Division of Surgery and Interventional Science, University College London, London, UK. .,Department of Urology, Barts Health NHS Trust, London, UK. .,Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK.
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Alsyouf M, Nappi L, Nichols C, Daneshmand S. Plasma Micro-RNA 371 Expression in Early-Stage Germ Cell Tumors: Are We Ready to Move Toward Biology-Based Decision Making? J Clin Oncol 2023; 41:2478-2482. [PMID: 36758194 DOI: 10.1200/jco.22.02002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Affiliation(s)
- Muhannad Alsyouf
- Department of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Lucia Nappi
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Craig Nichols
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Siamak Daneshmand
- Department of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
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Alsyouf M, Daneshmand S. Retroperitoneal Lymph Node Dissection Should Be a Standard-of-Care Treatment Option For Stage II Seminoma. EUR UROL SUPPL 2023; 49:67-68. [PMID: 36793748 PMCID: PMC9922910 DOI: 10.1016/j.euros.2022.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2022] [Indexed: 01/29/2023] Open
Affiliation(s)
| | - Siamak Daneshmand
- Corresponding author. Department of Urology, USC/Norris Comprehensive Cancer Center, 1441 Eastlake Avenue, Los Angeles, CA 90089, USA. Tel. +1 323 865 3700; Fax: +1 323 865 0120.
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Phase 2 Single-arm Trial of Primary Retroperitoneal Lymph Node Dissection in Patients with Seminomatous Testicular Germ Cell Tumors with Clinical Stage IIA/B (PRIMETEST). Eur Urol 2022:S0302-2838(22)02775-0. [PMID: 36372627 DOI: 10.1016/j.eururo.2022.10.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 10/10/2022] [Accepted: 10/22/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Primary retroperitoneal lymph node dissection (RPLND) for clinical stage (CS) IIA/B seminoma without adjuvant treatment is an experimental treatment to avoid radiotherapy- or chemotherapy-related toxicity from standard treatment. OBJECTIVE The PRIMETEST trial aimed to prospectively evaluate the oncological efficacy and surgical safety of primary RPLND. DESIGN, SETTING, AND PARTICIPANTS PRIMETEST is a single-arm, single-center prospective phase 2 trial. Patients with seminoma, unilateral retroperitoneal lymph node metastases <5 cm, and human chorionic gonadotropin levels <5 mU/ml were included. Patients with CS IIA/B seminoma at initial diagnosis, and recurrence under active surveillance or following adjuvant carboplatin for CS I disease were eligible. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Unilateral open or robot-assisted primary RPLND was performed. The primary endpoint of the study was progression-free survival (PFS) after 36 mo. The trial was considered positive if <30% of patients experienced a recurrence. RESULTS AND LIMITATIONS Between 2016 and 2021, 33 patients were accrued (nine with primary CS IIA/B, 19 recurrences during active surveillance, and five recurrences following adjuvant carboplatin). Thirteen and 20 patients had CS IIA and IIB, respectively. Open and robot-assisted RPLND procedures were performed in 14 (42%) and 19 (58%) patients, respectively. After a median follow-up of 32 mo (interquartile range 23-46), ten recurrences were detected (30%, 95% confidence interval: 16-49%); thus, the primary endpoint was not met. Infield recurrences occurred in three of ten patients. The current analysis of risk factors could not identify the predictors of recurrence. Three of 33 patients (9%) presented with pN0. CONCLUSIONS The PRIMETEST trial did not meet its primary endpoint. Nevertheless, PFS of 70% after a median follow-up of 32 mo suggests this approach to be of interest for highly selected patients. Selection criteria, however, need to be defined and validated in a larger prospective cohort of patients. Until then, surgery alone for the treatment of patients with CS IIA/B seminoma cannot be recommended outside of a clinical trial setting. PATIENT SUMMARY In this study, we investigated primary surgery as an alternative to conventional treatment (chemotherapy or radiation therapy) in patients with metastatic seminoma. The primary objective of the study, to prevent at least 30% of patients from recurrence, was not met. However, certain patients may benefit from this approach and thereby avoid chemotherapy or radiation therapy. Predictive factors need to be analyzed to better select patients for this surgery-only approach.
