Clinical Stage I Research Articles

Survival analysis of HIV/AIDS patients with access to highly antiretroviral therapy in Ningbo during 2004-2015

Objective: To understand the epidemiology characteristics and survival status of HIV/AIDS patients with access to highly antiretroviral therapy (HAART) in Ningbo during 2004-2015. Methods: A retrospective cohort study was conducted among HIV/AIDS patients diagnosed between 2004 and 2015. Life Tables were used to estimate survival rates, and Kaplan-Meier curve with Log rank test were used to describe the survival curves and the Cox proportional hazard model was used to determine predictors of mortality. Results: Of the subjects, the median age when starting HAART was 35 years (IQR: 27-45 years). Most of them were males, local residents, married, infected through heterosexual sexual transmission, and their baseline CD4 T cells counts were mainly ≤200 cells/μl, and most of them were at clinical stageⅠ(WHO). The cumulative survival rate was 96.75% for the first year, 92.36% for the fifth year, 91.87% for the seventh year and 90.02% for the tenth year. The risk of the mortality was 17.34 times higher for those aged >60 years compared with those aged ≤20 years (95%CI: 2.11-142.71), 2.83 times higher for those at clinical stage Ⅳ(WHO) compared with those at clinical stageⅠ (WHO) (95% CI: 1.67-4.80) and 3.26 times higher for those with drug resistance compared with those without drug resistance (95%CI: 1.77-6.01). Blood transmission, lower CD4+ T cell level, BMI <18.5, unmarried were the risk factors for the mortality. Conclusions: The effect of HAART was obvious in the HIV/AIDS patients in Ningbo, their survival rate was high. The finding indicated that it is necessary to strengthen the health care for old population and health education about AIDS prevention and control, and conduct large scale screening. Early discovery, early diagnosis, early treatment and improving treatment compliancy are still the effective ways to reduce the mortality.

Efficacy of lymph node dissection during robotic-assisted lobectomy for non-small cell lung cancer: retrospective review of 159 consecutive cases.

We investigated whether robotic-assisted surgery improves mediastinal lymph node dissection (MLND). We analyzed patients (pts) who underwent robotic-assisted video-assisted thoracoscopic surgery (R-VATS) lobectomy for non-small cell lung cancer (NSCLC) over 36 months. Perioperative outcomes, tumor histology, numbers, locations, and status of all lymph nodes (LNs), and TNM (tumor, nodal, and metastasis) stage changes were analyzed. One hundred fifty-nine pts had mean tumor size 3.3±0.2 cm, most commonly being adenocarcinoma. Assessment of ≥3 N2 stations occurred in 156 (98.1%) pts, with 141 (88.7%) pts having >3 N2 stations reported. Mean total N1 + N2 stations assessed was 5.6±0.1 stations, including mean 4.1±0.1 N2 stations assessed. Mean N2 LNs reported was 7.2±0.3 LNs, and mean total N1 + N2 LNs reported was 13.4±0.4 LNs. There were 118 (74.2%) clinical stage-I pts versus 96 (60.4%) pathologic stage-I pts. Overall, 48 (30.2%) pts were upstaged, including 13 pts with cN0-pN1, 13 pts with cN0-pN2, 4 pts with cN1-pN2, and 18 pts with changes in T. R-VATS lobectomy is safe and results in perioperative outcomes comparable to those reported for conventional VATS. R-VATS MLND is effective at detecting occult metastatic disease during lobectomy for NSCLC.

