Nonseminomatous Testicular Cancer Research Articles

A new biomarker for lung metastasis in non-seminomatous testicular cancer: De Ritis Ratio.

We aimed to show that the De Ritis Ratio (DRR) may be a new biomarker for lung metastasis in non-seminomatous Testicular Cancers (TC). Patients who underwent radical orchiectomy due to TC between January 2010 and January 2021 were included in the study. Demographic characteristics, preoperative laboratory and radiological findings and pathological data of the patients were recorded. The DRR was calculated from preoperative peripheral blood analysis. A total of 124 patients with non-seminomatous TC were included. Mean patient age was 30.67±7.45 years, and the mean tumour diameter was 4.69±2.55 cm. 61 patients had T1, 51 had T2, and 12 had T3 disease. 42 of them had lung metastasis; 82 of them had no lung metastasis. The optimal DRR threshold was 1.21 for lung metastasis. [Area Under the Curve (AUC): 0.724 with a sensitivity of 81% and specificity of 74%]. DRR was determined as an independent prognostic factor for lung metastasis in univariate and multivariate analyses (p=0.002). A high preoperative DRR can be used to detect the presence of lung metastases in non-seminomatous TCs.

Association of Lymph Node Count and Survival after Primary Retroperitoneal Lymphadenectomy for Nonseminomatous Testicular Cancer.

Retroperitoneal lymph node dissection (RPLND) for men with clinical stage (CS) I or II testicular nonseminomatous germ cell tumor (NSGCT) has both staging and therapeutic implications. We aimed to investigate the impact of lymph node count (LNC) on outcome after primary RPLND for men with CS I or II NSGCT using a nationally representative data set. A retrospective analysis of men who received a primary RPLND for CS I or II NSGCT was performed using the National Cancer Database. The Kaplan-Meier method was used to determine overall survival (OS) according to LNC. Logistic regression analyses were used to identify factors associated with LNC >20 and factors predictive of lymph node-positive (pN+) disease after primary RPLND. Of 1,376 men who comprised our analytical cohort, 50.1% and 49.9% had 1-20 lymph nodes (LNs) and >20 LNs removed, respectively. Five-year OS rates were 96.4% and 99.1% for men with 1-20 and >20 LNs resected, respectively (p=0.004). A higher proportion of men with >20 LNs removed were treated at academic centers, had private insurance, presented with higher AJCC (American Joint Committee on Cancer) CS and were more likely to have pN+ disease, compared to those with 1-20 LNs removed. Factors significantly associated with pN+ disease after RPLND include higher AJCC CS and LNC (per 10-count increase). Higher LNC after primary RPLND significantly increases the likelihood of identifying pN+ disease and is associated with improved OS. Our data support the therapeutic implications of a thoroughly performed RPLND in the primary setting.

Sentinel lymph node mapping in post chemotherapy nonseminoma testicular cancer patients undergoing retroperitoneal lymph node dissection: A series of nine cases.

Objective(s):Testicular germ cell cancers are the most common solid malignancy among young men at the age ranging between 14 and 35 years. In this study, we evaluated the feasibility of sentinel lymph node mapping using intraoperative injection of radiotracer in nonseminomatous testicular cancer patients with history of orchiectomy who were candidate for retroperitoneal lymph node dissection (RPLND) in post-chemotherapy setting.Methods:Nine consecutive cases were included in the study. Technetium-99m-labelled phytate was injected in two divided doses in the stump of the spermatic cord, through transabdominal approach. A hand-held gamma probe was used for radio-guided retroperitoneal sentinel lymph node detection intraoperatively and confirming the location of the sentinel lymph nodes.Results: Detection rate and the false negative rate were estimated as the main indices. The detection rate was 6/9 (66%) and the false negative rate was 0/2 (0%). Location of the dissected sentinel lymph nodes were interaortocaval (2 patients), internal iliac (1 patient), external iliac (1 patient), common iliac (2 patients), and paraaortic (1 patient).Conclusion:Sentinel lymph node mapping technique seems to be feasible and promising in post chemotherapy non-seminoma testis cancer patients who are candidate for RPLND; however, further larger studies are needed to increase and standardize the detection rate.

The absence of spermatogenesis in radical orchiectomy specimen is associated with advanced-stage nonseminomatous testicular cancer.

