Non-seminoma Patients Research Articles

Can serum tumor marker densities according to tumor volume and testicle size be used to predict progression in patients with testicular cancer?

The objective of this study is to determine the role of tumor marker density (TMD) values such as alpha-fetoprotein tumor volume ratio (ATVR), beta-human chorionic gonadotropin tumor volume ratio (βTVR), alpha-fetoprotein testicle size ratio (ATSR), beta-human chorionic gonadotropin testicle size ratio (βTSR), lactate dehydrogenase tumor volume ratio (LTVR), and lactate dehydrogenase testicle size ratio (LTSR) in the determination of progression-free survival (PFS) in patients with testicular cancer. A retrospective study was conducted of 95 patients followed-up in our clinic with a diagnosis of testicular cancer between January 2015 and August 2022. Patients were grouped according to clinical stage, as either early stage (n = 50) or advanced stage (n = 45). Clinical and pathological data and TMD values for all patients were recorded. The median age of patients was 35 years (21-63 years). All TMDs except LTVR in advanced stage patients were found to be significantly higher than those of early stage patients (p < 0.05). Median ATVR (2.58 vs. 0.0), ATSR (0.63 vs. 0.03), βTVR (0.9 vs. 0.009), and βTSR (0.18 vs. 0.007) of the nonseminoma patients were found to be significantly higher than those of the seminoma patients, respectively (p < 0.001). Progression-free survival (months) was decreased in seminoma patients with high values of βTVR (11.3 ± 1.9 vs. 35.2 ± 0.7), βTSR (16.2 ± 3.4 vs. 35.2 ± 0.75), LTVR (17.7 ± 3.4 vs. 35.2 ± 0.7), and LTSR (21.5 ± 3.13 vs. 35.09 ± 0.8) (p < 0.001). Decreased PFS (months) was associated with higher values of ATVR (5.37 ± 0.7 vs. 35.05 ± 0.93), βTVR (7.4 ± 1.5 vs. 34.6 ± 1.3), ATSR (5.37 ± 0.75 vs. 35.05 ± 0.9), βTSR (7 ± 1.5 vs. 34.6 ± 1.3), and LTSR (7.9 ± 1.2 vs. 34.3 ± 1.5) in nonseminoma patients (p < 0.001). Based on multivariate analysis, βTVR-LTVR and ATVR-ATSR were determined to be independent risk factors for reduced PFS in seminoma and nonseminoma patients, respectively (p < 0.05). The results of this study suggest that the calculation of TMDs could be a promising and simple method for prediction of PFS among testicular cancer patients.

MiR-371a-3p Predicting Viable Tumor in Patients Undergoing Retroperitoneal Lymph Node Dissection for Metastatic Testicular Cancer: The SWENOTECA-MIR Study.

The SWENOTECA-MIR prospective multicenter study aims to assess the clinical value of miR-371a-3p as a novel marker in metastatic germ cell tumor patients undergoing retroperitoneal lymph node dissection (RPLND), to predict the presence of viable residual tumor. A total of 114 patients (86 nonseminomas, 28 seminomas) who underwent surgery for presumed metastatic disease pre chemotherapy (primary RPLND) and post chemotherapy RPLND were included. The expression of miR-371a-3p was evaluated using reverse transcription-digital droplet polymerase chain reaction before and after RPLND. Pre- and postoperative miR-371a-3p levels were statistically compared, and optimism-corrected performance calculations compared with conventional serum tumor markers. Associations were evaluated by logistic regression. Patients who underwent primary RPLND were categorized into seminoma and nonseminoma groups. Among the seminoma patients (n = 24) undergoing primary RPLND, all had normal conventional markers. Six patients received adjuvant treatment before surgery. miR-371a-3p exhibited a sensitivity of 74%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 21% for viable tumor. The levels of miR-371a-3p significantly decreased after surgery. In the nonseminoma group (n = 18) treated with primary RPLND, 22% had elevated conventional markers and 3 had received prior adjuvant treatment. miR-371a-3p showed a sensitivity of 34%, specificity of 88%, positive predictive value of 67%, and negative predictive value of 62% for the primary nonseminoma patients. No association was observed between stage or prior adjuvant treatment and the outcome of the miR test. In the postchemotherapy group (n = 72), the miR-371a-3p sensitivity was 9%, reducing to 0 when excluding patients with seminoma (n = 4). Teratomas and benign histology were essentially negative. Our study highlights miR-371a-3p as a fairly sensitive and highly specific marker for prechemotherapy seminomas, outperforming conventional markers. However, in prechemotherapy nonseminomas as well as in postchemotherapy patients, we observed low sensitivity and no significant differences in miR-371a-3p levels before and after surgery, suggesting limited utility for miR-371a-3p in this context.