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Nicolai N, Nazzani S, Tesone A, Macchi A, Piva L, Salvioni R, Stagni S, Torelli T, Agostini E, Celso F, Giannatempo P, Procopio G, Avuzzi B, Lanocita R, Cattaneo L, Catanzaro M, Biasoni D. Retroperitoneal lymph-node dissection (RPLND) as upfront management in stage II germ-cell tumours: evaluation of safety and efficacy. TUMORI JOURNAL 2022:3008916221112697. [PMID: 35915559 PMCID: PMC10363949 DOI: 10.1177/03008916221112697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Patients with stage II germ-cell tumours (GCT) usually undergo radiotherapy (seminoma only) or chemotherapy. Both strategies display a recognised risk of long-term side effects. We evaluated retroperitoneal lymph node dissection (RPLND) as exclusive treatment in stage II GCT. METHODS Between 2008 and 2019 included, 66 selected stage II GCT patients underwent primary open (O-) or laparoscopic (L-)RPLND. Type of procedure and extent of dissection, operative time, node rescue, hospital stay, complications (according to Clavien-Dindo), administration of chemotherapy, relapse and site of relapse were evaluated. RESULTS Five patients had pure testicular seminoma. Nineteen (28.8%) had raised markers prior to RPLND; 48 (72.7%), 16 (24.2%) and two (3.0%) were stage IIA, IIB and IIC, respectively. O-RPLND and unilateral L-RPLND were 36 and 30 respectively. Six stage II A patients (12.5%) had negative nodes. Four patients underwent immediate adjuvant chemotherapy. One patient was lost at follow-up. After a median follow-up of 29 months, 48 (77.4%) of the 62 patients undergoing RPLND alone remained recurrence-free; one patient had an in-field recurrence following a bilateral dissection. According to procedure, number of rescued nodes (O-RPLND: 25. IQR 21-31; L-RPLND: 20, IQR 15-26; p: 0.001), hospital stay (L-RPLND: 3 days, IQR 3-4; O-RPLND: 6 days, IQR 5-8; p: .001) and grade ≥2 complications (L-RPLND 7%, O-RPLND 22%; p: 0.1) were the only significant differences. CONCLUSION Primary RPLND is safe in stage II GCT, including seminoma, and may warrant a cure rate greater than 70%. When feasible, L-RPLND may be as effective as O-RPLND with better tolerability.
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Affiliation(s)
- Nicola Nicolai
- Testis Surgery Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy.,Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | | | - Antonio Tesone
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Alberto Macchi
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Luigi Piva
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Roberto Salvioni
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Silvia Stagni
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Tullio Torelli
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Edoardo Agostini
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Francesco Celso
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Patrizia Giannatempo
- Medical Oncology Dept, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Giuseppe Procopio
- Medical Oncology Dept, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Barbara Avuzzi
- Radiation Oncology Dept, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Rodolfo Lanocita
- Radiology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Laura Cattaneo
- Pathology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Mario Catanzaro
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Davide Biasoni
- Urology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
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Therapy of clinical stage IIA and IIB seminoma: a systematic review. World J Urol 2022; 40:2829-2841. [PMID: 34779882 PMCID: PMC9712301 DOI: 10.1007/s00345-021-03873-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/25/2021] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The optimal treatment for clinical stage (CS) IIA/IIB seminomas is still controversial. We evaluated current treatment options. METHODS A systematic review was performed. Only randomized clinical trials and comparative studies published from January 2010 until February 2021 were included. Search items included: seminoma, CS IIA, CS IIB and therapy. Outcome parameters were relapse rate (RR), relapse-free (RFS), overall and cancer-specific survival (OS, CSS). Additionally, acute and long-term side effects including secondary malignancies (SMs) were analyzed. RESULTS Seven comparative studies (one prospective and six retrospective) were identified with a total of 5049 patients (CS IIA: 2840, CS IIB: 2209). The applied treatment modalities were radiotherapy (RT) (n = 3049; CS IIA: 1888, CSIIB: 1006, unknown: 155) and chemotherapy (CT) or no RT (n = 2000; CS IIA: 797, CS IIB: 1074, unknown: 129). In CS IIA, RRs ranged from 0% to 4.8% for RT and 0% for CT. Concerning CS IIB RRs of 9.5%-21.1% for RT and of 0%-14.2% for CT have been reported. 5-year OS ranged from 90 to 100%. Only two studies reported on treatment-related toxicities. CONCLUSIONS RT and CT are the most commonly applied treatments in CS IIA/B seminoma. In CS IIA seminomas, RRs after RT and CT are similar. However, in CS IIB, CT seems to be more effective. Survival rates of CS IIA/B seminomas are excellent. Consequently, long-term toxicities and SMs are important survivorship issues. Alternative treatment approaches, e.g., retroperitoneal lymph node dissection (RPLND) or dose-reduced sequential CT/RT are currently under prospective investigation.