To assess if clinical, pathological, and spermatogenesis factors are associated with clinical staging in patients with testicular germ cell tumors. We retrospectively reviewed the pathology reports and slides from 267 men who underwent radical orchiectomy for testicular cancer at our institution during 1998-2019. Histologic slides were reviewed and the presence of mature spermatozoa was documented. Clinical, laboratory and radiographic characteristics were recorded. Logistic regression analyses were used to identify factors associated with advanced disease stage at diagnosis. Of 267 male patients, 115 (43%) patients had testicular non-seminomatous germ cell tumors (NSGCT) and 152 (57%) seminomatous germ cell tumors (SGCT). Among NSGCT patients, those presenting with metastatic disease had a higher proportion of predominant (>50%) embryonal carcinoma (64% vs. 43%, respectively, P = 0.03), and lymphovascular invasion (45.8% vs. 26.6%, respectively, P = 0.03) than non-metastatic patients. Spermatogenesis was observed in 56/65 (86.2%) and 36/49 (73.5%) of non-metastatic and metastatic NSGCT patients, respectively (P = 0.09). On semen analysis, severe oligospermia (<5 million/ml) was more common in metastatic than in non-metastatic NSGCT (26.5% vs. 8.3%, respectively, P = 0.04). On multivariate analysis, predominant embryonal carcinoma and lack of spermatogenesis in pathological specimens were associated with metastatic disease. The absence of spermatogenesis and a high proportion of embryonal carcinoma was associated with advanced disease in patients with NSGCT. Whether it may also translate as a predictor of oncologic outcome needs further evaluation.

The relationship of neutrophil to lymphocyte ratio with testicular cancer.

ABSTRACTPurpose:To assess the relationship between testicular germ cell tumors (TGCT) and neutrophil to lymphocyte ratio (NLR) and to determine whether this ratio can be used as a serum tumor marker.Material and Methods:Sixty-one patients with testicular germ cell tumors were included into the study. Patients were grouped as localized and non-localized. Histologically patients were categorized as seminoma and nonseminomatous germ cell tumors. Complete blood cell count was measured the day before surgery and at the postoperative 1st month. Preoperative and postoperative mean NLR values were compared.Results:Thirty-six patients (59%) had seminomas and 25 patients (41%) had nonseminomatous testicular cancer. Forty-five patients (73.8%) had localized and 16 patients (26.2%) had non-localized testicular cancer. There was a statistically significant difference between preoperative and postoperative mean NLR of the localized patients (p=0.001) but no such difference was detected for non-localized patients (p=0.576). Nineteen patients with localized seminomas had normal preoperative serum tumor markers. There was a significant difference between preoperative and postoperative mean NLR in this group of patients (p=0.010). Twenty-six patients with localized tumors had preoperative increased serum tumor markers which normalized after orchiectomy. Mean NLR of these patients significantly decreased from 3.10±2.13 to 1.62±0.59 postoperatively (p=0.010).Conclusions:NLR appears to be a useful marker for TGCT. It is successful in predicting localized and non-localized disease in early postoperative period.

Lymphadenectomy during Potentially Curative Pulmonary Metastasectomy - Recommendations of an Expert Consensus Panel using the Delphi Process

The aim of the consensus approach was to improve the quality of care by agreement on definitions and standards, in order to harmonise lymphadenectomy during lung metastasectomy. The Delphi process consisted of two rounds of anonymous voting before discussion at a consensus meeting to reach final consensus within a group of experts. Consensus was assumed when > 75% of the panel agreed. Of 76 invited experts (board certified thoracic surgeons leading high-volume thoracic departments), 49 and 47 participated in the first and second round questionnaire, respectively. 43 experts attended the consensus meeting and reached consensus on the following: surgical approach for solitary subpleurally located lung metastasis is videothoracoscopy compared to anterolateral thoracotomy for multiple lung metastases. Lymphadenectomy is performed irrespective of the surgical approach. Systematic lymphadenectomy or sampling are core elements of pulmonary metastasectomy for colorectal, renal and non-seminomatous testicular cancer. The size of pulmonary metastasis does not influence lymphadenectomy per se. Pulmonary metastasectomy is not abolished in case of intraoperatively detected lymph node metastases. An expert group agreed on recommendations for lymphadenectomy during pulmonary metastasectomy using the Delphi process.