Conditional Risk of Relapse in Surveillance for Clinical Stage I Testicular Cancer

BackgroundPatients on surveillance for clinical stage I (CSI) testicular cancer are counseled regarding their baseline risk of relapse. The conditional risk of relapse (cRR), which provides prognostic information on patients who have survived for a period of time without relapse, have not been determined for CSI testicular cancer. ObjectiveTo determine cRR in CSI testicular cancer. Design, setting, and participantsWe reviewed 1239 patients with CSI testicular cancer managed with surveillance at a tertiary academic centre between 1980 and 2014. Outcome measurements and statistical analysiscRR estimates were calculated using the Kaplan-Meier method. We stratified patients according to validated risk factors for relapse. We used linear regression to determine cRR trends over time. Results and limitationsAt orchiectomy, the risk of relapse within 5 yr was 42.4%, 17.3%, 20.3%, and 12.2% among patients with high-risk nonseminomatous germ cell tumor (NSGCT), low-risk NSGCT, seminoma with tumor size ≥3cm, and seminoma with tumor size <3cm, respectively. However, for patients without relapse within the first 2 yr of follow-up, the corresponding risk of relapse within the next 5 yr in the groups was 0.0%, 1.0% (95% confidence interval [CI] 0.3–1.7%), 5.6% (95% CI 3.1–8.2%), and 3.9% (95% CI 1.4–6.4%). Over time, cRR decreased (p≤0.021) in all models. Limitations include changes to surveillance protocols over time and few late relapses. ConclusionsAfter 2 yr, the risk of relapse on surveillance for CSI testicular cancer is very low. Consideration should be given to adapting surveillance protocols to individualized risk of relapse based on cRR as opposed to static protocols based on baseline factors. This strategy could reduce the intensity of follow-up for the majority of patients. Patient summaryOur study is the first to provide data on the future risk of relapse during surveillance for clinical stage I testicular cancer, given a patient has been without relapse for a specified period of time.

The Evolving Management of Patients With Clinical Stage I Seminoma

To determine trends in management and factors associated with men receiving either chemotherapy or radiation therapy post orchiectomy for clinical stage I (CSI) seminoma in a contemporary setting. The National Cancer Data Base was queried for all patients with CSI seminoma from 1998 to 2012. Adjuvant treatment after orchiectomy was classified into 3 groups: surveillance, radiotherapy, and chemotherapy. Yearly trends in management are described. Subgroup analysis for the years 2010-2012 was completed using logistic regression to determine predictors of receiving treatment. Of 80,385 patients with testicular cancer, 16,931 had CSI seminoma. There was a progressive decline in the use of post-orchiectomy treatment from 1998 to 2012. In the years 2010-2012 (n = 5816), 59.9% of patients chose surveillance compared with 25.1% receiving radiotherapy and 15.0% receiving chemotherapy. Regression modeling demonstrated that men aged 18-30 were less likely (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.69-1.00, P = .048) to receive treatment than those aged 31-37. Increasing pathologic stage was associated with a greater likelihood of treatment (OR 1.77, 95% CI 1.52-2.06), whereas patients treated at academic hospitals were less likely to receive adjuvant therapy (OR 0.77, 95% CI 0.62-0.94). Despite a trend toward increased use of post-orchiectomy surveillance for patients with CSI seminoma, a significant portion of patients are still receiving treatment. Pathologic stage and treating hospital type have the strongest association with management decisions. Improved guideline adherence may reduce the potential for adverse effects after chemotherapy or radiation therapy for CSI seminoma.

Treatment of stage I seminoma, with one course of adjuvant carboplatin or surveillance, risk-adapted recommendations implementing patient autonomy: a report from the Swedish and Norwegian Testicular Cancer Group (SWENOTECA)

