Multicenter evaluation of [-2]proprostate-specific antigen and the prostate health index for detecting prostate cancer

BACKGROUND

Total prostate-specific antigen (tPSA) is flawed for prostate cancer (PCa) detection. [-2]proprostate-specific antigen (p2PSA), a molecular isoform of free PSA (fPSA), shows higher specificity compared with tPSA or percentage of free PSA (%fPSA). The prostate health index (Phi), a measure based on p2PSA and calculated as p2PSA/fPSA × √tPSA, was evaluated in a multicenter study for detecting PCa.

METHODS

A total of 1362 patients from 4 different study sites who had tPSA values of 1.6-8.0 μg/L (668 patients with PCa, 694 without PCa) underwent ≥10 core biopsies. Serum concentrations of tPSA, fPSA (both calibrated against a WHO reference material), and p2PSA were measured on Access2 or DxI800 analyzers (Beckman Coulter).

RESULTS

The percentage ratio of p2PSA to fPSA (%p2PSA) and Phi were significantly higher in all PCa subcohorts (positive initial or repeat biopsy result or negative digital rectal examination) (P < 0.0001) compared with patients without PCa. Phi had the largest area under the ROC curve (AUC) (AUC = 0.74) and provided significantly better clinical performance for predicting PCa compared with %p2PSA (AUC = 0.72, P = 0.018), p2PSA (AUC = 0.63, P < 0.0001), %fPSA (AUC = 0.61) or tPSA (AUC = 0.56). Significantly higher median values of Phi were observed for patients with a Gleason score ≥7 (Phi = 60) compared with a Gleason score <7 (Phi = 53; P = 0.0018). The proportion of aggressive PCa (Gleason score ≥7) increased with the Phi score.

CONCLUSIONS

The results of this multicenter study show that Phi, compared with tPSA or %fPSA, demonstrated superior clinical performance in detecting PCa at tPSA 1.6-8.0 μg/L (i.e., approximately 2-10 μg/L in traditional calibration) and is better able to detect aggressive PCa.

A Multicentre Evaluation of the Role of the Prostate Health Index (PHI) in Regions with Differing Prevalence of Prostate Cancer: Adjustment of PHI Reference Ranges is Needed for European and Asian Settings

Asians have a lower incidence of prostate cancer (PC). We compared the performance of the Prostate Health Index (PHI) for 2488 men in different ethnic groups (1688 Asian and 800 European men from 9 sites) with PSA 2-20ng/ml and PHI test and transrectal ultrasound-guided biopsy results available. Of these, 1652 men had PSA 2-10ng/ml and a normal digital rectal examination and underwent initial biopsy. The proportions of PC (Gleason ≥6) and higher-grade PC (HGPC, Gleason ≥7) across different PHI ranges were compared. The performance of PSA and PHI was compared using the area under the receiver operating characteristic curve (AUC) and decision curve analyses (DCA). Among Asian men, HGPC would be diagnosed in 1.0%, 1.9%, 13%, and 30% of men using PHI thresholds of <25, 25-35, 35-55, and >55, respectively. At 90% sensitivity for HGPC (PHI >30), 56% of biopsies and 33% of Gleason 6 PC diagnoses could have been avoided. Among European men, HGPC would be diagnosed in 4.1%, 4.3%, 30%, and 34% of men using PHI thresholds of <25, 25-35, 35-55, and >55, respectively. At 90% sensitivity for HGPC (PHI >40), 40% of biopsies and 31% of Gleason 6 PC diagnoses could have been avoided. AUC and DCA confirmed the benefit of PHI over PSA. The benefit of PHI was also seen at repeat biopsy (n=397) and for PSA 10-20ng/ml (n=439). PHI is effective in cancer risk stratification for both European and Asian men. However, population-specific PHI reference ranges should be used. PATIENT SUMMARY: The Prostate Health Index (PHI) blood test helps to identify individuals at higher risk of prostate cancer among Asian and European men, and could significantly reduce unnecessary biopsies and overdiagnosis of prostate cancer. Different PHI reference ranges should be used for different ethnic groups.

Intravesical recurrence after radical nephroureterectomy for upper tract urothelial carcinomas: predictors and impact on subsequent oncological outcomes from a national multicenter study

OBJECTIVES

To identify predictive factors and assess the impact on oncological outcomes of intravesical recurrence after radical nephroureterectomy (RNU) in upper tract urothelial carcinoma (UTUC).