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First-line salvage treatment options for germ cell tumor patients failing stage-adapted primary treatment : A comprehensive review compiled by the German Testicular Cancer Study Group. World J Urol 2022; 40:2853-2861. [PMID: 35226138 PMCID: PMC9712404 DOI: 10.1007/s00345-022-03959-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 02/01/2022] [Indexed: 12/30/2022] Open
Abstract
PURPOSE In this review, we summarize and discuss contemporary treatment standards and possible selection criteria for decision making after failure of adjuvant or first-line cisplatin-based chemotherapy for primarily localized or metastatic germ cell tumors. METHODS This work is based on a systematic literature search conducted for the elaboration of the first German clinical practice guideline to identify prospective clinical trials and retrospective comparative studies published between Jan 2010 and Feb 2021. Study end points of interest were progression-free (PFS) and overall survival (OS), relapse rate (RR), and/or safety. RESULTS Relapses of clinical stage I (CS I) patients irrespective of prior adjuvant treatment after orchiectomy are treated stage adapted in accordance for primary metastatic patients. Surgical approaches for sole retroperitoneal relapses are investigated in ongoing clinical trials. The appropriate salvage chemotherapy for metastatic patients progressing or relapsing after first-line cisplatin-based chemotherapy is still a matter of controversy. Conventional cisplatin-based chemotherapy is the international guideline-endorsed standard of care, but based on retrospective data high-dose chemotherapy and subsequent autologous stem cell transplantation may offer a 10-15% survival benefit for all patients. Secondary complete surgical resection of all visible residual masses irrespective of size is paramount for treatment success. CONCLUSIONS Patients relapsing after definite treatment of locoregional disease are to be treated by stage-adapted first-line standard therapy for metastatic disease. Patients with primary advanced/metastatic disease failing one line of cisplatin-based combination chemotherapy should be referred to GCT expert centers. Dose intensity is a matter of ongoing debate, but sequential high-dose chemotherapy seems to improve patients' survival.
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Alsyouf M, Daneshmand S. Clinical stage II seminoma: management options. World J Urol 2021; 40:343-348. [PMID: 34655305 DOI: 10.1007/s00345-021-03854-8] [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: 09/11/2021] [Accepted: 10/01/2021] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The management of clinical stage II seminoma has evolved with a recent emphasis on minimizing long-term morbidity while achieving oncologic cure. METHODS In this review we discuss the available management options for clinical stage II seminoma with an emphasis on the emerging role of surgery in this patient population. RESULTS Historically, treatment options available to clinical stage II seminoma patients were limited to radiotherapy and chemotherapy. Survival rates with these options are excellent; however, both are associated with significant long-term morbidities including cardiovascular, pulmonary, and neurologic toxicities. Additionally, higher rates of secondary malignancies are witnessed in this young patient population, decades after successful treatment of the primary cancer. Recently, retroperitoneal lymph node dissection has been proposed as a first-line treatment option for patients with low-volume metastatic seminoma. CONCLUSION The SEMS and PRIMETEST trials are two studies examining the role of primary retroperitoneal lymph node dissection in clinical stage II seminoma, and early data show significant promise.
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Affiliation(s)
- Muhannad Alsyouf
- USC Department of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Ave., suite 7416, Los Angeles, CA, 90089, USA
| | - Siamak Daneshmand
- USC Department of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Ave., suite 7416, Los Angeles, CA, 90089, USA.
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Yang H, Obiora D, Tomaszewski JJ. Outcomes and expanding indications for robotic retroperitoneal lymph node dissection for testicular cancer. Transl Androl Urol 2021; 10:2188-2194. [PMID: 34159101 PMCID: PMC8185654 DOI: 10.21037/tau.2020.03.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Treatment of testicular cancer has made significant progress in the past decades in terms of reduction of treatment-associated morbidity and preventing over-treatment. At the forefront of this progression is utilization of the da Vinci robot to perform retroperitoneal lymph node dissections (RPLNDs) via a minimally invasive approach. The robot offers multiple potential advantages such as smaller incisions, improved 3D visualization, more precise dissection, and faster convalescence, leading to its increased usage the past several years. In this chapter, we summarize the recent progress made in robotic surgery for testicular cancer and its potential in the future. Promising preliminary data has also renewed interest in defining the role of primary RPLND in patients with seminoma, potentially sparing patients of the harmful long-term radiation and cisplatin-based chemotherapy. SEMS and PRIMETEST trials are ongoing trials that will provide significant insight into this area and potentially expand the role of robotic RPLND.