The purpose of the protocol was to reduce the treatment burden in clinical stage I (CSI) seminoma by offering risk-adapted treatment. The protocol aimed to prospectively validate the proposed risk factors for relapse, stromal invasion of the rete testis and tumor diameter >4 cm, and to evaluate the efficacy of one course of adjuvant carboplatin. From 2007 to 2010, 897 patients were included in a prospective, population-based, risk-adapted treatment protocol implementing one course of adjuvant carboplatin AUC7 (n = 469) or surveillance (n = 422). In addition, results from 221 patients receiving carboplatin between 2004 and 2007 are reported. At a median follow-up of 5.6 years, 69 relapses have occurred. Stromal invasion of the rete testis [hazard ratio (HR) 1.9, P = 0.011] and tumor diameter >4 cm (HR 2.7, P < 0.001) were identified as risk factors predicting relapse. In patients without risk factors, the relapse rate (RR) was 4.0% for patients managed by surveillance and 2.2% in patients receiving adjuvant carboplatin. In patients with one or two risk factors, the RR was 15.5% in patients managed by surveillance and 9.3% in patients receiving adjuvant carboplatin. We found no increased RR in patients receiving carboplatin <7 × AUC compared with that in patients receiving ≥7 × AUC. Stromal invasion in the rete testis and tumor diameter >4 cm are risk factors for relapse in CSI seminoma. Patients without risk factors have a low RR and adjuvant therapy is not justified in these patients. The efficacy of adjuvant carboplatin is relatively low and there is need to explore more effective adjuvant treatment options in patients with high-risk seminoma. The data do not support the concept of a steep dose response for adjuvant carboplatin.

Risk stratification of clinical stage I (CSI) non-seminomatous germ cell testicular tumors (NSGCT): A retrospective analysis of experience at Indiana University (IU).

e16052Risk Stratification of Clinical Stage I (CSI) Non-Seminomatous Germ Cell Testicular Tumors (NSGCT): A Retrospective Analysis of Experience at Indiana University (IU) Background: Nearly 50% of...

Sperm count in Swedish clinical stage I testicular cancer patients following modern adjuvant treatment.

4542Background: Little is known regarding sperm production following modern adjuvant treatment in clinical stage I (CSI) testicular cancer (TC).Methods: 182 TC patients aged 18-50 were prospectivel...

Controversies in the management of clinical stage I testicular seminoma.

IntroductionFollowing orchiectomy patients with clinical stage I (CSI) testicular seminoma may be managed by active surveillance (AS) or adjuvant treatment (radiotherapy or chemotherapy). In view of the published data on long-term toxicity, mainly second malignant neoplasms (SMNs), adjuvant radiotherapy (ART) is currently no longer recommended as adjuvant therapy for these patients. The purpose of our recent study was to compare the impact of two selected treatment approaches – AS versus adjuvant chemotherapy (ACT) on survival in patients with CSI testicular seminoma.Material and methodsThe cross-sectional study analyzed a total of 106 patients collected at a single centre between 4/2008–8/2015, with CSI testicular seminoma, stratified into two groups according to risk-adapted therapeutic approaches.ResultsIn group A (low-risk), consisting of 84 patients, who underwent AS, relapse occurred in 10 (11.9%) patients after a mean follow-up of 13.8 months. In group B (high-risk), consisting of 22 patients, who were treated with ACT, relapse occurred in two (9.1%) patients after a mean follow-up of 13.8 months. Overall survival of patients in both groups was 100% with a mean follow-up of 25.3 months. The statistically significant difference in progression-free survival (PFS) between these two groups was not found.ConclusionsACT seems to be adequate treatment for patients with high-risk of relapse, as well as AS for those with low-risk of relapse. Despite its excellent prognosis, optimal management of CSI testicular seminoma remains controversial, with variations in expert opinion and international guidelines.

Update in germ cell tumours.

The purpose of this study is to update the reader on advances in postpubertal male germ cell tumours (GCTs) over the last 18 months. Single nucleotide polymorphisms, including in four sex-determination genes, have been identified as additional genetic susceptibility loci to testicular GCT development. New insights into cisplatin resistance implicate the PDGFR-PIK3CA-AKT and RAS pathways. Circulating tumour cells and circulating microRNAs are potential new biomarkers. In clinical stage I (CS-I) GCT, two large studies have confirmed the excellent outcomes achieved with surveillance, which is now the management option of choice for CS I-A nonseminoma and all CS-I seminomas; CS I-B nonseminoma remains controversial. First-line trials of dose-dense multidrug regimens reported promising results but have not yet supplanted BEPx4. Survivorship issues, including secondary malignancies from chemotherapy, remain important in this disease and are a continuing focus of ongoing research. Important research questions remain across all aspects of GCT. The next decade is likely to produce many new and exciting discoveries that will benefit GCT patients.