METHODS

Using a national multicentric retrospective dataset, we identified all patients with UTUC who underwent a RNU between 1995 and 2010 (n = 482). Intravesical recurrence was tested as a prognostic factor for survival through univariable and multivariable Cox regression analysis.

RESULTS

Overall, intravesical recurrence occurred in 169 patients (35 %) with a median age of 69.2 years (IQR: 60-76) and after a median follow-up of 39.5 months (IQR: 25-60). Actuarial intravesical recurrence-free survival estimates at 2 and 5 years after RNU were 72 and 45 %, respectively. On univariable analyses, previous history of bladder tumor, tumor multifocality, laparoscopic approach, pathological T-stage, presence of concomitant CIS and lymphovascular invasion were all associated with intravesical recurrence. On multivariable analysis, previous history of bladder cancer, tumor multifocality and laparoscopic approach remained independent predictors of intravesical recurrence. Existence of intravesical recurrence was not correlated with worst oncological outcomes in terms of disease recurrence (p = 0.075) and cancer-specific mortality (p = 0.06).

CONCLUSIONS

In the current study, intravesical recurrence occurred in 35 % of patients with UTUC after RNU. Previous history of bladder cancer, tumor multifocality, concomitant CIS and laparoscopic approach were independent predictors of intravesical recurrence. These findings are in line with recent published data and should be considered carefully to provide a definitive surveillance protocol regarding management of urothelial carcinomas regardless of the location of urothelial carcinomas in the whole urinary tract.

The percentage of prostate-specific antigen (PSA) isoform [-2]proPSA and the Prostate Health Index improve the diagnostic accuracy for clinically relevant prostate cancer at initial and repeat biopsy compared with total PSA and percentage free PSA in men aged ≤65 years

OBJECTIVES

To prospectively test the diagnostic accuracy of the percentage of prostate specific antigen (PSA) isoform [-2]proPSA (%p2PSA) and the Prostate Health Index (PHI), and to determine their role for discrimination between significant and insignificant prostate cancer at initial and repeat prostate biopsy in men aged ≤65 years.

PATIENTS AND METHODS

The diagnostic performance of %p2PSA and PHI were evaluated in a multicentre study. In all, 769 men aged ≤65 years scheduled for initial or repeat prostate biopsy were recruited in four sites based on a total PSA (t-PSA) level of 1.6-8.0 ng/mL World Health Organization (WHO) calibrated (2-10 ng/mL Hybritech-calibrated). Serum samples were measured for the concentration of t-PSA, free PSA (f-PSA) and p2PSA with Beckman Coulter immunoassays on Access-2 or DxI800 instruments. PHI was calculated as (p2PSA/f-PSA × √t-PSA). Uni- and multivariable logistic regression models and an artificial neural network (ANN) were complemented by decision curve analysis (DCA).

RESULTS

In univariate analysis %p2PSA and PHI were the best predictors of prostate cancer detection in all patients (area under the curve [AUC] 0.72 and 0.73, respectively), at initial (AUC 0.67 and 0.69) and repeat biopsy (AUC 0.74 and 0.74). t-PSA and %f-PSA performed less accurately for all patients (AUC 0.54 and 0.62). For detection of significant prostate cancer (based on Prostate Cancer Research International Active Surveillance [PRIAS] criteria) the %p2PSA and PHI equally demonstrated best performance (AUC 0.70 and 0.73) compared with t-PSA and %f-PSA (AUC 0.54 and 0.59). In multivariate analysis PHI we added to a base model of age, prostate volume, digital rectal examination, t-PSA and %f-PSA. PHI was strongest in predicting prostate cancer in all patients, at initial and repeat biopsy and for significant prostate cancer (AUC 0.73, 0.68, 0.78 and 0.72, respectively). In DCA for all patients the ANN showed the broadest threshold probability and best net benefit. PHI as single parameter and the base model + PHI were equivalent with threshold probability and net benefit nearing those of the ANN. For significant cancers the ANN was the strongest parameter in DCA.

CONCLUSION

The present multicentre study showed that %p2PSA and PHI have a superior diagnostic performance for detecting prostate cancer in the PSA range of 1.6-8.0 ng/mL compared with t-PSA and %f-PSA at initial and repeat biopsy and for predicting significant prostate cancer in men aged ≤65 years. They are equally superior for counselling patients before biopsy.