Complex treatment of residual metastatic germ cell cancer: A single center experience

BackgroundTesticular cancer is the most common solid malignancy among men aged 15–35. Radical orchiectomy and platinum-based chemotherapy (BEP) are curative in the majority of patients, including advanced, metastatic cases. According to current urooncology guidelines all non-seminoma patients harbouring post-chemotherapy residual masses of ≥ 1 cm should undergo salvage retroperitoneal lymph node dissection (RPLND). However, only 10% of residual tumors contain viable disease. ObjectiveTo assess patient outcomes and complications considering different treatment regimens and clinical characteristics. Materials and methodsIn a retrospective cross-sectional study patients (n=127) who underwent postchemotherapy RPLND between 2007 and 2023 at our referral center were evaluated. The patients received systemic treatment at various oncology centers. The number of BEP cycles received were occasionally different from standard. Only patients with normal postchemotherapy serum tumor markers and primary testicular or extragonadal germ cell neoplasms were included. Treatment groups were established according to the number of BEP cycles received, and the extent of RPLND (bilateral or modified template). Treatment outcomes and complications were assessed. ResultsStandard 3–4 courses of BEP were received by 100 (78,7%) patients, while 11 (8,7%) patients underwent less, and 16 (12,6%) more courses than standard. On histopathologic evaluation viable germ cell tumor, teratoma, and necrosis/fibrosis was present in 26 (20,5%), 67 (52,7%) and 34 (26,8%) of specimen, respectively. In the 5–6 BEP series subgroup high rate of viable disease (37,5%) was found and significantly more nephrectomies were performed, than other chemotherapy subgroups. Extratesticular GCT, viable disease in residual mass or progression after RPLND indicated lower survival. Mild (Clavien-Dindo I-II) or no postoperative complications were reported in 93,7% of cases. ConclusionsThe study suggests no significant benefit from exceeding 3–4 courses of BEP. Timely salvage RPLND should be performed in high volume centers for optimal treatment outcomes with acceptable complication rates. Adherence to the Heidenreich criteria is advisable where practical.

Survival differences in non-seminoma testis cancer patients according to race/ethnicity

BackgroundHistoric evidence suggests that non-Caucasian race/ethnicity predisposes to higher testis cancer-specific mortality (CSM) in non-seminoma. However, it is unknown, whether higher CSM in non-Caucasians applies to Hispanics or Asians or African-Americans, or all of the above groups. In contemporary patients, we tested whether CSM is higher in these select non-Caucasian groups than in Caucasians, in overall and in stage-specific comparisons: stage I vs. stage II vs. stage III. MethodsThe Surveillance, Epidemiology, and End Results (SEER) database (2004 −2019) was used. Kaplan-Meier plots and multivariable Cox regression models tested the effect of race/ethnicity on CSM after stratification for stage (I vs. II vs. III) and adjustment for prognosis groups in stage III. ResultsIn all 13,515 non-seminoma patients, CSM in non-Caucasians was invariably higher than in Caucasians. In stage-specific analyses, race/ethnicity represented an independent predictor of CSM in Hispanics in stage I (HR 1.8, p = 0.004), stage II (HR 2.2, p = 0.007) and stage III (HR 1.4, p < 0.001); in African-Americans in stage I (HR 3.2; p = 0.007) and stage III (HR 1.5; p = 0.042); and in Asians in only stage III (HR 1.6, p = 0.01). ConclusionsIn general, CSM is higher in non-Caucasian non-seminoma patients. However, the CSM increase differs according to non-Caucasian race/ethnicity groups. Specifically, higher CSM applies to all stages of non-seminoma in Hispanics, to stages I and III in African-Americans and only to stage III in Asians. These differences are important for individual patient management, as well as for design of prospective trials.

A population-based validation of the IGCCCG Update Consortium for survival in metastatic non-seminoma testis cancer.