Three-dimensional computerized quantification for lung invasive adenocarcinoma with different histopathological subtypes in clinical stage I

Objective To study three-dimensional computerized quantification for clinical stageⅠ lung invasive adenocarcinoma with different histopathological subtypes. Methods Pathological and HRCT data of 273 patients within clinical stage Ⅰ lung invasive adenocarcinoma underwent surgery from January 2005 to December 2012 were retrospectively collected. The proportion of ground glass opacity component and solid component in tumor were calculated by three-dimensional computerized quantification. All specimens were classified into 3 grades (grade 1 as the lepidic pattern of invasive adenocarcinoma, grade 2 acinar or papillary patterns, grade 3 micropapillary or solid patterns). The proportion of different components among different histopathological grades was evaluated by Kruskal-Wallis test. The correlation between components in tumor and histopathologic subtypes grade were evaluated by Spearman correlation. Results In 273 patients, 49(17.9%) were assessed as grade 1, 208(76.2%) grade 2, and 16(5.9%) grade 3. The proportion of ground glass opacity component and solid component in grade 1, grade 2, and grade 3 were 18.40% (10.00% –33.45%), 6.55% (2.00% –18.00%), 1.70% (0.20% –3.85%) and 29.80% (11.75% – 47.35%), 66.60% (35.40% –83.85%), 88.50% (75.28% –93.60%), respectively. Significant differences among different histopathological grades were observed(χ2=37.74,47.73,P<0.01). The proportion of ground glass opacity component was negative correlation with histopathologic grade (r=-0.37, P<0.01), while the proportion of solid component was positive correlation with histopathologic grade(r=0.42,P<0.01). Conclusion Three-dimensional computerized quantification for lung invasive adenocarcinoma may predict histopathological grade. Key words: Lung neoplasms; Adenocarcinoma; Tomography, X-ray computed; Pathology

P1-31-6 - Synchronous Multiple Neoplasms Consist of Myelodysplastic Syndrome and Colon Cancer

Background: In the last decade, as for the colon cancer, chemotherapies strategy progressed. We nominate result for not only it but also the enlightenment activity of the early diagnosis. It is not unusual for even our dairy practice (hematology fields) to meet with colon cancer.Methods: We investigated myelodyspastic syndrome case who experienced colon cancer. Bone marrow puncture performed and diagnosed by bone marrow picture, cytogenetic study and flow cytometry. The diagnosis of colon cancer performed previous hospital. The patient did not receive adjubant chemotherapy. The definition of multiple neoplasms followed Warren & Gates theory. And as for the definition of synchronous type, a diagnosis interval is less than 6 months, metachronous type interval is more than 6 months.Result: The case is 64-year-old male who was diagnosed and received operation of resection for colon cancer at 2012. Tumor lesion was Sigmoid colon, type I. Pathological findings were papillotubullar adenocarcinoma, clinical stageI, abusolute curable resection, and he did not receive adjubant chemotherapy. During observation period, hematological examination revealed moderate leukocytosis, severe anemia and marked thrombocytopenia. He was preferred to our department and performed bone marrow puncture and biopsy, so we diagnosed myelodysplastic syndrome (Refractory Anemia) in 2012, so this case was synchronous multiple neoplasms, interval is 2 month. He received transfusion 2 times per month as outer-patients.Conclusion: Multiple neoplasms is influenced by each prognosis. This case mostly influenced by myelodysplastic syndrome and up to December 2013, he needed blood transfusion but spends his life ordinary.

Patterns of relapse in patients with clinical stage I testicular cancer managed with active surveillance.