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Affiliation(s)
- Hailiu Yang
- Division of Urology, Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Daisy Obiora
- Division of Urology, Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Jeffrey J Tomaszewski
- Division of Urology, Department of Surgery, MD Anderson Cancer Center at Cooper, Cooper Medical School of Rowan University, Camden, NJ, USA
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Role of primary retroperitoneal lymph node dissection in stage I and low-volume metastatic germ cell tumors. Curr Opin Urol 2020; 30:251-257. [PMID: 31972635 DOI: 10.1097/mou.0000000000000736] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Early-stage testicular cancers are highly curable. Following orchidectomy, management options for stage I disease include active surveillance, nerve-sparing retroperitoneal lymph node dissection (nsRPLND) and primary chemotherapy as recommended by the current guidelines. Primary RPLND has for decades played an integral part of treatment in patients with early-stage testicular germ cell tumors (TGCT), particularly in nonseminomatous germ cell tumors (NSGCT) with focus on reducing the long-term morbidity. We review the role of RPLND in stage I NSCGT as well as stage II A/B NSGCT and as seminoma. RECENT FINDINGS Radiation therapy and systemic chemotherapy are established treatments for seminoma; however, long-term data has demonstrated the association of such therapies with late toxicity including secondary malignancies, hearing loss, cardiovascular disease as well as metabolic syndromes. Given the well established role of RPLND in NSGCTs, clinicians have developed an interest in utilization of surgery for low-volume retroperitoneal metastatic disease. Two prospective clinical trials (SEMS and PRIMETEST) are underway to determine the role of RPLND alone in low volume metastatic seminoma. SUMMARY RPLND is a highly effective treatment for early-stage germ cell tumors but represents overtreatment in low-volume stage I disease where active surveillance is recommended. RPLND has shown a promising role in low-volume stage II seminomas. Two phase II clinical trials are underway to further determine the curative potential of this approach.
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Parimi S, Rauw JM, Ko JJ. Systemic Therapies for Metastatic Testicular Germ Cell Tumors: Past, Present and Future. CURRENT CANCER THERAPY REVIEWS 2019. [DOI: 10.2174/1573394714666180706150427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Testicular germ cell tumors (TGCTs) are unique to that of most other solid tumors because
they are highly curable in the metastatic setting. While the use of cisplatin-based chemotherapy
continues to drive cure in this patient population, important improvements in the delivery
of therapy, creation of risk-adjusted treatment paradigms, and salvage-therapy options have further
enhanced survival as well. The future holds promise for a more multidisciplinary approach to
care, through advancements in biochemical markers and a better understanding of how surgical
and radiotherapy approaches can integrate into our existing management strategies.
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Affiliation(s)
- Sunil Parimi
- BC Cancer Agency, 2410 Lee Avenue, Victoria, BC, V8R 4X1, Canada
| | - Jennifer M. Rauw
- BC Cancer Agency, 2410 Lee Avenue, Victoria, BC, V8R 4X1, Canada
| | - Jenny J. Ko
- BC Cancer Agency, 32900 Marshall Rd, Abbotsford, BC, V2S 0C2, Canada
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Retroperitoneal Lymph Node Dissection as an Alternative Treatment Strategy for Low Volume, Clinical Stage II Testicular Seminoma: A Survey of Patients and Providers. UROLOGY PRACTICE 2019. [DOI: 10.1016/j.urpr.2018.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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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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von Amsberg G, Hamilton R, Papachristofilou A. Clinical Stage IIA-IIC Seminoma: Radiation Therapy versus Systemic Chemotherapy versus Retroperitoneal Lymph Node Dissection. Oncol Res Treat 2018; 41:360-363. [PMID: 29763926 DOI: 10.1159/000489408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/19/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Clinical stage II (CSII) seminoma is defined by the presence of pure seminoma accompanied by retroperitoneal lymph node metastases. In patients with bulky disease (lymph nodes > 5 cm in diameter), platinum-based chemotherapy is the widely accepted standard of care. However, the optimal choice of treatment for CSIIA and IIB is more controversial. METHODS We performed a PubMed search using the key words stage II seminoma, BEP (cisplatin, etoposide, and bleomycin), hockey-stick radiotherapy, dog-leg radiotherapy and retroperitoneal lymph node dissection. Most relevant publications were summarized for this review. RESULTS To date, no randomized trials have prospectively compared radiotherapy (RT), chemotherapy (CT) and retroperitoneal lymph node dissection (RLND) for CSII seminoma. Because of the predominantly retrospective analyses and only few prospective trials data interpretation is complex. In CSIIA with lymph nodes of < 2 cm, RT and CT seem to be equally effective, while in CSIIB, a decreased number of relapses were observed in CT-treated patients. In addition, RT seems to be associated with a higher incidence of long-term sequelae when compared with CT. CONCLUSION Prospective clinical trials are needed to systematically compare the different treatment modalities. De-escalation of treatment intensity without loss of efficacy is required to improve long-term outcome for this young patient population.