In 2021, the International Germ Cell Cancer Collaborative Group (IGCCCG) Update Consortium reported improved overall survival (OS) rates in a modern cohort of metastatic non-seminoma testis cancer patients within each of the IGCCCG prognosis groups (96% in good vs. 89% in intermediate vs. 67% in poor), compared to the previous IGCCCG publication (92% in good vs. 80% in intermediate vs. 48% in poor). We hypothesized that a similar survival improvement may apply to a contemporary North-American population-based cohort of non-seminoma testis cancer patients. The Surveillance, Epidemiology, and End Results (SEER) database (2010-2018) was used. Kaplan-Meier plots and multivariable Cox regression models tested the effect of IGCCCG prognosis groups on overall mortality (OM). Of 1672 surgically treated metastatic non-seminoma patients, 778 (47%) exhibited good vs. 251 (15%) intermediate vs. 643 (38%) poor prognosis. In the overall cohort, five-year OS rate was 94% for good prognosis vs. 87% for intermediate prognosis vs. 65% for poor prognosis. In multivariable Cox regression models predicting OM, intermediate (Hazard ratio [HR] 2.4, 95% confidence interval [CI] 1.4-3.9, P<0.001) and poor prognosis group (HR 6.6, 95% CI 1.0-1.0, P<0.001) were independent predictors of higher OM, relative to good prognosis group. The survival improvement reported by the IGCCCG Update Consortium is also operational in non-seminoma testis cancer patients within the most contemporary SEER database. This observation indicates that the survival improvement is not only applicable to centres of excellence, but also applies to other institutions at large.

Clinico-epidemiological Profile and Outcome of Testicular Germ Cell Tumors: A Retrospective Study from a Tertiary Cancer Centre of North-East India

Introduction: Testicular Germ Cell Tumor (GCT) is a disease of young adults and is also highly curable. But in India, most of the patients present in an advanced stage and succumb to the disease as compared to the Western nations where patients present at an earlier stage and are mostly cured. Also, there is a scarcity of literature on testicular GCT from the Indian subcontinent. We present our experience from the Tata Memorial Centre of North-east India. Methods: This retrospective study was conducted at Tata Memorial Centre - BBCI, Guwahati for the period of 5 years from January 2018 to December 2022. The study focused on epidemiology, clinical presentation, and treatment outcomes. Results: Seventy-two cases of testicular GCTs were studied (28 cases were seminoma, and 44 were non-seminoma). Most common presenting stage was stage I in seminoma (53.6%), and stage III (77.2%) in non-seminoma. As per the International Germ Cell Cancer Collaborative Group (IGCCCG) classification, 25%, 35%, and 40% of patients were good-risk, intermediate-risk, and poor-risk in non-seminoma. In patients with seminoma, 54% and 46% were in good and intermediate-risk, respectively. Seventy-two percent and 21% had achieved a radiologic complete response (CR) and partial response (PR) with conventional chemotherapy in patients with seminoma. Radiologic CR and PR rates were 20% and 61% among non-seminoma patients. The median recurrence-free survival (RFS) was 43 months. RFS was better in seminoma versus non-seminoma, stage I versus stage III, and good-risk versus high-risk group. Conclusion: Most of our patients presented with an advanced stage of the disease and a high nodal burden. In patients with non-seminoma GCT, the best response to conventional chemotherapy was a partial response. The use of an alternative chemotherapy regimen to improve outcomes for such patients can be further explored.

Excellent survival in relapsed stage I testicular cancer

BackgroundTwo thirds of patients with germ-cell cancer (GCC) present as clinical stage I (CSI). Following orchiectomy, active surveillance (AS) has become their standard management. However, 15–50% of patients eventually relapse with metastatic disease after AS. Relapses need to be detected early in order to achieve cure and avoid overtreatment.MethodsWe retrospectively analyzed consecutive GCC patients treated at two Swiss academic centers between 2010 and 2020. Patients with stage IS and extragonadal primaries were excluded. We compared disease characteristics and survival outcomes of patients relapsed from initial CSI to patients with de novo metastatic disease. Primary endpoint was the IGCCCG category at the time of relapse. Main secondary endpoints were progression-free survival (PFS) and overall survival (OS).ResultsWe identified 360 GCC patients with initial CSI and 245 de novo metastatic patients. After a median follow-up of 47 months, 81 of 360 (22.5%) CSI patients relapsed: 41 seminoma (Sem) and 40 non-seminoma (NSem) patients. All Sems relapsed in the IGCCCG good prognosis group. NSem relapsed with good 29/40 (72.5%) and intermediate 11/40 (27.5%) prognostic features; 95.1% of relapses occurred within five years post-orchiectomy. Only 3 relapsed NSem patients died from metastatic disease. Five-year OS for relapsed CSI patients was 100% for Sem and 87% (95% CI: 61–96%) for NSem patients; five-year PFS was 92% (95% CI: 77–97) and 78% (95% CI: 56–90) for Sem and NSem, respectively. When stratified by IGCCCG prognostic groups, good risk relapsed patients had a trend towards better OS and PFS as compared to de novo metastatic patients.ConclusionsGCC patients who relapse after initial CSI can be detected early by active surveillance and have an excellent survival.