To evaluate the performance of active surveillance as a management strategy in broad populations and to inform the development of surveillance schedules by individual patient data regarding timing and type of relapse. Retrospective study including data from 2,483 clinical stage I (CSI) patients, 1,139 CSI nonseminoma and 1,344 CSI seminoma managed with active surveillance, with the majority treated between 1998 and 2010. Clinical outcomes including relapse and death, time distribution, extent of relapse and method of relapse detection observed on active surveillance were recorded. Relapse occurred in 221 (19%) CSI-nonseminoma and 173 (13%) CSI-seminoma patients. Median time to relapse was 4 months (range, 2-61 months), 8 months (range, 2-77 months) and 14 months (range, 2-84 months) for lymphovascular invasion-positive CSI nonseminoma, lymphovascular invasion-negative CSI nonseminoma and CSI seminoma. Most relapses were observed within the first 2 years/3 years after orchiectomy for CSI nonseminoma (90%)/CSI seminoma (92%). Relapses were detected by computed tomography scan/tumor-markers in 87%/3% of seminoma recurrences, in 48%/38% of lymphovascular invasion-negative and 41%/61% of lymphovascular invasion-positive patients, respectively. 90% of CSI-nonseminoma and 99% of CSI-seminoma relapses exhibited International Germ Cell Collaborative Group good-risk features. Three patients with CSI nonseminoma died of disease (0.3%). One patient with CSI seminoma and two patients with CSI nonseminoma died because of treatment-related events. Overall, advanced disease was seen in both early- and late-relapse patients. All late recurrences were cured with standard therapy. Five-year disease-specific survival was 99.7% (95% CI, 99.24% to 99.93%). Active surveillance for CSI testis cancer leads to excellent outcomes. The vast majority of relapses occur within 2 years of orchiectomy for CSI nonseminoma and within 3 years for CSI seminoma. Late and advanced stage relapse are rarely seen. These data may inform further refinement of rationally designed surveillance schedules.

Characterization of relapse in patients with clinical stage I (CSI) nonseminoma (NS-TC) managed with active surveillance (AS): A large multicenter study.

4503 Background: Large single institution trials have demonstrated that AS for patients with CSI NS-TC is safe and effective. Information on timing and extent of relapse following AS has the potential to guide intensity and duration of imaging on AS. Methods: Retrospective clinical data on CSI patients were obtained from existing large databases, including institutions/regions which have a standardized policy of centralized management of testicular cancer including AS for patients with CSI NS-TC. In all, 1,034 patients with CSI NS-TC managed with AS were reviewed of whom 886 had no lymphovascular invasion (LVI-), 220 had lymphovascular invasion (LVI+) and 28 had unknown lymphovascular status (LVI unknown). Results: A total of 221 relapses occurred with 150/886 (17%) of LVI– pts , 60/120 (50%) LVI+ pts and 11/28 (39%) of LVI unknown pts (Table). Median follow-up was 63 months (1-163 months). At last follow up 1,013/1,034 (98%) were alive without disease, 16/1,034 (1.5%) were dead of other causes and 7/1,035 (0.05%) were alive with disease or dead of disease. Relapse was identified by marker elevation and/or abdominal imaging in almost all patients. Few patients relapsed with IGCCCC intermediate (18/221, 8%) or poor risk disease (3/221, 1.4%). Conclusions: AS for CSI NS-TC is safe and effective, using a policy of centralized management with loco-regional delivery of care. Our multinational outcomes compare well to single institutional reports. Relapse other than with IGCCC good risk disease was uncommon and death from disease was rare. Compared to patients with LVI-, relapses in LVI + CSI patients occur earlier and few relapses are detected past the first year of follow-up. This data may help in the design of follow up schedules tailored towards the relapse risk in CSI NS-TC AS. [Table: see text]

One course of adjuvant BEP in clinical stage I, nonseminoma: Mature and expanded results from the SWENOTECA group.