985P - The effects of primary testicular tumour localization on prognosis in patients with nonseminomatous testis cancer

Background5-year survival with platinum-based combination chemotherapies in testicular cancer is 95%. Existing prognostic scoring scales may be insufficient to predict which patient will benefit from treatment. Additional prognostic factors should be determined. Unlike left testicular vein, right testicular vein drains to vena cava. Therefore, the systemic spread of the testicular cancers of each side considered to be different due to the difference of vascular structures of the right and left testis. In this study, we aimed to investigate the effects of tumor localization on survival in patients with nonseminomatous testicular cancer. MethodsWe enrolled 321 non-seminomatous testicular cancer patients who followed up at Gulhane Research and Training Hospital in between January 1981, and December 2015. We retrospectively obtained data of demographic features, histopathological results, information of surgical operations and chemo-radiotherapy protocols, history of autologous stem cell transplantation from patients’ files. ResultsWe enrolled 321 non-seminomatous testicular carcinoma patients and summarized demographic information and treatment methods in the table. Median age was 34 (18-77) years. The primary tumor was in left testis in 152 (47.2%) patients and in right testis in 170 (52.8%) patients. The most common histopathological diagnosis was mixed non-seminomatous germ cell tumor (39.4%). One hundred forty-six (44.3%) cases were metastatic at the time of diagnosis. Median follow-up period was 88.3 months (1-386). Median 10-year survival rate was 74.1%, and the 20-year survival rate was 70.7%. We examined the effect of primary tumor localization and found that primary tumor localization was significantly different regarding survival between left and right testis (337.6 months vs. NR, p=0.001). In patients with a right testicular tumor the recurrence rate was significantly higher (84.7% vs. 68.2%; p=0.002). ConclusionsThe localization of primary testicular tumor (left or right) was statistically significant regarding survival. The effect of tumor localization on survival was independent of the presence of metastasis at the time of diagnosis, histopathological type, site of metastasis, and disease stage. Legal entity responsible for the studyGulhane Education and Research Hospital. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Lymph node count impacts survival following post-chemotherapy retroperitoneal lymphadenectomy for non-seminomatous testicular cancer: a population-based analysis.

To evaluate the prognostic significance of lymph node count (LNC) at post-chemotherapy retroperitoneal lymphadenectomy (PC-RPLND) in metastatic non-seminomatous germ cell tumour (NSGCT) using the Surveillance, Epidemiology, and End Results (SEER) database and National Cancer Database (NCDB). SEER (2000-2013, n=572) and NCDB (2004-2013, n=731) identified patients undergoing PC-RPLND for Stage II and III NSGCT. Correlation between linear or categorial variables and LNC was conducted using Spearman's rank correlation or Kruskal-Wallis test by ranks. Patients were stratified by ≤20, 21-40, and >40LNs for Kaplan-Meier analysis. Cox proportional hazards models evaluated the association of LNC at PC-RPLND with overall mortality (OM) in the NCDB and cancer-specific mortality (CSM) in the SEER database. The relationship between LNC and OM or CSM was also modelled as a non-linear function to determine a threshold for survival benefit. Amongst all patients, the median (interquartile range) LNC was 17(3-26)LNs in the NCDB, and 18(6-31)LNs in the SEER database. More recent diagnosis year, higher hospital volume, higher median income, private insurance status, and positive LNC were associated with greater total LNC in one or both databases (P<0.05). On Kaplan-Meier analysis, >40LNs was associated with 5-year cancer-specific survival (CSS) of 99% and overall survival (OS) of 96%, whereas ≤20LNs had a 5-year CSS of 91% and OS of 78% (CSS, P=0.04; OS, P<0.01). Risk-adjusted Cox model showed increasing LNC (per node) was inversely associated with OM (hazard ratio [HR] 0.96, 95% confidence interval [CI], 0.94-0.98; P<0.01) and CSM (HR 0.96, 95% CI, 0.94-0.99; P=0.01). Non-linear modelling showed the greatest benefit in OM at between 10 and 20LNs, but continued survival benefit for OM and CSM beyond 20LNs. Greater LNC during PC-RPLND appears to be associated with improved CSS and OS in NSGCT. Our data support the role of thorough RPLND for post-chemotherapy metastatic NSGCT.

Management of Residual Mass in Germ Cell Tumors After Chemotherapy.

The purpose of this review is to educate medical oncologists on the management of patients with residual germ cell tumors and the role of surgical resection after platinum-based chemotherapy. Patients with non-seminomatous testicular cancer and residual enlarged retroperitoneal lymph nodes > 1cm following induction chemotherapy with normal tumor markers should undergo a post-chemotherapy retroperitoneal lymph node dissection. All patients with primary mediastinal non-seminoma should undergo surgical resection of the mediastinal mass post-chemotherapy. These are complex surgeries and require expert surgeons in high-volume centers. Patients with advanced testicular seminoma who have residual masses less than 3cm after chemotherapy can be observed without further intervention. Patients with a residual mass > 3cm should be evaluated with PET scan after 6weeks of chemotherapy. Residual mass with negative PET scan can be followed by surveillance while a positive PET scan requires further work up to rule out active disease.