Conditional survival of stage III non-seminoma testis cancer patients

PurposeIn many primaries other than non-seminoma testis cancer, the risk of death due to cancer decreases with increasing disease-free interval duration after initial diagnosis and treatment. This effect is known as conditional survival and is relatively unexplored in stage III non-seminoma patients, where it may matter most in clinical decision-making. We examined the effect of disease-free interval duration on overall survival in stage III non-seminoma patients. Materials and MethodsWithin the Surveillance, Epidemiology, and End Results Database (2004–2018), stage III non-seminoma patients were identified. Multivariable Cox regression analyses and conditional survival models were applied. ResultsOf 2,092 surgically treated stage III non-seminoma patients, 385 (18%) exhibited good vs. 558 (27%) intermediate vs. 1,149 (55%) poor prognosis. In multivariable Cox regression models, poor prognosis group independently predicted overall mortality (HR 3.3, P < 0.001). In conditional survival analyses based on 36 months’ disease-free interval duration, 5-year overall survival estimates were as follows: good prognosis patients 96 vs. 89% at initial diagnosis without accounting for disease-free interval duration (Δ=+7); intermediate prognosis patients 94 vs. 85% at initial diagnosis without accounting for disease-free interval duration (Δ=+9); poor prognosis patients 94 vs. 65% at initial diagnosis without accounting for disease-free interval duration (Δ=+29). ConclusionsConditional survival estimates based on 36 months’ disease-free interval duration provide a more accurate and more optimistic outlook for stage III non-seminoma patients than predictions defined at initial diagnosis, without accounting for disease-free interval duration.

Testicular GERM cell tumors treatment outcome in a national cancer institution in Peru.

e17031 Background: Testicular germ cell tumor (TGCT) is the most common neoplasm in young men and the incidence has been increasing over the last few decades, especially among Hispanic men. Multidisciplinary management is associated with excellent oncological outcomes. Here, we describe the treatment outcome of TGCT patients treated in single institution in Peru. Methods: We conducted a retrospective study of TGCT treated at Instituto Nacional de Enfermedades Neoplasicas from 2016 to 2019. Clinical and pathological data were collected from medical records. Progression-free survival (PFS) and overall survival (OS) were analyzed by the Kaplan-Meier method and compared with long-rank test. A level of p &lt; 0.05 was considered significant. The statistical package SPSS v19 was used for the data analysis. Results: 221 patients were identified, 56% were non-seminomatous (NS) and 44% were seminomatous (S). Orchiectomy was performed in 94% of patients, only 6% underwent orchiectomy after chemotherapy. In both groups, the treatment regimens were: BEP (Bleomycin/Etoposide/cisplatin) 90%, Carboplatin 8.1% and EP (Etoposide/Cisplatin) 1.8%. 42 (21%) of patients receive rescue therapy, being the most frequent TIP (paclitaxel/ifosfamide/cisplatin). In NS patients, 5-year PFS was superior in good risk compared with poor risk (100% vs. 86%, p = 0.028) and for tumor markers level, S0 was superior to S3 (100% vs. 82%, p = 0.008). In S, 5-year PFS was no significant in any of groups of analysis. With a median follow-up of 57 months, OS in NS was 91%, 83% and 81% in 12, 36 and 60 months, respectively and OS in S was 96%, 87% and 87% in 12, 36 and 60 months, respectively. The analysis of 5-year OS according to clinical stage and risk stratification are shown in the Table 1. Only 2 patients received high-dose chemotherapy and still in complete response. Conclusions: Despite the high incidence of advanced TGCT, our patients had excellent survival results; being lower in those with CS III (both NS and S groups), poor risk and S3 for NS, and intermediate risk for S. Multidisciplinary management in a high volume institution is important for better outcomes in our patients. [Table: see text]

Validation of a Prediction Model for Post-chemotherapy Fibrosis in Nonseminoma Patients.

Our purpose was to validate Vergouwe´s prediction model using the Swedish and Norwegian Testicular Cancer Group (SWENOTECA) RETROP database and define its clinical utility. The Vergouwe´s prediction model for benign histopathology in post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) uses the following variables: Presence of teratoma in orchiectomy specimen, pre-chemotherapy level of Alpha fetoprotein, ß-Human chorionic gonadotropin and Lactate dehydrogenase, and lymph node size pre- and post-chemotherapy. The validation cohort consisted of patients included in RETROP, a prospective population-based database of patients in Sweden and Norway with metastatic nonseminoma that underwent PC-RPLND 2007-2014. Discrimination and calibration analyses were used to validate Vergouwe´s prediction model results. Calibration plots were created and Hosmer-Lemeshow test was calculated. Clinical utility expressed as opt-out net benefit (NBoptout ) was analysed using decision curve analysis. Overall, 284 patients were included in the analysis, of whom 130 (46%) had benign histology after PC-RPLND. Discrimination analysis showed good reproducibility with AUC of 0.82 (95% CI 0.77-0.87) compared to Vergouwe´s prediction model (AUC between 0.77 and 0.84). Calibration was acceptable with no recalibration. Using a prediction threshold of 70% for benign histopathology, NBoptout was 0.098. Using the model and this threshold, 61 patients would have been spared surgery. However only 51 of 61 were correctly classified as benign. The model was externally validated with good reproducibility. In a clinical setting, the model may identify patients with a high chance of benign histopathology, thereby sparing patients of surgery. However, meticulous follow-up is required.