Twenty-year experience with jejunal conduits

OBJECTIVES

To assess the results of jejunal conduit urinary diversion, with particular attention to electrolyte imbalance and long-term renal function.

METHODS

From 1976 to 1994, 50 patients underwent urinary diversion using a short jejunal loop (10 to 12 cm) placed transperitoneally. Of these patients, 18 received pelvic irradiation before diversion. Renal function and configuration of the upper urinary tract were assessed by creatinine clearance and excretory urography.

RESULTS

Median follow-up was 26 months (3 to 204). Of 50 patients, 22 had a follow-up more than 5 years later (median 86 months). Eight patients (16%) underwent 10 revision procedures postoperatively. Late complications related to urinary diversion included renal calculi (12%), parastomal hernia (6%), pyelonephritis (4%), ureterojejunal obstruction (4%), and stomal prolapse (2%). Electrolyte imbalance occurred in 2 patients (4%) and was easily corrected by 4 g sodium bicarbonate. No significant decrease in creatinine clearance (P = 0.6) was found in 22 patients with a follow-up of more than 5 years; however, of these patients, 2 had a decrease in creatinine clearance of greater than 20%, due to ureterojejunal obstruction. Of 42 ureterorenal units, hydronephrosis occurred and increased in 1 and 2 cases, respectively, and renal scarring occurred and progressed in 2 and 2 cases, respectively.

CONCLUSIONS

Urinary diversion using a short length of jejunum placed transperitoneally is a reliable procedure and gives good long-term renal function. Electrolyte imbalances are rare. Moreover, jejunal conduit can be used in almost all situations, especially after pelvic irradiation.

Immunohistochemical expression of p63, p53 and MIB-1 in urinary bladder carcinoma. A tissue microarray study of 158 cases

P63 is a member of the p53 family, which plays a role in the differentiation of urothelium and is supposed to play a role in urothelial carcinogenesis. P53 and MIB-1 are recognised in many studies as predictive markers of progression, but few studies in the literature have examined p63. The aims of our study were to explore the expression of p63 in bladder carcinomas and to compare this expression to p53 and MIB-1, as well as to stage and grade. Tissue microarrays were performed on 158 urothelial carcinomas (56 pTa, 45 pT1 and 57>or=pT2). Immunohistochemical studies were performed with p63, p53 and MIB-1 antibodies. In our study we observed that p63 immunostaining is present in all cell layers in papillary urothelial neoplasm of low malignant potential (PUNLMP), but partially lost in non-invasive papillary urothelial carcinoma low grade (NILGC) and in pT1/>or=pT2 bladder cancers. P53 and MIB-1 displayed lower expression in PUNLMP/NILGC vs non-invasive papillary urothelial carcinoma high grade (NIHGC)/pT1, but there was no correlation between the expression of p63, p53 and MIB-1. Our study demonstrates that p63 expression distinguishes between PUNLMP/NILGC and NIHGC/pT1 (p=4.10(5)). A statistical difference disserving pTa and pT1/>or=pT2 with a statistical significance (p<10(-6)) could also be observed. P63 should be considered as an additional biomarker that might help pathologists to classify their patients.

Congenital pelvic arteriovenous malformation in male patients: a rare cause of urological symptoms and role of embolization

OBJECTIVES

Congenital pelvic arteriovenous malformations (pAVM) are rare in male patients. The purpose of our study was to obtain information about the presenting symptoms, differential diagnosis, radiological diagnosis and therapy.

PATIENTS AND METHODS

The record of two men with congenital pAVM were reviewed to evaluate the initial symptomatology, diagnostic examinations and findings, therapeutic procedures and clinical outcome. Furthermore, our data are compared to the findings of all men reported in the literature.

RESULTS

Including the two cases reported by us, the data on 17 men with congenital pAVM could be analyzed. Most men presented with unspecific symptoms like pelvic discomfort, pain, impotence or dysuria. The radiological diagnosis was established by magnetic resonance imaging (MRI) or by computed tomography (CT) and was confirmed by angiography in all cases. Therapy consisted of surgical excision in nine cases, embolization in four cases, embolization and surgery in three cases and medical supervision in one case.

CONCLUSION

Pelvic arteriovenous malformations in male patients are rare. Because of the lack of specific symptoms, they are difficult to diagnose. CT or MRI and arteriography make the diagnosis. Intra-arterial embolization can be considered as the first line treatment.