(OA16) Repeat Whole Brain Radiation Therapy Using a Pulsed Reduced Dose Rate Technique

Limited salvage options exist for patients with multiple recurrent brain metastases previously treated with whole brain radiation therapy (WBRT). Pulsed reduced dose rate radiation therapy (PRDR) is a biologically-unique irradiation strategy that lowers the effective dose rate, potentially decreasing toxicity to normal tissue by allowing for sublethal damage repair. PRDR has been shown to be safe and effective in patients with gliomas receiving partial brain re-irradiation. To our knowledge, this technique has not been reported before in patients with brain metastases who have received repeat WBRT with PRDR. We report our early outcomes using repeat WBRT with PRDR. We conducted a retrospective review of all brain tumor patients treated with PRDR at our institution. We further analyzed patients with brain metastases previously treated with WBRT who received repeat WBRT with PRDR at the time of clinical and/or radiographic progression. PRDR treatments were delivered with a series of 0.20 Gy pulses given over a 3-minute period, resulting in an apparent dose rate of 0.0667 Gy/min. Patients were treated with parallel-opposed whole brain lateral fields with dose prescribed to isocenter. We identified 26 patients who received WBRT with PRDR from 2012 to 2017 . We excluded 4 patients from further analysis as 2 patients had not received prior WBRT and 2 patient expired during treatment course due to extracranial disease. Primary histology included breast cancer (n=8), melanoma (n=5), NSCLC (n=6), non-seminomatous testicular cancer (n=1), SCLC (n=1) and sarcoma (n=1). Initial WBRT dose regimens included 30 Gy in 10 fractions (n=14), 37.5 Gy in 15 fractions (n=7), and 39.6 Gy in 18 fractions (n=1). KPS was 70-100 for all patients at time of first WBRT. Median time to progression after first WBRT was 7.7 months (range 1.3 - 54.8 months) at which time patients underwent repeat WBRT with PRDR. Patients received daily fractions of 2 – 3 Gy (median = 2 Gy) to a total dose of 20 Gy - 30 Gy (median = 24 Gy). KPS at repeat irradiation was 70-100 and age ranged from 28.3 yrs to 77.0 yrs (mean = 55.38 yrs). With a mean follow-up of 7.1 months (range 0.63 – 33.4 months), mean time to intracranial progression after repeat WBRT with PRDR was 4.7 months (range 0.53 – 15.5 months). Four patients had intracranial disease control after repeat WBRT with PRDR for > 6 months and 1 patient is still alive at the time of this review. No acute grade 3 toxicities were seen as a result of reirradiation based on CTCAE v4.03. Grade 1/2 toxicities included fatigue, anorexia, and alopecia. To our knowledge, this is the first report of repeat WBRT with PRDR. This technique appears to be a safe and feasible option for patients with multiple brain metastases who previously received WBRT. Future prospective studies using this technique are being considered.

Prognostic value of ABO blood group in patients with nonseminomatous testicular cancer who treated with autologous stem cell transplantation

Abstract Aim Even though ABO blood group surface antigens are expressed in red blood cells, they can be observed in many normal and pathologic cells. Relationship between ABO blood groups and progression and prognosis of cancer has been mainly demonstrated in gastric and pancreatic cancer. However there is no study in current literature about its relation with testicular cancer. The aim of this study is to demonstrate the prognostic value of the ABO blood group in nonseminomatous testicular cancer patients who treated with high dose chemotherapy and autologous stem cell transplantation. Material and method 64 patients who diagnosed as non-seminomatous testicular cancer and treated with HDC and OSCT in Gulhane Medical Oncology Clinic between January 2011 and December 2016 were enrolled to the study. Patients' age, TNM stage, chemotherapy protocols and blood group characteristics were obtained retrospectively. Results The mean age of patients was 31.4 (18–61) years. Blood groups of patients' were as follows: A blood group 19 (29.7%), B blood group 7 (10.9%), O blood group 34 (53.1%), AB blood group 4 (6.3%). Rh was negative in 3 patients (4.7%) and Rh positive in 61 patients (95.3%). 1-year progression-free survival (PFS) was 72.5% and 2-year PFS was 68.4%. 1-year overall survival (OS) was 82% and 2-years OS was 72%. While 1-year and 2-year OS was 88.2% and 84.4% in O blood group individuals, respectively, it was 75.6% and 59.5% in all other blood types, respectively. Although the OS was superior in individuals with O blood group, the difference was not reached the statistically significance (p = 0.071). When O blood group was compared with other blood groups in terms of PFS, 1 year PFS was 79.1% in O blood group and 65.2% in the all other blood groups (p = 0.19). Conclusion OS and PFS were superior in O blood group than other blood groups, however the difference was not reached statistical significance. In the literature, there is no study that focused on the relationship between stem cell transplantation and blood groups. ABO blood groups are the phenotype of a person's genotype and may reflect differences in the individual's immune mechanisms. However, due to small number of cases and heterogeneity of the group, the results and the strength of the study may have affected negatively. So, the prognostic importance of ABO blood groups can be shown with multi-center studies that performed with larger number of cases.