Testicular germ cell tumours’ clinical stage I: comparison of surveillance with adjuvant treatment strategies regarding recurrence rates and overall survival—a systematic review

PurposeTesticular germ cell tumours (GCTs) represent the most common malignancy in young adult males with two thirds of all cases presenting with clinical stage I (CSI). Active surveillance is the management modality mostly favoured by current guidelines. This systematic review assesses the treatment results in CSI patients concerning recurrence rate and overall survival in non-seminoma (NS) and pure seminoma (SE) resulting from surveillance in comparison to adjuvant strategies.Methods/systematic reviewWe performed a systematic literature review confining the search to most recent studies published 2010–2021 that reported direct comparisons of surveillance to adjuvant management. We searched Medline and the Cochrane Library with additional hand-searching of reference lists to identify relevant studies. Data extraction and quality assessment of included studies were performed with stratification for histology (NS vs. SE) and treatment modalities. The results were tabulated and evaluated with descriptive statistical methods.ResultsThirty-four studies met the inclusion criteria. In NS patients relapse rates were 12 to 37%, 0 to 10%, and 0 to 11.8% for surveillance, chemotherapy and for retroperitoneal lymph node dissection (RPLND) while overall survival rates were 90.7−100%, 91.7−100%, and 97−99.1%, respectively. In SE CSI, relapse rates were 0−22.3%, 0−5%, and 0−12.5% for surveillance, radiotherapy, chemotherapy, while overall survival rates were 84.1−98.7%, 83.5−100%, and 92.3−100%, respectively.ConclusionIn both histologic subgroups, active surveillance offers almost identical overall survival as adjuvant management strategies, however, at the expense of higher relapse rates. Each of the management strategies in CSI GCT patients have specific merits and shared-decision-making is advised to tailor treatment.

Prognostic factors in patients with clinical stage I nonseminoma—beyond lymphovascular invasion: a systematic review

ObjectiveTo systematically evaluate evidence on prognostic factors for tumor recurrence in clinical stage I nonseminoma patients other than lymphovascular invasion (LVI).MethodsWe performed a systematic literature search in the biomedical databases Medline (via Ovid) and Cochrane Central Register of Controlled Trials (search period January 2010 to February 2021) for full text publications in English and German language, reporting on retro- or prospectively assessed prognostic factors for tumor recurrence in patients with stage I nonseminomatous germ cell tumors.ResultsOur literature search yielded eleven studies reporting on 20 potential prognostic factors. Results are based on cohort studies of mostly moderate to low quality. Five out of eight studies found a significant association of embryonal carcinoma (EC) in the primary tumor with relapse. Among the different risk definitions of embryonal carcinoma (presence, predominance, pure), presence of EC alone seems to be sufficient for prognostification. Interesting results were found for rete testis invasion, predominant yolk sac tumor, T-stage and history of cryptorchidism, but the sparse data situation does not justify their clinical use.ConclusionsNo additional factors that meet the prognostic value of LVI, especially when determined by immunohistochemistry, could be identified through our systematic search. The presence of EC might serve as a second, subordinate prognostic factor for clinical use as the data situation is less abundant than the one of LVI. Further efforts are necessary to optimize the use of these two prognostic factors and to evaluate and validate further potential factors with promising preliminary data.

