ESMO Consensus Conference on testicular germ cell cancer: diagnosis, treatment and follow-up

The European Society for Medical Oncology (ESMO) consensus conference on testicular cancer was held on 3-5 November 2016 in Paris, France. The conference included a multidisciplinary panel of 36 leading experts in the diagnosis and treatment of testicular cancer (34 panel members attended the conference; an additional two panel members [CB and K-PD] participated in all preparatory work and subsequent manuscript development). The aim of the conference was to develop detailed recommendations on topics relating to testicular cancer that are not covered in detail in the current ESMO Clinical Practice Guidelines (CPGs) and where the available level of evidence is insufficient. The main topics identified for discussion related to: (1) diagnostic work-up and patient assessment; (2) stage I disease; (3) stage II-III disease; (4) post-chemotherapy surgery, salvage chemotherapy, salvage and desperation surgery and special topics; and (5) survivorship and follow-up schemes. The experts addressed questions relating to one of the five topics within five working groups. Relevant scientific literature was reviewed in advance. Recommendations were developed by the working groups and then presented to the entire panel. A consensus vote was obtained following whole-panel discussions, and the consensus recommendations were then further developed in post-meeting discussions in written form. This manuscript presents the results of the expert panel discussions, including the consensus recommendations and a summary of evidence supporting each recommendation. All participants approved the final manuscript.

The management strategies for stage I seminoma

About 80% of men with seminomatous testicular germ-cell cancer are diagnosed with stage I disease. For many years, the standard treatment for this patient group has been radiation to para-aortic and iliacal lymph nodes at the same side as the orchiectomy. However, iliac radiotherapy is unnecessary in patients without prior inguinal or scrotal surgery. Furthermore, in recent years, other treatment modalities for this patient group have evolved. The use of single-agent carboplatin has shown promising results, similar to the effects obtained by radiotherapy. In addition, surveillance after primary orchiectomy with no additional treatment is found to be a safe follow-up for many of these patients. On the basis of new knowledge about primary tumour risk factors, it is now possible to identify patients at a particular high risk of relapse (rete testis invasion, primary tumour size > 4 cm, or both). This will be a helpful tool to identify patients who can be safely included into a surveillance strategy, and those who could have adjuvant treatment. The final decision about treatment will depend on risk factors, capacity of the healthcare service to carry out frequent follow-up examinations and the patient's own preferences. In this paper, we will discuss advantages and disadvantages of the various treatment options in the management of stage I seminoma.

How is quality of life in prostate cancer patients influenced by modern treatment? The Wallenberg Symposium

OBJECTIVES

To identify complications of various forms of treatments for prostate cancer and their influence on patients' quality of life with the ultimate goal of suggesting a Quality of Life Questionnaire specific for prostate cancer for further validation.

METHODS

The literature was screened for reports on the more common complications following various forms of therapy for prostate cancer. Frequencies were summarized. The scarce literature reporting on quality of life in prostate cancer was reviewed and conflicting data were discussed and reassessed. Suggested questionnaires used in other studies were critically scrutinized and the various questions recorded.

RESULTS

Following radical surgery, impotence and incontinence were the most common complications reducing patients' quality of life. The literature was not uniform with regard to whether loss of sexual function was regarded as a worse complication than loss of urinary control. Following radiotherapy, intestinal problems and sexual dysfunction were the dominating side effects. Quality of life was best preserved in surveillance-only series. Following endocrine therapy, not only impotence and hot flushes were focused upon, but also mental dysfunction and intestinal dysfunction from nonsteroidal antiandrogens, additionally, the importance of effective palliation was highlighted. A Quality of Life Questionnaire should contain general domains relevant to cancer patients, cancer-specific questions, and prostate-cancer-specific questions. The latter group includes: worry for prostate cancer and its prognosis, bone/pelvic pain, lower urinary tract symptoms, urinary incontinence, urinary diversion, bowel function, sexual function, endocrine effects, and satisfaction with medical care for prostate cancer.

CONCLUSIONS

A modern trial of prostate cancer treatment should be regarded as insufficient without including a validated Quality of Life Questionnaire.