Limited post-chemotherapy retroperitoneal resection of residual tumour in non-seminomatous testicular cancer: complications, outcome and quality of life

Background: Resection of residual masses after chemotherapy plays a crucial role in management of patients with germ cell tumours (GCTs). The extent of surgery is controversial and we present the experiences from Aarhus University Hospital over a 20-year period. The aim was to evaluate survival, complications, working ability and quality of life (QOL) following a limited surgical procedure performed to resect residual masses in non-seminomatous testicular cancer patients after chemotherapy.Material and methods: A consecutive patient cohort of 109 patients having surgery between 1993 and 2013 was investigated. Hospital records were reviewed and complications were graded according to the Clavien-Dindo classification. QOL data were assessed in a cross-sectional analysis using the European Organisation for Research and Treatment of Cancer (EORTC), QLQ-C30 version 3.0. Patients were matched 1:1 with controls to evaluate the influence of surgical resection on the QOL.Results: With a median follow-up of 10.3 years, 11 relapses in retroperitoneum were recorded in 10 patients (9%), and four patients (5%) died of disease progression. The majority of relapses in patients considered having no evidence of disease (NED) after primary retroperitoneal surgery occurred 10 + years after treatment and was outside the field of the elective lymph node dissection. Twenty-seven (44%) grade I, 15 (24%) grade II, 7 (11%) grade IIIa and 13 (21%) grade IIIb complications were recorded. No grade IV and V complications were observed. Twenty-three patients (20%) reported loss of antegrade ejaculation. We found no significant differences between patients and controls regarding QOL.Conclusion: The survival outcome and complication rate are favourable and are comparable to studies involving full and modified template lymph node dissection. We find that limited resection constitutes an applicable and safe procedure. Limited surgical resection did not influence the patients’ long-term QOL. Longer follow-up might be considered.

Association of plasminogen-activator inhibitor 1 (PAI-1) 4G/5G gene polymorphism with survival and chemotherapy-related vascular toxicity in non-seminomatous testicular cancer (TC)

5083 Background: High PAI-1 expression by tumor has been associated with poor prognosis in different cancer types, while high systemic PAI-1 levels may increase the risk of vascular thrombosis. We investigated whether the 4G/5G del/ins polymorphism in the PAI-1 promoter (rs1799889; 4G might lead to higher transcription), is associated with differences in survival and prevalence of cardiovascular events in TC. METHODS: Data were collected on survival and cardiovascular events (venous thromboembolism [VTE] and coronary heart disease [CHD]) of TC patients treated with standard platinum based chemotherapy from 1977-2004. PAI-1 genotype was determined from non-tumor genomic DNA by a Taqman SNP assay. Genotypes were compared for survival (Kaplan-Meier curves + log-rank and Cox-regression analysis), disease outcome (logistic regression) and prevalence of VTE and CHD (χ(2)-test). RESULTS: Data are available for 324 patients with median follow-up of 10 yrs (range 0-28). The 3 genotypes 4G/4G (n = 84), 4G/5G (n = 164), and 5G/5G (n = 76) do not differ in age and initial chemotherapy regime. However, the 4G/4G variant shows a higher prevalence of International Germ Cell Cancer Classification (IGCCC) poor prognosis compared to 4G/5G + 5G/5G (24% vs 10%; p = 0.003), as well as a decreased TC related survival compared to 4G/5G + 5G/5G (83% vs 94%; p = 0.001) with a hazard ratio of 2.68 for TC related death (95%CI 1.26-5.72; adjusted for IGCCC p = 0.011). In addition, the 4G/4G variant shows an odds ratio of 3.35 for refractory TC and early relapses (<2 yrs) (95% CI 1.48-7.58; p = 0.004). The 3 genotypes do not differ significantly in prevalence of VTE (4G/4G 11.9%, 4G/5G 8.5%, 5G/5G 7.9%; p = 0.616) and CHD during/after chemotherapy (4G/4G 6.0%; 4G/5G 4.9%; 5G/5G 2.6%; p = 0.594). CONCLUSIONS: The 4G/4G variant of the PAI-1 4G/5G gene polymorphism is associated with IGCCC poor prognosis, reduced survival and higher prevalence of refractory disease and early relapses. No effect on vascular toxicity was found. The 4G/4G variant of the PAI-1 gene may be an unfavorable prognostic factor as well as an unfavorable predictive factor for response to chemotherapy in patients with TC. No significant financial relationships to disclose.