How to classify, diagnose, treat and follow-up extragonadal germ cell tumors? A systematic review of available evidence

PurposeTo present the current evidence and the development of studies in recent years on the management of extragonadal germ cell tumors (EGCT).MethodsA systematic literature search was conducted in Medline and the Cochrane Library. Studies within the search period (January 2010 to February 2021) that addressed the classification, diagnosis, prognosis, treatment, and follow-up of extragonadal tumors were included. Risk of bias was assessed and relevant data were extracted in evidence tables.ResultsThe systematic search identified nine studies. Germ cell tumors (GCT) arise predominantly from within the testis, but about 5% of the tumors are primarily located extragonadal. EGCT are localized primarily mediastinal or retroperitoneal in the midline of the body. EGCT patients are classified according to the IGCCCG classification. Consecutively, all mediastinal non-seminomatous EGCT patients belong to the “poor prognosis” group. In contrast mediastinal seminoma and both retroperitoneal seminoma and non-seminoma patients seem to have a similar prognosis as patients with gonadal GCTs and metastasis at theses respective sites. The standard chemotherapy regimen for patients with a EGCT consists of 3–4 cycles (good vs intermediate prognosis) of bleomycin, etoposid, cisplatin (BEP); however, due to their very poor prognosis patients with non-seminomatous mediastinal GCT should receive a dose-intensified or high-dose chemotherapy approach upfront on an individual basis and should thus be referred to expert centers Ifosfamide may be exchanged for bleomycin in cases of additional pulmonary metastasis due to subsequently planned resections. In general patients with non-seminomatous EGCT, residual tumor resection (RTR) should be performed after chemotherapy.ConclusionIn general, non-seminomatous EGCT have a poorer prognosis compared to testicular GCT, while seminomatous EGGCT seem to have a similar prognosis to patients with metastatic testicular seminoma. The current insights on EGCT are limited, since all data are mainly based on case series and studies with small patient numbers and non-comparative studies. In general, systemic treatment should be performed like in testicular metastatic GCTs but upfront dose intensification of chemotherapy should be considered for mediastinal non-seminoma patients. Thus, EGCT should be referred to interdisciplinary centers with utmost experience in the treatment of germ cell tumors.

Oncological outcomes of testicular cancer patients: 10 years of experiences resulting from a single university-based hospital

Abstract Purpose To explore clinical and pathological characteristics of testicular cancer and also identify factors associated with its oncological outcomes. Testicular cancer has a very good prognosis. Actually, we aim to report on 10 years of experience in the real-world practice of treating testicular cancer in a university-based hospital. Methods This is a retrospective cohort study of testicular cancer patients in Songklanagarind hospital; from January 2007 and December 2016, all eligible testicular cancer patients were included. Clinical characteristics (age, physical examination findings, tumour markers, histopathology, clinical stage, and initial treatment) and clinical outcomes were collected. These patients were divided into two groups: seminoma patients (seminomas) and non-seminoma patients (non-seminomas). Clinical characteristics and outcomes of treatment were analysed, and factors associated with oncological outcomes were identified. Results In 45 patients, median age 33 years, with diagnosis of testicular cancer, seminomas and non-seminomas were responsible for 23 (52.8%) and 22 (49%) of the cases, respectively. The median time of follow-up was 80.6 months (range: 1.8 to 120 months). The five-year OS was 94.7% and 57.1% in the seminoma and non-seminoma groups, respectively. For non-seminomas, five-year OS were 71.4%, 50%, and 42.9% in stage Ib–IIIa, IIIb, and IIIc, respectively, and for seminoma they were 92.3% and 100% in stage Ib–IIIa and IIIb, respectively. Multivariable analysis showed that non-seminoma, higher staging, and higher IGCCC risk were associated with poorer survival, significantly (p &lt; 0.05). Conclusions Seminoma has a good prognosis and survival at all stages, whereas, in the non-seminoma group, higher staging and IGCCC risk were independent factors associated with a poorer prognosis.

Low socioeconomic position is a risk factor for delay to treatment and mortality of testicular cancer patients in Hungary, a prospective study

BackgroundIn Hungary, the mortality rate for testicular germ cell cancer (TGCC) is 0,9/100000 which is significantly higher than the EU average. We prospectively evaluated the effect of socioeconomic position on patient delay and therapy outcomes.MethodsQuestionnaires on subjective social status (MacArthur Subjective Status Scale), objective socioeconomic position (wealth, education, and housing data), and on patient’s delay were completed by newly diagnosed TGCC patients.ResultsPatients belonged to a relatively high socioeconomic class, a university degree was double the Hungarian average, Cancer-specific mortality in the highest social quartile was 1.56% while in the lowest social quartile 13.09% (p = 0.02). In terms of patient delay, 57.2% of deceased patients waited more than a year before seeking help, while this number for the surviving patients was 8.0% (p = 0.0000). Longer patient delay was associated with a more advanced stage in non-seminoma but not in seminoma, the correlation coefficient for non-seminoma was 0.321 (p < 0.001). For patient delay, the most important variables were the mother’s and patient’s education levels (r = − 0.21, p = 0.0003, and r = − 0.20, p = 0.0005), respectively. Since the patient delay was correlated with the social quartile and resulted in a more advanced stage in non-seminoma, the lower social quartile resulted in higher mortality in non-seminoma patients (p = 0.005) but not in seminoma patients (p = 0.36) where the patient delay was not associated with a more advanced stage.ConclusionsBased on our result, we conclude that to improve survival, we should promote testicular cancer awareness, especially among the most deprived populations, and their health care providers.