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Retroperitoneal Lymph Node Dissection as Primary Treatment for Metastatic Seminoma. Adv Urol 2018; 2018:7978958. [PMID: 29487620 PMCID: PMC5816883 DOI: 10.1155/2018/7978958] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/13/2017] [Indexed: 12/04/2022] Open
Abstract
Reducing the long-term morbidity in testicular cancer survivors represents a major area of interest. External beam radiation therapy and systemic chemotherapy are established treatments for seminoma; however, they are associated with late toxicities such as cardiovascular disease, insulin resistance, and secondary malignancy. Retroperitoneal lymph node dissection (RPLND) is a standard treatment for nonseminomatous germ cell tumors (NSGCT) that has minimal long-term morbidity. Given the efficacy of RPLND in management of NSGCT, interest has developed in this surgery as a front-line treatment for seminoma with isolated lymph node metastasis to the retroperitoneum. Four retrospective studies have shown promising results when surgery is performed for seminomas with low-volume retroperitoneal metastases. To better determine if RPLND can be recommended as a primary treatment option, two prospective clinical trials (SEMS and PRIMETEST) are underway. This review will examine the literature, discuss the benefits/limitations of RPLND, and compare the methodologies of the two ongoing clinical trials.
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Abstract
Testicular cancer is a rare urological malignancy with high cure rate. The development of highly effective systemic treatment regimens along with advances in surgical treatment of advanced disease has led to continued improvement in outcomes. Patients with testicular cancer who are treated following the treatment guideline mostly achieved high quality of life and long-term survival. However, patients who were identified as having non-guideline directed care were at significantly higher risk of relapse. In this book chapter, we introduce in depth the modern management of testicular cancer, including diagnosis, staging and risk stratification, treatment strategies of seminoma and non-seminoma germ cell tumors, follow-up protocols, and salvage treatment for disease relapse. We also review new studies and updates on medical and surgical management of advanced testicular cancer.
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Hu B, Shah S, Shojaei S, Daneshmand S. Retroperitoneal Lymph Node Dissection as First-Line Treatment of Node-Positive Seminoma. Clin Genitourin Cancer 2015; 13:e265-e269. [PMID: 25682512 DOI: 10.1016/j.clgc.2015.01.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 01/04/2015] [Accepted: 01/16/2015] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The long-term morbidity associated with treating advanced seminoma can be significant. Retroperitoneal lymph node dissection (RPLND) has established oncologic efficacy in treating germ cell tumors with minimal long-term toxicity. We describe our experience with RPLND as a front-line treatment of lymph node-positive seminoma. MATERIALS AND METHODS We reviewed our institutional review board-approved testicular cancer database to find the patients with pure seminoma and isolated retroperitoneal lymph node disease who had undergone primary RPLND. The clinical and pathologic variables were obtained. The follow-up data were used to determine recurrence and death. RESULTS Four patients with a mean age of 37 years were identified. All patients had normal tumor markers and retroperitoneal lymphadenopathy measuring 1.1, 1.5, 1.8, and 5.5 cm before RPLND. Of the 4 patients, 3 had had seminoma diagnosed at orchiectomy and 1 (with a 5.5-cm retroperitoneal lymphadenopathy and a burned out primary testicular mass) had had seminoma diagnosed at RPLND after 2 nondiagnostic retroperitoneal biopsies. All patients had undergone nerve-sparing, template, extraperitoneal RPLND and were discharged home after 3 days. An average of 3 positive lymph nodes were found. Of the 4 patients, 3 had pathologic stage IIA and 1 stage IIB disease, with no patient undergoing adjuvant therapy. At a mean follow-up period of 25 months, no patient had experienced disease recurrence, and none had died. All patients maintained antegrade ejaculation, and no long-term complications had developed. CONCLUSION Our small series has demonstrated encouraging oncologic efficacy for RPLND as a primary treatment of retroperitoneal lymph node-positive seminoma. A multi-institutional phase II trial of RPLND for stage IIA seminoma is being developed.
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Affiliation(s)
- Brian Hu
- Department of Urology, USC Institute of Urology, USC Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Swar Shah
- Department of Urology, USC Institute of Urology, USC Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Sepehr Shojaei
- Department of Urology, USC Institute of Urology, USC Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Siamak Daneshmand
- Department of Urology, USC Institute of Urology, USC Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine, Los Angeles, CA.