4553 Background: The SWENOTECA group has since 1998 offered patients with clinical stage I (CSI) nonseminoma (NSGCT) treatment based on a risk-adapted approach. Patients with lymphovascular invasion (VASC+) were recommended one course of adjuvant chemotherapy (ACT) with bleomycin, etoposide and cisplatin (BEP). Patients without lymphovascular invasion (VASC-) had the choice between one course of adjuvant BEP or active surveillance. Methods: From 1998-2010, 491 patients with CSI NSGCT received one course of adjuvant BEP. Following histopathological evaluation 247 patients were classified as VASC+, 239 as VASC- and five patients had uncertain VASC status. All patients were included into a prospective, community-based, multicenter SWENOTECA management program. Initial results from patients treated during 1998-2005 have earlier been reported. We now report the mature data, expanded with patients treated during 2005-2010. Results: The median follow-up was 8.0 years. Eleven relapses were observed. After one course of adjuvant BEP 2.3% of patients relapsed. In regard to VASC status 3.4% of VASC+ and 1.3% of VASC- patients relapsed. The latest relapse was detected 3.3 years after ACT. Ten patients have died, only one due to testicular cancer. The 5 and 10-year overall survival rates were 98.9% and 96.8%, respectively. The 5 and 10-year disease-specific survival rates were 100% and 99.6% respectively. Conclusions: One course of adjuvant BEP reduces the risk of relapse in CSI NSGCT with over 90%. These mature results confirm our earlier results on one course of adjuvant BEP. There is no evidence of late relapses, or chemotherapy-resistance in relapses following ACT. To detect relapses, a follow-up of five years is sufficient.

During twenty years of Cisplatin-based therapy the face of nonseminomatous testicular germ cell tumors is still changing: an evaluation of presentation, management, predictive factors and survival

To assess the changing presentation and treatment of nonseminomatous testicular germ cell tumors (NSGCT) and to investigate predictive factors for the status of metastasis at diagnosis and on relapse and death. Retrospective record review of 147 patients that underwent inguinal orchiectomy from 1987-2007. Follow-up data was available for 102 patients (median follow-up: 80 months (0-243); 96 patients alive). Mean patients age increased (p = 0.015) and more patients were diagnosed in clinical stage I (CSI) (p = 0.040). The fraction of yolk sac (YS) elements inclined (p = 0.030) and pT2 tumors increased (p < 0.001). Retroperitoneal lymph node dissection (RPLND) declined whereas more patients were treated with chemotherapy (p < 0.001; p = 0.004). There was an increase in relapse free (RFS) and cancer specific survival (CSS) due to an improvement in patients with disseminated disease (p = 0.014; p < 0.001). The presence of YS and teratoma elements showed a reduction in the odds ratio (OR) for metastasis at diagnosis (p = 0.002, OR: 0.262; p = 0.009, OR: 0.428) whereas higher pT-stage was associated to their presence (p = 0.039). Patients with disseminated disease (CS > I) showed a declined CSS compared to CSI patients (p = 0.055). The presence of YS elements was associated to an improved RFS (p = 0.038). In our single institution study the face of NSGCT markedly changed over 20 years even after the introduction of Cisplatin-based chemotherapy. These changes were accompanied by an improvement in RFS and CSS. When dealing with NSGCT patients such observations now and in the future should be taken into account.

Decision making in clinical stage I (CSI) testicular cancer (TC).