The Association of Medicaid Insurance and Affordable Care Act Expansions with Survival among Patients with Testicular Cancer.

Following passage of the Affordable Care Act, Medicaid access was expanded in several states beginning in 2014. We sought to determine the oncologic implications by comparing outcomes between testicular germ cell tumor patients with Medicaid and those without insurance, and by assessing for changes in outcomes after 2014. A total of 18,506 men with seminomatous or nonseminomatous germ cell tumors were identified within the Surveillance, Epidemiology, and End Results database (2007-2016). Multivariable Cox proportional hazards, Fine and Gray competing-risks regression, propensity score matching, cumulative incidence plots and segmented Poisson regression models were used. Compared to no insurance, Medicaid insurance was not associated with differences in all-cause mortality or cancer-specific mortality among seminoma patients (all-cause mortality: HR=1.24, p=0.87; cancer-specific mortality: HR=0.92, p=0.75) or nonseminoma patients (all-cause mortality: HR=1.13, p=0.33; cancer-specific mortality: HR=1.10, p=0.51). Among matched Medicaid and uninsured patients, there was again no difference in cancer-specific mortality for those with seminoma (p=0.81) or nonseminoma (p=0.23). There was a 99% increase in Medicaid enrollment in expansion states in the post-Affordable Care Act era. There was no difference in post-expansion all-cause mortality between expansion states and nonexpansion states for men with seminoma (p=0.42) or nonseminoma (p=0.53). Medicaid enrollment increased in expansion states following the Affordable Care Act. However, there was no difference in survival between Medicaid patients and uninsured patients, or between patients in expansion states versus nonexpansion states, highlighting the need for population-level policy interventions to improve access and quality of care among testicular cancer patients with Medicaid.

Unilateral or Bilateral Retroperitoneal Lymph Node Dissection in Nonseminoma Patients with Postchemotherapy Residual Tumour? Results from RETROP, a Population-based Mapping Study by the Swedish Norwegian Testicular Cancer Group

BackgroundThe distribution of retroperitoneal lymph node metastases for patients with nonseminoma and a residual tumour of 10–49 mm in a population-based setting is unknown. This information is needed to justify selection of patients for a unilateral template resection. ObjectiveTo describe the location of retroperitoneal metastases and recurrences in patients with nonseminoma germ cell tumour (NSGCT) with a residual tumour of 10–49 mm. Design, setting, and participantsRETROP is a population-based prospective observational mapping study of 213 patients in Sweden and Norway with a retroperitoneal residual tumour of 10–49 mm who underwent postchemotherapy retroperitoneal lymph node dissection for metastatic NSGCT during 2007–2014 with median follow-up of 100 mo. Patients were classified according to the testis primary tumour and the distribution of unilateral or bilateral lymph node metastases (with reference to the aorta) present on pre- and/or postchemotherapy computed tomography (CT) scans. Outcome measurements and statistical analysisThe distribution and rate of teratoma or cancer in unilateral or bilateral retroperitoneal fields and the location and rate of retroperitoneal recurrence were measured. Results and limitationsIn total, 65% of the patients had unilateral retroperitoneal lymph node metastases (RLNMs) on CT scans. Patients with unilateral RLNMs had a low risk of contralateral teratoma or cancer (1.6% for right- and 2.6% for left-sided NSGCT) or retroperitoneal recurrence (0% for right- and 4% for left-sided NSGCT). A weakness of the study is that the pathology specimen could not be fully designated to one specific area for some of the patients. ConclusionsMen with postchemotherapy residual disease of 10–49 mm and unilateral metastases on pre- and postchemotherapy CT scans have a low risk of contralateral disease and should be considered for a unilateral template resection. Patient summaryThe surgeon can use computed tomography (CT) scans in deciding on the extent of lymph node dissection in patients with testicular cancer.

Does Determining Tumor Markers from the Testicular Vein Enable Better Diagnosis and Prognosis?