Safety and Early Oncologic Effectiveness of Primary Robotic Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Testicular Cancer

BackgroundPrimary robot-assisted retroperitoneal lymph node dissection (R-RPLND) has been studied as an alternative to open RPLND in single-institution series for patients with low-stage nonseminomatous germ cell tumors (NSGCT). ObjectiveTo evaluate a multicenter series of primary R-RPLND for low-stage NSGCT. Design, setting, and participantsBetween 2011 and 2015, 47 patients underwent primary R-RPLND at four centers for Clinical Stage (CS) I-IIA NSGCT. Surgical procedureR-RPLND was performed using the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Outcome measurements and statistical analysisData were collected regarding patient demographics, primary tumor characteristics, pathologic findings, and clinical outcomes. Results and limitationsForty-two patients (89%) were CS I and five (11%) were CS IIA. The median operative time was 235min (interquartile range [IQR]: 214–258min), estimated blood loss was 50ml (IQR: 50–100ml), node count was 26 (IQR: 18–32), and length of stay was 1 d. There were two intraoperative complications (4%), four early postoperative complications (9%), no late complications, and the rate of antegrade ejaculation was 100%. Of the eight patients (17%) with positive nodes (seven pN1and one pN2), five (62%) received adjuvant chemotherapy. The one recurrence was out of template in the pelvis after adjuvant chemotherapy (resected teratoma). The median follow-up was 16 mo and the 2-yr recurrence-free survival rate was 97% (95% confidence interval: 82–100%). Limitations include retrospective design and limited follow-up. ConclusionsOur multicenter experience supports R-RPLND as a potential option at experienced centers in select patients with low-stage NSGCT. Informal comparison to open and laparoscopic series suggests R-RPLND has an acceptably low morbidity profile, but oncologic efficacy evaluation requires further evaluation. Patient summaryWe examined outcomes after robot-assisted retroperitoneal lymph node dissection for patients with low-stage nonseminomatous testicular cancer with our data suggesting the robotic approach has acceptable morbidity and early oncologic outcomes.

MP23-09 ROBOT-ASSISTED LAPAROSCOPIC RETROPERITONEAL LYMPH NODE DISSECTION FOR NON-SEMINOMATOUS TESTICULAR CANCER IN THE PRIMARY SETTING: A RETROSPECTIVE MULTI-INSTITUTIONAL ANALYSIS