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Albers P, Albrecht W, Algaba F, Bokemeyer C, Cohn-Cedermark G, Fizazi K, Horwich A, Laguna M. [EAU guidelines on testicular cancer: 2011 update. European Association of Urology]. Actas Urol Esp 2012; 36:127-45. [PMID: 22188753 DOI: 10.1016/j.acuro.2011.06.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 06/28/2011] [Indexed: 12/31/2022]
Abstract
CONTEXT On behalf of the European Association of Urology (EAU), guidelines for the diagnosis, therapy, and follow-up of testicular cancer were established. OBJECTIVE This article is a short version of the EAU testicular cancer guidelines and summarises the main conclusions from the guidelines on the management of testicular cancer. EVIDENCE ACQUISITION Guidelines were compiled by a multidisciplinary guidelines working group. A systematic review was carried out using Medline and Embase, also taking Cochrane evidence and data from the European Germ Cell Cancer Consensus Group into consideration. A panel of experts weighted the references, and a level of evidence and grade of recommendation were assigned. RESULTS There is a paucity of literature especially regarding longer term follow-up, and results from a number of ongoing trials are awaited. The choice of treatment centre is of the utmost importance, and treatment in reference centres within clinical trials, especially for poor-prognosis nonseminomatous germ cell tumours, provides better outcomes. For patients with clinical stage I seminoma, based on recently published data on long-term toxicity, adjuvant radiotherapy is no longer recommended as first-line adjuvant treatment. The TNM classification 2009 is recommended. CONCLUSIONS These guidelines contain information for the standardised management of patients with testicular cancer based on the latest scientific insights. Cure rates are generally excellent, but because testicular cancer mainly affects men in their third or fourth decade of life, treatment effects on fertility require careful counselling of patients, and treatment must be tailored taking individual circumstances and patient preferences into account. TAKE HOME MESSAGE Although testicular cancer has excellent cure rates, the choice of treatment centre is of the utmost importance. Expert centres achieve better results for both early stage testicular cancer (lower relapse rates) and overall survival (higher stages within clinical trials). For patients with clinical stage I seminoma, adjuvant radiotherapy is no longer recommended as first-line adjuvant treatment.
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Abstract
CONTEXT On behalf of the European Association of Urology (EAU), guidelines for the diagnosis, therapy, and follow-up of testicular cancer were established. OBJECTIVE This article is a short version of the EAU testicular cancer guidelines and summarises the main conclusions from the guidelines on the management of testicular cancer. EVIDENCE ACQUISITION Guidelines were compiled by a multidisciplinary guidelines working group. A systematic review was carried out using Medline and Embase, also taking Cochrane evidence and data from the European Germ Cell Cancer Consensus Group into consideration. A panel of experts weighted the references, and a level of evidence and grade of recommendation were assigned. RESULTS There is a paucity of literature especially regarding longer term follow-up, and results from a number of ongoing trials are awaited. The choice of treatment centre is of the utmost importance, and treatment in reference centres within clinical trials, especially for poor-prognosis nonseminomatous germ cell tumours, provides better outcomes. For patients with clinical stage I seminoma, based on recently published data on long-term toxicity, adjuvant radiotherapy is no longer recommended as first-line adjuvant treatment. The TNM classification 2009 is recommended. CONCLUSIONS These guidelines contain information for the standardised management of patients with testicular cancer based on the latest scientific insights. Cure rates are generally excellent, but because testicular cancer mainly affects men in their third or fourth decade of life, treatment effects on fertility require careful counselling of patients, and treatment must be tailored taking individual circumstances and patient preferences into account.
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The most common, clinically significant misdiagnoses in testicular tumor pathology, and how to avoid them. Adv Anat Pathol 2008; 15:18-27. [PMID: 18156809 DOI: 10.1097/pap.0b013e318159475d] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Testicular tumors are both increasing in frequency and disproportionately occur in young men; furthermore, different forms of neoplasm require different treatments. These considerations make the accurate diagnosis of testicular tumors especially important. Many of the critical distinctions involve the differentiation of seminoma from one or more potential mimics because seminoma is not only the most common testicular neoplasm but it is also the only malignant testicular tumor that is commonly treated with radiation, which is ineffective in other malignancies of the testis. For the most part, accurate diagnosis can be achieved by careful light microscopic evaluation, although appropriate immunostains can provide diagnostic assistance if doubt persists. This article discusses a number of clinically important differential diagnoses in the testis that are common sources of misinterpretations. These include: seminoma versus embryonal carcinoma, seminoma versus yolk sac tumor, seminoma versus Sertoli cell tumor, seminoma with syncytiotrophoblast cells versus choriocarcinoma, granulomatous seminoma versus granulomatous orchitis, intertubular seminoma versus orchitis, lymphoma versus seminoma or embryonal carcinoma, dermoid cyst versus teratoma, scar versus regressed germ cell tumor, and "anaplastic" spermatocytic seminoma versus usual seminoma or embryonal carcinoma.