Total and free serum prostate specific antigen levels during the first month of acute prostatitis

OBJECTIVES

The level of total prostate specific antigen (PSA) rises in acute prostatitis. The PSA fraction responsible for this increase and the evolution of the free/total PSA ratio are little known at the present time. We therefore carried out a prospective study of the evolution of total and free PSA levels and the free-to-total PSA ratio for one month after diagnosis of acute prostatitis.

PATIENTS AND METHODS

Between January 1999 and February 2001, 31 consecutive patients (mean age 51 years) were treated for acute prostatitis. No patient had a history of prostate cancer or of recent prostatitis. Measurement of C-reactive protein (CRP), total PSA and free PSA was done at days 0, 3, 10 and 30.

RESULTS

During the first month of acute prostatitis and under an adapted antibiotherapy, CRP progressively decreased and returned to normal levels at about day 10. Total PSA level increased up to day 3 and then gradually decreased until at least the end of the first month. The level of free PSA decreased up to day 10 and was still low at one month, leading to a decrease in the free-to-total PSA ratio which was reached its lowest level at day 10 and was still low at one month.

CONCLUSION

The increased level of total PSA in acute prostatitis is secondary to the proportional increase in bound serum PSA and decrease in free PSA. Free PSA was still low at one month, maintaining a low free-to-total PSA ratio.

Cluster randomized trial to evaluate the impact of team training on surgical outcomes

Background

The application of safety principles from the aviation industry to the operating room has offered hope in reducing surgical complications. This study aimed to assess the impact on major surgical complications of adding an aviation-based team training programme after checklist implementation.

Methods

A prospective parallel-group cluster trial was undertaken between September 2011 and March 2013. Operating room teams from 31 hospitals were assigned randomly to participate in a team training programme focused on major concepts of crew resource management and checklist utilization. The primary outcome measure was the occurrence of any major adverse event, including death, during the hospital stay within the first 30 days after surgery. Using a difference-in-difference approach, the ratio of the odds ratios (ROR) was estimated to compare changes in surgical outcomes between intervention and control hospitals.

Results

Some 22 779 patients were enrolled, including 5934 before and 16 845 after team training implementation. The risk of major adverse events fell from 8·8 to 5·5 per cent in 16 intervention hospitals (adjusted odds ratio 0·57, 95 per cent c.i. 0·48 to 0·68; P &lt; 0·001) and from 7·9 to 5·4 per cent in 15 control hospitals (odds ratio 0·64, 0·50 to 0·81; P &lt; 0·001), resulting in the absence of difference between arms (ROR 0·90, 95 per cent c.i. 0·67 to 1·21; P = 0·474). Outcome trends revealed significant improvements among ten institutions, equally distributed across intervention and control hospitals.

Conclusion

Surgical outcomes improved substantially, with no difference between trial arms. Successful implementation of an aviation-based team training programme appears to require modification and adaptation of its principles in the context of the the surgical milieu. Registration number: NCT01384474 (http://www.clinicaltrials.gov).

Comparison of Two Prostate Cancer Risk Calculators that Include the Prostate Health Index

BACKGROUND

Risk prediction models for prostate cancer (PCa) have become important tools in reducing unnecessary prostate biopsies. The Prostate Health Index (PHI) may increase the predictive accuracy of such models.

OBJECTIVES

To compare two PCa risk calculators (RCs) that include PHI.

DESIGN, SETTING, AND PARTICIPANTS

We evaluated the predictive performance of a previously developed PHI-based nomogram and updated versions of the European Randomized Study of Screening for Prostate Cancer (ERSPC) RCs based on digital rectal examination (DRE): RC3 (no prior biopsy) and RC4 (prior biopsy). For the ERSPC updates, the original RCs were recalibrated and PHI was added as a predictor. The PHI-updated ERSPC RCs were compared with the Lughezzani nomogram in 1185 men from four European sites. Outcomes were biopsy-detectable PC and potentially advanced or aggressive PCa, defined as clinical stage >T2b and/or a Gleason score ≥7 (clinically relevant PCa).

RESULTS AND LIMITATIONS

The PHI-updated ERSPC models had a combined area under the curve for the receiver operating characteristic (AUC) of 0.72 for all PCa and 0.68 for clinically relevant PCa. For the Lughezzani PHI-based nomogram, AUCs were 0.75 for all PCa and 0.69 for clinically relevant PCa. For men without a prior biopsy, PHI-updated RC3 resulted in AUCs of 0.73 for PCa and 0.66 for clinically relevant PCa. Decision curves confirmed these patterns, although the number of clinically relevant cancers was low.