e15034 Background: Optimal management of CSI seminomatous (S) and nonseminomatous (NS) TC is an open question. Quality of life and patient preferences are the principal end-points for the best treatment choice. Multidisciplinary approach is required for CSI TC patients to allow an individualized treatment with a patient-centered approach and an active participation in decisions. The “shared decision making” (SDM) is the prevailing approach because patients together with clinicians arrive at a mutually agreed-on choice. We have a project concerning the involvement of patients with CSI TC in the SDM. Methods: We used some key points of SDM: define the problem; treatment options; discuss pros/cons; clarify patient preferences; clarify the patient’s understanding. Educational material are offered to patients. From 2005 to 2012, 32 patients with CSI TC were evaluated. For each patient some clinical and socio-demographic features, type of treatment chosen and some sequel related to treatment were analyzed. Results: Patients characteristics are reported in the table. 4 S patients chose surveillance, 10 chemotherapy and 6 radiotherapy. 2 NS patients chose surveillance, 9 chemotherapy. 4 relapsed: 1 S patient after 13 months from chemotherapy and 1 during the surveillance after 24 months. 2 NS patients relapsed after 12 and 18 months both during the surveillance. All relapsed patients received chemotherapy. Metabolic alterations were analyzed. 1 S patient treated with chemotherapy had a cardiovascular accident. Conclusions: We observed an high gap between surveillance and the active treatments: there is no best choice for every one so we should improve decision-making process and decision aids into the management of CSI patients with TC. [Table: see text]

Experience of the treatment for clinical Stage-I seminoma over a period of 10 years

Patients with clinical stage I seminoma accounts for 70%-80% of patients with this disease. This study was to analyze the relationship between different therapeutic methods and the prognosis of this disease. The data of all patients with clinical Stage I seminoma treated by multi-disciplinary approach from 1999 to 2008 in Sun Yat-sen University Cancer Center were analyzed. The patients were divided into 3 groups based on the treatment they received after orchiectomy: 30 patients treated with chemotherapy, 8 with radiotherapy, and 20 under surveillance. The prognosis of different treatment groups was evaluated. Among the 58 patients with stage I seminoma, 57 were followed up successfully. The median follow-up time was 50 months (range, 8-115 months). No relapse or metastasis was seen in the chemotherapy group. One patient relapsed in the radiotherapy group. Four patients had metastasis of retroperitoneal lymph node in the surveillance group. The disease-free survival was higher in the chemotherapy group than that in the surveillance group (P=0.005). There was no significant difference in the relapse-free survival between the surveillance group and the radiotherapy group (P=0.364). Chemotherapy is a safe and effective treatment for patients with Stage-1 seminoma after radical orchidectomy.

Clinical stage I seminoma: the case for surveillance

We believe that active surveillance is the optimal choice for compliant men who are able to handle the mental burden of not receiving adjuvant treatment. This takes into consideration the fact that a small number of men with clinical stage I (CSI) seminoma on surveillance will recur but are salvageable with equivalent outcome compared to those having adjuvant treatment which exposes eight in ten men to unnecessary short- and long-term risks with still the possibility of recurrence requiring salvation. This review will focus on CSI seminoma and the controversies surrounding its treatment and based upon current available evidence will outline the case for surveillance.

Risk factor analysis of mediastinal lymph node metastasis in non-small cell lung cancer patients and the strategy of mediastinoscopy prior to surgery