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Mezvrishvili Z, Managadze L. Retroperitoneal lymph node dissection for high-risk stage I and stage IIA seminoma. Int Urol Nephrol 2007; 38:615-9. [PMID: 17111085 DOI: 10.1007/s11255-005-4793-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The clinical results of radiotherapy in low-stage seminoma are excellent with negligible early morbidity. However, in a long-term follow-up various complications may occur. On the other hand, experience in nonseminomas shows that surgical morbidity has decreased markedly after invention of a nerve-sparing technique. These issues served as a rationale for us to perform the primary retroperitoneal lymph node dissection (RPLND) in seminoma patients. MATERIALS AND METHODS Fourteen pure seminoma patients (10 high-risk stage I and four with clinical stage IIA) underwent nerve-sparing RPLND from September, 1997 to December, 2002. RESULTS Pathological evaluation revealed lymph node involvement in three out of 10 clinical stage I and in all four stage IIA cases. The patients' acceptance of the surgery was good. Minor intra- and early postoperative complications were observed in two cases. Antegrade ejaculation was preserved in all patients. No retroperitoneal or distant recurrences have been observed. All patients were free of disease with the mean follow-up period of 56 months. CONCLUSION The excellent results and minimum morbidity of nerve-sparing RPLND together with the increased concerns on late complications of radiotherapy may turn the preference of surgery in low-stage seminoma into the subject of future discussion.
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Affiliation(s)
- Zaza Mezvrishvili
- National Center of Urology, Tsinandali Str. 9, 0144, Tbilisi, Georgia.
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Albers P, Albrecht W, Algaba F, Bokemeyer C, Cohn-Cedermark G, Horwich A, Klepp O, Laguna MP, Pizzocaro G. Guidelines on Testicular Cancer. Eur Urol 2005; 48:885-94. [PMID: 16126333 DOI: 10.1016/j.eururo.2005.06.019] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Accepted: 06/23/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To up-date the 2001 version of the EAU testicular cancer guidelines. METHODS A non-structured literature review until January 2005 using the MEDLINE database has been performed. Literature has been classified according to evidence-based medicine levels. RESULTS Testicular cancer is a highly curable disease. Excellent cure rates have been achieved by standardization of treatment, interdisciplinary management, and tremendous success in performing clinical trials. Currently, the aims of testicular cancer treatment are as follows: for patients with low-stage disease, a reduction in treatment is proposed to improve long-term toxicity in these patients with unaltered life expectancy; for about 10% of patients with advanced disease and poor prognosis, intensification of treatment (including high-dose chemotherapy and new drugs as well as aggressive surgical approaches) is being investigated to improve long-term cure rates. CONCLUSION Guidelines will improve clinical practice only if they are regularly updated. This update presents the state-of-the-art management of testicular cancer patients in 2005.
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Affiliation(s)
- Peter Albers
- Department of Urology, Klinikum Kassel GmbH Mönchebergstr. 41-43, Kassel, Germany.
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Patel MI, Motzer RJ, Sheinfeld J. Management of recurrence and follow-up strategies for patients with seminoma and selected high-risk groups. Urol Clin North Am 2004; 30:803-17. [PMID: 14680316 DOI: 10.1016/s0094-0143(03)00063-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Seminoma is characterized by high sensitivity to both radiation and chemotherapy. Localized recurrences in the retroperitoneum after surveillance for stage I can be treated with radiotherapy; however, multiple or large bulky retroperitoneal recurrences or systemic metastasis requires cisplatin-based chemotherapy. Salvage chemotherapy for those who recur after initial CR to induction chemotherapy is based on ifosfamide- and cisplatin-containing regimens. Incomplete response or failure after induction chemotherapy requires high-dose chemotherapy and stem cell rescue. Patients with seminoma need long-term follow-up because of the possibility of late recurrence and the risk of a second primary tumor.
