Editorial: testis cancer--paradigm for reduction in morbidity without sacrifice of efficacy.

Abstract

Testicular cancer has become one of the most curable solid malignancies and represents a model of cooperation among medical oncologists, radiation oncologists and urological oncologists. The development of effective chemotherapy during the last 25 years has permitted revolutionary changes in the management of this once often fatal malignancy. With a cure rate for individuals with low stage disease approaching 100% and more than 80% for patients with advance disease, oncologists have turned their attention to reducing the side effects of treatment, yet still maintaining high likelihood of cure. Because approximately 70% of patients with testicular tumor have no clinical evidence of metastatic disease, a central issue relates to the stratification into true stage 1 disease, which should be cured with orchiectomy alone, versus micrometastatic disease in the retroperitoneum. Even with modern technology of improved computerized tomography (CT), tumor markers and chest CT, approximately 25% of patients with clinical stage 1 disease will ultimately be discovered to have pathological stage 2 disease. Thus, retroperitoneal lymphadenectomy has remained the gold standard for accurate staging and potential therapy for patients with risk factors of retroperitoneal nodal involvement. In this issue of The Journal, Ohyama et al (page 1390) evaluate lymphoscintigraphy and sentinel lymph node biopsy as a laparoscopic procedure with gamma probe guidance as a potential staging tool for clinical stage 1 testicular tumor. The concept of sentinel lymph node identification and biopsy has been popularized in other urological malignancies, including penile, bladder and prostate cancer. Although this procedure looks promising in a small subset of patients, the concept of sentinel node biopsy in most urological malignancies remains controversial. The central problem of clinical staging is the reliance of CT on size criteria alone for delineation of malignancy. The development of fusion of positron emission tomography and CT may abrogate this limitation in the future. With high cure rates in a young male population, fertility and ejaculatory function become increasingly important. Langenstroer et al (page 1396) used decision analysis models to assess whether primary nerve sparing retroperitoneal lymph node dissection or surveillance would be more appropriate in terms of preservation of ejaculatory function. Primary nerve sparing retroperitoneal lymph node dissection, with or without use of templates, should result in a high likelihood of preservation of ejaculation but is dependent on surgeon skill. This application of decision analysis technical models, using 1-way sensitivity analysis and threshold analyses with subsequent 2-way sensitivity analyses, allows a prediction of the likelihood of preservation of ejaculatory function based on surgeon skill and other factors. These techniques are especially applicable when large numbers of patients from clinical series are not available. Another of the remaining controversies in the treatment of testicular cancer is the management of a residual mass in a patient who has received chemotherapy for nonseminomatous germ cell tumor. Approximately 40% of these masses are proven histologically to be fibrosis or necrosis and approximately 50% will harbor teratomatous components. If necrosis or fibrosis could be accurately predicted, post-chemotherapy retroperitoneal lymph node dissection could be avoided in that subset of patients. In this issue of The Journal Beck et al (page 1402) performed a retrospective review of 644 patients who underwent post-chemotherapy retroperitoneal lymph node dissection to assess the likelihood of teratoma in the retropertitoneum. Unfortunately, even lack of teratoma in the primary tumor did not exclude teratoma in the residual mass in approximately half of the patients. Although other parameters have been used to predict presence or absence of necrosis and fibrosis, such as percentage of embryonal carcinoma in the primary specimen, marker reduction, overall size of mass reduction, and so forth, no factor has emerged that will reliably predict the presence or absence of teratoma or malignant elements in the remaining mass. Thus, in 2002 residual masses after chemotherapy require complete resection, often with nerve sparing techniques as well. These 3 articles illustrate the continued search for mechanisms to limit the side effects of chemotherapy or surgical approaches and thereby reduce morbidity. It is tantalizing to hope that we will have effective chemotherapeutic regimens for other urological malignancies that will allow us to expand the frontiers of treatment to increase curability and decrease morbidity.