An EORTC phase II study of the efficacy and safety of linomide in the treatment of advanced renal cell carcinoma

The aim of this study was to determine the objective tumour response rate and duration of response and toxicity of linomide (Roquinimex) treatment in patients with disseminated renal cell carcinoma, pretreated or not pretreated with immunotherapy. From March 1991 to July 1992, 72 patients with metastatic and progressive renal cell cancer were entered of whom 9 (12%) were not evaluable for response. Linomide was given orally, twice weekly, 5 mg during the first week with dose escalation to 10 mg during the second week and 15 mg thereafter. Treatment was continued until disease progression or unacceptable toxicity. No haematological toxicity but slight anaemia was observed. A significant WBC (white blood cell count) increase (P < 0.0001, paired T-test) was found during treatment. The most often reported non-haematological side-effects were: flu-like syndrome (54%, grade III-IV 7%), nausea/vomiting (41% and 3%, respectively) and neurotoxicity (34% and 2%). Most side-effects were of mild or moderate intensity (WHO grade 1 or 2). The objective overall response rate was 4%: 1 CR and 2 PRs. Stable disease was reported for 28 patients (40%). The duration of response was 17, 22 and 30 (CR) months. Median time to progression was 5 months. Linomide at the given dose and schedule is well tolerated, but has limited antitumour activity in metastatic renal cell carcinoma.

K-ras oncogene codon 12 point mutations in testicular cancer

A significant association between N-ras oncogene activating point mutations and testicular cancer has recently been reported. We have studied DNA samples from the blood and fresh tumor tissues of 17 Norwegian testicular cancer patients (11 seminomas/6 nonseminomas). Point mutations in K-ras-2 and N-ras exons 1 and 2 were studied by denaturing gradient gel electrophoresis (DGGE) and by oligonucleotide hybridization. No N-ras mutations were detected in these tumor samples, but two K-ras-2 exon 1 mutations were found in two of the seminoma tumors (stage I and II tumors) using the DGGE technique. The mutations were confirmed by dot blotting and oligonucleotide hybridization and identified as a G-->T and a G-->A point mutation in K-ras-2 codon 12, leading to a valine and a serine substitution, respectively. All the white blood cell DNAs were negative. As a positive control for DGGE screening, we ran two plasmid constructs carrying human N-ras exon 2 sequences with mutations. To study the role of ras gene activation in testicular cancer, a larger tumor sample population will be investigated.

Rare and unusual tumors of the genitourinary tract

The entity of small cell undifferentiated carcinoma of the urinary tract is clearly recognized, though treatment still poses considerable difficulties. Small cell undifferentiated carcinoma may lead to systemic symptoms by hormone production, even in patients with localized tumors. The survival rates of adults with Wilms' tumor approach only 50% of those seen in children. Cisplatin may be effective in relapsing patients. Cancer of the female urethra should be treated by combined surgery and radiotherapy. One should differentiate between urachal and nonurachal adenocarcinoma. DNA ploidy seems to be an important prognostic parameter in adenocarcinoma of the bladder. After orchiectomy, adjuvant chemotherapy is recommended even in testis-confined malignant lymphoma. Organ-preserving surgery and radiotherapy should be used in malignant lymphoma of the bladder. Patients with uncommon urologic tumors should be treated at larger cancer centers. Alternatively, the clinician should at least enter relevant information on patients seen with these malignancies into collective databases. This review summarizes the clinical aspects of rare and unusual tumors of the genitourinary tract in adults.

The role of CT in demonstrating perivesical tumor growth in the preoperative staging of carcinoma of the urinary bladder

Carcinoma of the urinary bladder was staged both clinically and by CT in 32 patients before they underwent total cystectomy. Eleven of the patients had perivesical growth demonstrated at histopathological examination of the cystectomy specimen. This was diagnosed by CT in all 11 of these patients before cystectomy, but it was discovered by clinical staging in only four patients prior to cystectomy. Seven patients without histopathologically proved perivesical growth were considered to have perivesical spread as demonstrated by CT findings. Three of these patients had perivesical fibrosis that was misinterpreted as perivesical tumor growth, and in all seven patients the perivesical changes were adjacent to the area of present or previous changes in the bladder wall. CT is a valuable addition to clinical staging because it demonstrates perivesical tumor growth.