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Affiliation(s)
- Manish I Patel
- Department of Urology, Memorial Sloan-Kettering Cancer Center, 353 E. 68th Street, New York, NY 10021, USA
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Horwich A, Huddart RA. Adjuvant chemotherapy for high-risk low-stage germ-cell tumours. Curr Opin Urol 2002; 12:431-4. [PMID: 12172432 DOI: 10.1097/00042307-200209000-00011] [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: 10/27/2022]
Abstract
PURPOSE OF REVIEW To review the assessment and management of early germ-cell tumours. RECENT FINDINGS A role has evolved for adjuvant chemotherapy in stage I disease postorchidectomy and in the primary management of stage II disease. SUMMARY A range of approaches offer high survival in early germ-cell tumours. Treatment should factor in patient choice and resource issues. More sensitive imaging with Positron Emission Tomography may allow more appropriate treatment decisions.
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Affiliation(s)
- Alan Horwich
- The Academic Unit of Radiotherapy and Oncology, The Royal Marsden NHS Trust and The Institute of Cancer Research, Sutton, Surrey UK
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Henley JD, Young RH, Ulbright TM. Malignant Sertoli cell tumors of the testis: a study of 13 examples of a neoplasm frequently misinterpreted as seminoma. Am J Surg Pathol 2002; 26:541-50. [PMID: 11979085 DOI: 10.1097/00000478-200205000-00001] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The distinction of Sertoli cell tumors from seminoma is critical to ensure proper treatment. Although usually straightforward, we highlight herein 13 malignant Sertoli cell tumors of the testis with light microscopic features that mimicked seminoma. All of the cases were received in consultation, 10 with submitting diagnoses of seminoma, usually of classic type, but three cases of spermatocytic type. Patients ranged from 15 to 80 years of age (median 37 years); all presented with testicular masses. The tumors were typically firm, white to yellow-tan, and often had foci of hemorrhage. The dominant microscopic pattern was nested or sheet-like, with some tumors having secondary patterns of trabeculae-solid tubules, hollow tubules, and pseudofollicles. Tumor cells were polygonal with conspicuous clear cytoplasm in 12 cases; the cytoplasm was focally eosinophilic in 10 cases, but this was never conspicuous. Nine tumors had cytoplasmic vacuoles, and three of four that were investigated stained for intracytoplasmic glycogen. Nuclei were small (5) to medium-sized (8), round-to-oval (13), and vesicular with irregular contours (11). Nucleoli were present in 11 tumors (six small; five large). Stromal fibrosis (12) and lymphoid infiltrates (10) were conspicuous, and tumor necrosis (11) and vascular invasion (8) also were seen. Mitotic figures ranged from <1 to 21/10 high power fields (HPF) (median 1/10 HPF). Staining for inhibin-alpha, epithelial membrane antigen, and cytokeratin (AE1/AE3) was positive in four of four, six of six, and three of six cases, respectively; placental alkaline phosphatase was negative in all five tumors investigated. The nested growth pattern, prominence of clear cells, lymphoid infiltrate, inconspicuous tubular differentiation, cytoplasmic glycogen, and prominent nucleoli caused these tumors to be mistaken for seminomas. The smaller, less pleomorphic nuclei of Sertoli cell tumors, their lower mitotic rate, and the absence of intratubular germ cell neoplasia are helpful differential features. Immunohistochemistry is a useful adjunct in confirming the diagnosis of Sertoli cell tumor, but only if the overlapping features are appreciated by conventional microscopy and the diagnosis of Sertoli cell tumor included in the differential.
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Affiliation(s)
- John D Henley
- Departments of Pathology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Chan LY, Wong SF, Yu VS. Advanced stage of dysgerminoma in testicular feminisation: is radical surgery necessary? Aust N Z J Obstet Gynaecol 2000; 40:224-5. [PMID: 10925918 DOI: 10.1111/j.1479-828x.2000.tb01155.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- L Y Chan
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Hong Kong
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Abstract
Testicular seminoma is highly curable with currently available treatments. Today, there is good evidence that patients with Stage I disease can be treated equally well with either immediate adjuvant para-aortic and ipsilateral pelvic radiotherapy or close surveillance with treatment at the time of relapse. The decision as to which of these management strategies is adopted in an individual case is a complex function of physician preference, and the emotional, social, and economic circumstances of the patient. Ongoing research in Stage I seminoma is focused at reducing the side-effects of treatment either by modifying the radiation treatment plan or by using adjuvant chemotherapy in lieu of radiation. Stage II patients with small bulk retroperitoneal lymphadenopathy have a high probability of long-term disease control with radiotherapy. Patients with bulky Stage II disease or Stage III disease should be treated with cisplatin-based chemotherapy.
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Affiliation(s)
- M F Milosevic
- Department of Radiation Oncology, Princess Margaret Hospital and the University of Toronto, Canada.
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