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I1 Apr 2016MP23-09 ROBOT-ASSISTED LAPAROSCOPIC RETROPERITONEAL LYMPH NODE DISSECTION FOR NON-SEMINOMATOUS TESTICULAR CANCER IN THE PRIMARY SETTING: A RETROSPECTIVE MULTI-INSTITUTIONAL ANALYSIS Michael Marshall, Haidar Abdul-Muhsin, Sean Stroup, Ithaar Derweesh, Michael Woods, James Porter, Erik Castle, and James L'Esperance Michael MarshallMichael Marshall More articles by this author , Haidar Abdul-MuhsinHaidar Abdul-Muhsin More articles by this author , Sean StroupSean Stroup More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , Michael WoodsMichael Woods More articles by this author , James PorterJames Porter More articles by this author , Erik CastleErik Castle More articles by this author , and James L'EsperanceJames L'Esperance More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.731AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robot-assisted laparoscopic retroperitoneal lymph node dissection (RA-RPLND) for testicular cancer is an advanced surgical technique that has been slow to gain acceptance due to technical challenges and concerns about patient safety and oncologic efficacy. Herein, we report a multi-institutional analysis of RA-RPLND compared to the traditional open midline approach (O-RPLND) in the primary setting. METHODS We conducted a multicenter, retrospective review of 117 men with non-seminomatous testicular cancer who underwent either RA-RPLND or O-RPLND in the primary setting. The robotic technique performed has been described previously. A prospective, nerve-sparing approach was used for a majority of cases. Pertinent comparisons were made between each approach. RESULTS From March 1999 to June 2015, 69 RA-RPLND and 48 O-RPLND were conducted in the primary setting. Patient demographics and operative times were similar between groups. RA-RPLND showed statistically better outcomes in regard to intraoperative blood loss, post-operative pain, and duration of post-operative hospitalization. A significant number of high-grade complications were noted in the O-RPLND group whereas none were noted in the RA-RPLND group. Oncologic efficacy was suggested by similarities in total number of lymph nodes obtained, presence of occult stage II disease, and overall recurrence rates between the two groups. CONCLUSIONS RA-RPLND for non-seminomatous testicular cancer in the primary setting is safer, less morbid, and better tolerated than the traditional open approach. Our data suggests oncologic equivalency between the two approaches substantiating the continued use of RA-RPLND to treat this select group of patients. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e264-e265 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Michael Marshall More articles by this author Haidar Abdul-Muhsin More articles by this author Sean Stroup More articles by this author Ithaar Derweesh More articles by this author Michael Woods More articles by this author James Porter More articles by this author Erik Castle More articles by this author James L'Esperance More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Postchemotherapy Retroperitoneal Lymph Node Dissection in Patients With Nonseminomatous Testicular Cancer: A Single Center Experiences.

Background:Testicular cancer accounts for about 1 - 1.5% of all malignancies in men. Radical orchiectomy is curative in 75% of patients with stage I disease, but advance stage with retroperitoneal lymph node involvement needs chemotherapy. All patients who have residual masses ≥ 1 cm after chemotherapy should undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND).Objectives:Treatment of advanced nonseminomatous testicular cancer is usually a combination of chemotherapy and surgery. We described our experience about postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in our center.Patients and Methods:In a retrospective cross-sectional study between 2006 and 2011, patients with a history of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in Imam Khomeini hospital were evaluated. All patients had normal postchemotherapy serum tumor markers and primary nonseminomatous cancer. We reviewed retrospectively clinical, pathological, and surgical parameters associated with PC-RPLND in our center.Results:Twenty-one patients underwent bilateral PC-RPLND. Mean age was 26.3 years (ranged 16 - 47). Mean size of retroperitoneal mass after chemotherapy was 7.6 cm. Mean operative time was 198 minutes (120 - 246 minutes). Mean follow-up time was 38.6 months. Pathologic review showed presence of fibrosis/necrosis, viable germ cell tumor and teratoma in 8 (38.1%), 10 (47.6%) and 3 (14.28%) patients, respectively. One patient in postoperative period of surgery and three patients in two first years after surgery were expired. Of 17 alive patients, only two (11.8%) had not retrograde ejaculation.Conclusions:PC-RPLND is one the major operations in the field of urology, which is associated with significant adjunctive surgeries. In appropriate cases, PC-RPLND was associated with good cancer specific survival in tertiary oncology center.

Bilateral testicular germ cell tumors in patients treated for clinical stage I non-seminoma within two risk-adapted SWENOTECA protocols

Background. A contralateral tumor occurs in 3.5–5% of men diagnosed with testicular germ cell cancer (TGCC). Biopsy of the contralateral testis may detect intratubular germ cell neoplasia ITGCNU, a precursor of TGCC. Biopsy of the contralateral testis to detect ITGCNU is controversial. If adjuvant chemotherapy (ACT) protects against bilateral cancer is debated.Material and methods. A total of 1003 patients with clinical stage I (CS I) non-seminomatous testicular germ cell cancer (NSGCT) were included in two prospective, population-based protocols. Fifteen patients were excluded. Treatment was either adjuvant chemotherapy (n = 494), or surveillance (n = 494). Contralateral testicular biopsy was recommended for all patients, but was performed only in 282 patients. In case of ITGCNU radiotherapy (RT) to 16 Gy was recommended.Results. During a follow-up of 8.3 years, 31 (3.6%) patients developed contralateral TGCC. ITGCNU was detected in 3.2% (9/282) of biopsied patients. The incidence of bilateral TGCC was similar following ACT, 2.5% (11/494), and surveillance, 3.4% (13/494), p = 0.41. Young age was a risk factor for metachronous TGCC (HR 0.93; 95% CI 0.88–0.99, p = 0.02). In total 2.2% (6/273) of patients without ITGCNU in the biopsy developed contralateral TGCC. One irradiated patient developed contralateral cancer, and one developed contralateral tumor before RT was given.Conclusion. ACT did not reduce the incidence of contralateral TGCC. Young patients had the highest risk of developing contralateral TGCC. The proportion of false negatives biopsies was higher than reported in earlier trials, but this may in part be related to patient selection, single biopsies and lack of mandatory immunohistochemistry.