CONCLUSION

Differences between RCs that include PHI are small. Addition of PHI to an RC leads to further reductions in the rate of unnecessary biopsies when compared to a strategy based on prostate-specific antigen measurement.

PATIENT SUMMARY

Risk prediction models for prostate cancer have become important tools in reducing unnecessary prostate biopsies. We compared two risk prediction models for prostate cancer that include the Prostate Health Index. We found that these models are equivalent to each other, and both perform better than the prostate-specific antigen test alone in predicting cancer.

Tissue expression of IL16 in prostate cancer and its association with recurrence after radical prostatectomy

BACKGROUND

Genetic polymorphism located within the IL16 gene has been reported to be associated with aggressive prostate cancer (PCa). Our aim was to establish whether the tissue expression of IL16 is a prognostic factor of survival in PCa.

METHODS

The files of patients who underwent radical prostatectomy (RP) between 1995 and 2001 were reviewed. The cases were selected and classified according to the D'Amico classification for risk of recurrence (intermediate or high). The value of IL16 and its receptor CCR5 (chemokine (C-C motif) receptor 5) expression levels were determined as witness of aggressiveness patterns and markers of biological relapse in patients with PCa treated by RP. A tissue microarray of 304 cases was constructed. IL16 and CCR5 expression levels were characterized by immunohistochemistry.

RESULTS

IL16 expression was correlated with high Gleason score (i.e., >7) (P < 0.01). It was not significant for CCR5. IL16 and CCR5 were not associated with prostate-specific antigen (PSA) or capsular extension of the disease. The accurate prediction of disease outcome, using stratification of cases, according to negative margins and D'Amico classification was significantly enhanced by status of IL16 expression (P ≤ 0.01). In univariate analyses, Gleason score, PSA level, stage and loss of IL16 expression were related to better biological-free survival (P < 0.05) but not CCR5. In a multivariate analysis, IL16 expression, Gleason score, and tumor stage were independent factors for biochemical-free survival (P = 0.001).

CONCLUSIONS

IL16 appears to be a useful prognostic factor in PCa. Its expression in PCa tissue was correlated to tumor aggressiveness and biochemical relapse of the disease.

Clinical relevance of genetic instability in prostatic cells obtained by prostatic massage in early prostate cancer

We investigated whether genetic lesions such as loss of heterozygosity (LOH) are detected in prostatic cells obtained by prostatic massage during early diagnosis of prostate cancer (CaP) and discussed their clinical relevance. Blood and first urine voided after prostatic massage were collected in 99 patients with total prostate-specific antigen (PSA) between 4 and 10 ng ml⁻¹, prior to prostate biopsies. Presence of prostatic cells was confirmed by quantitative RT–PCR analysis of PSA mRNA. Genomic DNA was analysed for LOH on six chromosomal regions. One or more allelic deletions were found in prostatic fluid from 57 patients analysed, of whom 33 (58%) had CaP. Sensitivity and specificity of LOH detection and PSA free to total ratio <15% for positive biopsy were respectively 86.7 and 44% (P=0.002) for LOH, and 55 and 74% (P=0.006) for PSA ratio <15%. Analysis of LOH obtained from prostatic tumours revealed similar patterns compared to prostatic fluid cells in 86% of cases, confirming its accuracy. The presence of LOH of urinary prostatic cells obtained after prostatic massage is significantly associated with CaP on biopsy and may potentially help to identify a set of patients who are candidates for further prostate biopsies.

Translocation (X;1) associated with a nonpapillary carcinoma in a young woman: a new definition for an Xp11.2 RCC subtype

We report a translocation (X;1)(p11.2;q21) associated with a nontubulopapillary renal cell carcinoma in a 23-year-old woman. To our knowledge this the first report of such an association. A review of the previously published cases of renal cell carcinoma with t(X;1) and its cytogenetic variants with Xp11.2 anomalies is included. The role of this karyotype abnormality as a clinical marker is discussed. The Xp11.2 abnormality could be a primary abnormality characterizing a particular type of RCC appearing in children and young adults of both sexes and in which the histological aspect is not specific.