To discuss the strategy of mediastinoscopy for the evaluation of mediastinal lymph node status (metastasis or not) of non-small cell lung cancer (NSCLC) prior to surgery. From October 2000 to June 2007, 152 consecutive NSCLC cases pathologically proven and clinically staged I-III were enrolled in the study. Of the 152 cases, there were 118 males and 34 females. Age ranged 24-79 years old and the median age was 58. All cases underwent CT and mediastinoscopy for the evaluation of mediastinal lymph node status prior to surgery. Compared with the results of final pathology, the positive rate of mediastinoscopy and the prevalence of mediastinal lymph node metastasis were calculated in the NSCLC patients with negative mediastinal or hilar lymph nodes on CT scan (the shortest axis of mediastinal or hilar lymph nodes <1 cm). Clinical characteristics used as predictive factor including sex, age, cancer location, type of pathology, T status, cancer type (central or peripheral), size of mediastinal lymph nodes (the shortest axis <1 cm or >1 cm) on CT scan and serum CEA level were analyzed by univariate and multivariate analysis with Binary logistic regression model to identify risk factors of mediastinal metastasis. The positive rate of mediastinoscopy was 11.6% (8/69) and the prevalence of mediastinal metastasis was 20.1% (14/69) in NSCLC with negative mediastinal or hilar lymph nodes on CT scan respectively. In clinical stage I (cT1-2N0M0) NSCLC the positive rate of mediastinoscopy was 11.3% (7/62), N2 accounting for 6.5% (4/62) and N3 4.8% (3/62), respectively; and the prevalence of mediastinal lymph node metastasis was 19.4% (12/62), N2 ccounting for 14.6% (9/62) and N3 4.8% (3/62), respectively. In the whole group both univariate and multivariate analysis showed that adenocarcinoma or mediastinal lymph nodes > or =1 cm in the shortest axis on CT scan was an independent risk factor to predict mediastinal lymph node metastasis. In NSCLC with negative mediastinal or hilar lymph nodes on CT scan both univariate and multivariate analysis showed that adenocarcinoma was a predictor of mediastinal lymph node metastasis. Conclusion We recommend the policy of routine mediastinoscopy in NSCLC prior to surgery if the mediastinal staging was only based on CT scan. Mediastinal lymph nodes > or =1 cm in the shortest axis on CT scan mandates preoperative mediastinoscopy. Adenocarcinoma also indicates mandatory mediastinoscopy even with negative mediastinal or hilar lymph nodes on CT scan.

Open versus laparoscopic retroperitoneal lymph node dissection (RPLND) in clinical stage I nonseminomatous germ-cell tumors (NSGCTs): Two contemporary series from a single institution

5084 Background: Primary RPLND is our choice for clinical stage I (CSI) NSGCTs. Open RPLND (O-RPLND) has been our standard policy since 1985, while laparoscopic RPLND (L-RPLND) has been introduced since the late-1990s. Methods: Between June 2003-March 2008, 150 consecutive CSI NSGCT patients (pts) have been submitted to O-RPLND (n = 91) or L-RPLND (n = 59). Pts with high risk disease (vascular invasion/embryonal carcinoma &gt; 90% in the primary tumor) were more frequently offered O-RPLND, while pts with low risk disease (none of the 2 above) were usually considered for L-RPLND. We reviewed our data focusing on: complications, operating time (OT), hospital stay (HS), number of removed nodes, occurrence of nodal metastases as well as of metastasis during follow-up and global need of chemotherapy (CT). Results: O-RPLND (91). 59/91 (64.8%) were high-risk patients. Median OT was 140 min (IQR 110–150). Five (5.5%) complications occurred: 4 lymphorrea and 1 hemorrhage. Median HS was 6 days (IQR 5–7). Nodal metastases were found in 24 (26.4%) pts. Median number of removed nodes was 20 (IQR 14–25). L-RPLND (59). 54/59 (91.2%) were low-risk patients. Median OT was 210 min (IQR 180–240). Ten (16.9%) complications occurred: 5 required conversions to open procedure due to intraoperative bleeding (4) or technical impossibility to conclude the procedure (1). Median HS was 4 days (IQR 4–5). Nodal metastases were found in 5 (8.5%) pts: 2 of them received immediate adjuvant CT. Median number of removed nodes was 14 (IQR 11–20). OT and HS were significantly better in O-RPLND and L-RPLND series, respectively (p.0001 at Mann Whitney test). After a median follow-up of 15.1 months (1–52), distant metastases were observed in 10 (0.7%) pts: 7/91 (7.7%) following O-RPLND and 1/59 (1.7%) following L-RPLND. CT was administered to 7 (7.7%) pts following O-RPLND and to 3 (5.1%) pts following L-RPLND. Conclusions: In this large case-series, no excess of recurrences but a higher rate of complications were recorded in L-RPLND pts. O-RPLND had a significant better OT while HS was shorter in L-RPLND series. Both procedures are still being applied: pts are currently offered one of the 2 modalities after counseling. No significant financial relationships to disclose.