Treatment outcome of patients with intermediate- and poor-prognosis metastatic testicular cancer in the 2000s: A multicenter experience in Japan.

397 Background: As a risk classification system of metastatic germ cell tumors, the International Germ Cell Consensus (IGCC) classification was proposed in 1997 and has received broad approval. We aimed to clarify the significance of the IGCC classification in the 2000s especially in intermediate and poor-prognosis patients in Japan. Methods: We analyzed 118 patients with intermediate- and poor-prognosis metastatic non-seminomatous germ cell testicular cancer treated at five university hospitals in Japan between 2000 and 2010. Data were collected on age, levels of serum AFP, HCG and LDH, lung metastases, spread to non-pulmonary visceral metastases (NPVM) and on treatment details (first, second and third-line chemotherapy and post-chemotherapy surgery) and survival data. Results: The median age at diagnosis was 31 years (range, 2-54 years). The median follow-up period of all patients was 57 months. Sixty-eight patients were classified as poor prognosis, having LDH elevation in 14 (21%), AFP in 13 (19%), HCG in 27 (40%), presence of NPVM in 44 (65%). As first line chemotherapy, 93 (79%) were treated by BEP (bleomycin, etoposide and cisplatin)-containing regimen. Of 118 patients, 75 (64%) received second-line chemotherapy, in which the most frequently used regimen was taxane-containing regimen, including TIP (paclitaxel, ifosfamide and cisplatin), TIN (paxlitaxel, ifosfamide and nedaplatin) and DIN (docetaxel, ifosfamide and nedaplatin). Third-line chemotherapy was carried out in 33 patients (28%). Eighty-nine patients (75%) underwent post-chemotherapy surgery. The 5-year overall survivals for intermediate (n=50) and poor (n=68) prognosis was 89% and 83% (P=0.23), respectively. In poor prognosis patients, patients with more than 2 poor-prognostic factors had significantly worse survival than those with only one prognostic factor (72% vs 91%, P=0.01). Conclusions: There was a trend of increase in survival for any risk groups and, in particular, large increase in survival for patients with a poor prognosis. Further classification of poor-prognosis patients into two subgroups has a potential to identify a patient group with very poor-prognosis.

FDG-PET/CT in a Patient with Poor-Risk Non-Seminoma Testis with Mature Teratoma and Secondary Gliosarcoma: Multimodality Imaging for Guiding Multimodality Treatment.

The value of F-18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in detecting viable tumours in patients with metastasised non-seminomatous testicular cancer and residual and new masses post chemotherapy remains to be determined. We describe the case of a 41-year-old patient with metastasised non-seminomatous testicular cancer, with both retroperitoneal and extra-retroperitoneal residual masses post chemotherapy, for whom FDG-PET/CT guided major treatment decisions. FDG-PET/CT correctly identified the locations of viable tumour, as was proved by histology, and successfully guided surgery. In conclusion, in selected cases surveillance of patients with non-seminomatous testicular cancer with FDG-PET/CT can guide major treatment decisions when considering surgery for metastatic disease.

Late relapse of non-seminomatous testicular cancer during treatment of multiple sclerosis with interferon β-1a: A case report.

Germ cell tumors (GCTs) comprise 95% of malignant tumors arising in the testes. The present study reports a patient diagnosed with non-seminomatous testicular cancer, stage IB, with a good risk prediction according to the International Germ Cell Cancer Collaborative Group classification. The patient received chemotherapy with bleomycin, etoposide and cisplatin, and achieved complete remission. Eleven years later, while receiving treatment with interferon β-1a for multiple sclerosis, the patient developed a relapse of the original cancer in the lungs and lymph nodes. The majority of GCTs relapse within the first two years of treatment, while 2–4% of patients can present with late relapses. There is no clear established association between multiple sclerosis and testicular cancer; we present the hypothesis that the inmunosupressor treatment that was administered for the multiple sclerosis promoted the cancer relapse.