Fibrous pseudotumor of the epididymis: imaging and pathologic correlation

We report the case of a 25-year-old man who presented a fibrous pseudotumor of the epididymis, a rare focal location of nodular and diffuse fibrous proliferation. We provide the ultrasonographic and MRI findings with pathologic correlation.

[Use of [-2] pro PSA and phi index for early detection of prostate cancer: a prospective of 452 patients]

INTRODUCTION

Early detection of prostate cancer (Pca) is a real challenge to reduce morbidity and mortality while avoiding over-diagnosis and over-treatment. The prostate specific antigen (PSA) is characterized by its imperfections justifying the evaluation of new serum or urinary specific markers allowing a better selection of patients at risk of developing aggressive Pca.

AIM

To compare the value of -2pro PSA and phi index to total and free PSA.

METHODS

Serum sampled from 452 patients from two university centers were used to determine levels of PSA before performing biopsies. The patients were included in this study based on the PSA serum concentration between 1.6 ng/mL and 8 ng/mL according to the WHO international standard. All biopsies were performed according to a standardized protocol consisting of 12 cores or more. Sera were analyzed centrally in one of the two institutions with on a single analyzer. Sera from 243 prostate cancer and 208 negative biopsies patients have been taken into account.

RESULTS

Sera were analyzed blinded for total PSA, free PSA and [-2] proPSA using Access(®) immunoassay method from Beckman Coulter. The Prostate Health Index (phi) was calculated using the formula phi=([-2] proPSA/fPSA)×sqrt (PSA). The median value of the phi index is significantly (P>0.0001) higher for patients with cancer (phi=65.8) compared to patients with negative biopsies (phi=40.6). At a given sensitivity, the phi index significantly increases the specificity of detection of prostate cancer compared to other markers.

CONCLUSION

The phi index currently appears as the best predictor of prostate cancer for patients with a total PSA between 1.6 and 8 ng/mL according to the WHO standard. The improvement in specificity of the phi index over tPSA could reduce significantly the numbers of unnecessary biopsies. Whether this new biomarker could be an indicator of aggressive prostate cancer remains to be confirmed.

[Radiotherapy in stage I testicular seminoma: retrospective study and review of literature]

INTRODUCTION

Seminoma accounts for about 40% of germ cell tumours of the testicle. In this retrospective analysis, we review literature concerning management of stage I seminoma.

MATERIALS AND METHODS

Between March 1987 and April 2001, 65 patients with stage I pure testicular seminoma received adjuvant radiotherapy with a 25 MV linear accelerator.

RESULTS

Median age was 33 years. Testicular tumour has been found on the right testis in 39 patients and on the left one in 24 patients. Patients have been treated using an anterior-posterior parallel pair and have received 20-25 Gy in 10-14 fractions. The target volume consisted of paraaortic, and paraaortic + homolateral iliac lymph nodes in 17 and 46 patients, respectively. Acute toxicity was mainly digestive, 38% of patients presenting nausea and vomiting. Median follow-up time was 37 months. All patients are alive in complete remission.

DISCUSSION

Because of good radio-sensitivity of seminoma, radiotherapy is regarded as standard adjuvant treatment (5 years relapse rate: 3-5%). Acute toxicity is dominated by moderate gastro-intestinal side effects. Secondary neoplasia represents one of the worst possible long-term complications of therapy. Waiting for ongoing randomised trials, the modern literature for seminoma reflects a trend toward lower radiation doses (20-25 Gy) and smaller treatment volumes (paraaortic field). Adjuvant chemotherapy with two courses of carboplatin, might be equivalent to radiotherapy but must be investigated in randomised trials. A surveillance policy is one of the other management options less recommended.

[Testicular germ-cell tumour: diagnosis and treatment]

Among germ cell tumours, seminomas hold a particular status related to their radio-sensitivity. Although radiotherapy remains the best treatment for Localized tumours of stage 1, in some cases, surveillance or chemotherapy may presently be considered as alternative therapies. Due to Long-term radiotherapy-related adverse effects, in particular the risk of second non-germ malignancies or cardiac morbidity, both dose and irradiation field are reduced in case of lymphatic retroperitoneal extension. Chemotherapy is the preferential treatment in more advanced stages, either with retroperitoneal bulky disease or with metastatic extension. Its efficacy allows Limiting surgical indications on residual masses, relying partly on the follow-up data of positron emission transaxial tomography assessment.