Introduction: β-HCG has been the only tumor marker evaluated in testicular vein (VT) blood until now. Objective: To evaluate the correlation between the tumor markers β-HCG, AFP, PLAP, and LDH from the VT and peripheral blood as well as their significance in predicting tumor recurrence and tumor stage. Methods: Patients with testicular cancer undergoing orchiectomy were studied retrospectively over a period of 20 years. Tumor stage, tumor histology, time to tumor recurrence, and tumor markers from VT and peripheral blood were analyzed. Minimal follow-up was 2 years. Statistical analysis was performed by means of Cox- and logistic regression models and Spearman rank correlation coefficients. Results: A total of 172 patients with an average follow-up of 9.9 years were investigated. The overall recurrence rate was 18% (seminoma patients 20.8%, nonseminoma patients 14.5%). Marker values measured from VT blood were higher than in peripheral blood and correlated strongly with the peripherally measured values. AFP obtained from peripheral blood was the only tumor marker allowing a statement on the recurrence probability. Tumor markers from VT blood showed no correlation with tumor stage. Discussion/Conclusion: Tumor markers from VT blood are significantly higher than in peripheral blood. Tumor markers obtained from VT blood do not provide clinical advantage in terms of assessing tumor stage and recurrence probability.

Long-term Testis Cancer Survivors in Canada—Mortality Risks in a Large Population-based Cohort

BackgroundTestis cancer (TC) patients are young with excellent cancer prognosis. Hence, the risk of late-onset treatment-related morbidity and mortality is of concern due to longer survival after treatment. ObjectiveWe set to characterize long-term survival of TC patients through a Canadian population dataset. Design, setting, and participantsWe used a population-based dataset, the Canadian Census Health and Environment Cohort (CanCHEC), to identify individuals diagnosed with TC between 1991 and 2010. We compared them with all other male individuals without TC. Outcome measurements and statistical analysisThe primary outcome was mortality due to cardiovascular disease (CVD) or nontesticular malignancy. Mann-Whitney or chi-square test was used where applicable. Data were analyzed using a Cox proportional hazard model with and without matching. Results and limitationsWe identified 1950 individuals with TC. We compared them with 1 300 295 men with no TC. There were 335 deaths in the study group during the study period (17.2%) with a mean follow-up of 19.6 yr. TC patients were at increased risk of death from secondary malignancies (hazard ratio [HR] 1.63, 95% confidence interval [CI] 1.39–1.91; p < 0.0001) with specific risks for hematologic neoplasms (HR 3.86, 95% CI 2.78–5.37; p < 0.001) and other malignancies (HR 2.41, 95% CI 1.76–3.29; p < 0.001). Gastrointestinal, hematologic, and respiratory toxicities were the most common secondary malignancies leading to death. When stratified according to histology, nonseminoma (NS) patients were at significantly increased risk of death from CVD (HR 2.03, 95% CI 1.27–3.25; p = 0.0032). Individuals with seminoma were at increased risk of death from other nontestis neoplasms (HR 1.46, 95% CI 1.17–1.82; p = 0.0007), specifically hematologic neoplasms (HR 2.09, 95% CI 1.18–3.72; p = 0.0118). ConclusionsNS patients are at increased risk of CVD-related death, whereas seminoma patients are at increased risk of death from non–testis-related malignancies. Patient summaryWe report long-term mortality following diagnosis of testis cancer. Nonseminoma patients have an increased risk of death from cardiovascular disease, while seminoma patients have an increased risk of death from secondary malignancies.

Testicular cancer: a 13-year retrospective review of ethnic disparities in the Waikato region, New Zealand.

The testicular cancer incidence in New Zealand is rising. We evaluated if testicular cancer outcomes differed by ethnicity in NZ. To study if ethnic disparities existed among testicular cancer patients and their outcomes treated at Waikato Regional Cancer Centre. Retrospective review of testicular cancer cases in the Medical Oncology database, Waikato Hospital, between 2001 and 2013 inclusive. Three hundred and twenty-five patients were seen, with median follow up of survivors being 101 (range 13-230) months. 95 (29.2%) were Māori, 210 (64.6%) NZ European and 20 (6.1%) of other ethnicity. One hundred and eighty-two patients were diagnosed with seminoma and 143 with non-seminoma. Māori represented 27.5% of seminoma and 31.4% of non-seminoma patients. Median age at diagnosis was 39 years for seminoma and 30 years for non-seminoma; Māori were significantly younger than non- Māori for both seminoma (median age 35 versus 42 years) and non-seminoma (median age 28 vs 34 years, respectively). While stage distribution of seminoma at diagnosis was similar for Māori and non-Māori (chi-squared P = 0.31), significantly more Māori had higher-stage non-seminoma than non-Māori (stage III in 44% and 22%, respectively, chi-squared P = 0.014). Survival for seminoma (logrank P = 0.19) and non-seminoma (logrank P = 0.89) patients did not differ significantly by ethnicity. Māori patients were younger at diagnosis of testicular cancer and presented with more advanced non-seminoma testicular tumours compared with non-Māori but survival was comparable.