Postchemotherapy Retroperitoneal Lymph Node Dissection Research Articles

La densidad de los ganglios linfáticos en la linfadenectomía retroperitoneal como marcador novel para predecir la recurrencia en pacientes con cáncer testicular de células germinales: estudio de casos y controles y experiencia clínica a largo plazo de un hospital de referencia terciario

Introduction and objectivesIn this retrospective study, we aimed to evaluate lymph node (LN) density in retroperitoneal lymph node dissection (RPLND) to analyze whether residual mass after chemotherapy might behave as predicting factor for recurrence in patients with germ cell testicular cancer (GCTC). Materials and methodsThe data of 185 patients that were operated between 12/2004 and 02/2017 because of GCTC were reviewed retrospectively. LN density was calculated. The patients were compared statistically in terms of demographic features, tumor characteristics, serum tumor marker levels, treatment strategies, and pathological results according to GCTC subtypes. Correlation analysis was performed to determine the parameters related to recurrent disease. ResultsThe median follow-up was 79 (31-179) months and the median age of the patients was 23 (16-71). The median tumor size was 4 (1-18) cm. Five (2.7%) patients had metastatic disease at initial diagnosis. Seminoma, non-seminomatous-GCT and mix type-GCTC was detected in 62 (33.5%), 60 (32.4%) and 63 (34.1%) patients, respectively. Following inguinal orchiectomy, 48 (25.9%) patients underwent follow-up, 126 (68.1%) patients underwent chemotherapy and 11 (5.9%) patients underwent radiotherapy. A total of 21 (11.4%) patients underwent post-chemotherapy RPLND. Early and late recurrence was seen in 3 (1.6%) and 2 (1.1%) of the patients, respectively. A mild to moderate, negative, but significant correlation was found between the recurrence and the number of LNs containing metastatic deposits and LN density (r= –0.490, P=.024 and r= –0.450, P=.041, respectively). ConclusionsThere was a negative correlation between the number of LNs containing metastatic deposits and LN density and recurrent disease.

Major complications of post-chemotherapy retroperitoneal lymph node dissection in a contemporary cohort of patients with testicular cancer and a review of the literature

BackgroundPost-chemotherapy retroperitoneal lymph node dissection (pc-RPLND) is one cornerstone in the clinical management of patients with nonseminomatous testicular germ cell tumours (GCT). A wide range of complication rates in this type of surgery is reported so far. We retrospectively evaluated the frequency of major complications by using the Clavien-Dindo classification and analysed the influence of various clinical factors on complication rates in pc-RPLND.MethodsWe retrospectively analysed 146 GCT patients undergoing pc-RPLND. Complications of grade III–V according to the Clavien-Dindo classification occurring within 30 days after surgery were registered along with the following clinical factors: age, body mass index (BMI), duration of surgery, number of anatomic fields resected, side of primary tumour, histology of surgical specimen, histology of primary tumour, and total dose of cisplatin applied prior to surgery. For comparison, we also evaluated 35 chemotherapy-naïve patients with primary RPLND and 19 with laparoscopic RPLND. We analysed types and frequencies of the various complications as well as associations with clinical factors using descriptive statistical methods.ResultsA total of 14.4% grade III–IV complications were observed in pc-RPLND, and 8.6% and 5.3% in primary and in laparoscopic RPLND, respectively. There was no perioperative mortality. Lymphocele was the most frequent adverse event (16% of grade III–IV complications). Operation time > 270 min (p = 0.001) and vital cancer in the resected specimen (p = 0.02) were significantly associated with higher complication rates. Left-sided resection fields involved two-fold higher complication rates, barely missing statistical significance (p = 0.06).ConclusionsPc-RPLND involves a grade III–V complication rate of 14.4%. Prolonged operation time and vital cancer in the residual mass are significantly associated with higher complication rates. The Clavien-Dindo classification system may allow inter-observer variation in rating complication grades, which may represent one reason for the wide range of reported RPLND complication rates. RPLND represents major surgery and surgeons active in this field must be competent to manage adverse events.

Post-chemotherapy Laparoscopic Retroperitoneal Lymph Node Dissection for Mixed Malignant Germ Cell Testicular Tumors.

Retroperitoneal lymph node dissection (RPLND) is performed to treat residual disease following chemotherapy for stage II and III testicular cancer. Significant morbidity can be associated with open RPLND. As such, laparoscopic techniques have been demonstrated to be safe and effective in select cases. Outcomes following post-chemotherapy laparoscopic RPLND for mixed malignant germ cell testicular tumors (MMGCT) are limited in the literature. We performed a retrospective chart review for patients who underwent laparoscopic RPLND at our institution for MMGCT from May 2006 to October 2016. Patient clinical data and perioperative and oncologic outcomes were recorded. Twenty-three patients underwent post-chemotherapy laparoscopic RPLND. Thirty-five percent (8/23) underwent bilateral template dissection, whereas 65% (15/23) underwent a modified unilateral template dissection. Robotic assistance was utilized in 22% (5/23) of cases. Bilateral template was inferior to unilateral template RPLND in operative time, estimated blood loss, open conversion rate, length of hospital stay, and complication rate. The mean follow-up was 35.1 months and 43.3 months for the bilateral and unilateral template groups, respectively. The mean lymph node yield and recurrence rate were similar between the 2 cohorts. One recurrence of mature teratoma was noted 67 months after unilateral laparoscopic RPLND. In select patients, laparoscopic RPLND for stage II and III MMGCT is safe and effective in the post-chemotherapy setting. Bilateral template laparoscopic RPLND was associated with inferior perioperative outcomes, but similar oncologic outcomes compared with unilateral template. Patients requiring bilateral template RPLND should be considered for an open approach.

Long-term Surveillance of Patients with Complete Response Following Chemotherapy for Metastatic Nonseminomatous Germ Cell Tumor

BackgroundThere is controversy regarding the management of patients with normal markers and residual masses (≤1 cm) after chemotherapy for nonseminomatous germ cell tumors (NSGCTs). ObjectiveTo determine long-term outcomes of a surveillance strategy in such patients. Design, setting, and participantsA retrospective review of our multidisciplinary testicular cancer database was performed. All patients who underwent primary chemotherapy for metastatic NSGCTs were identified between 1981 and 2016. A complete response (CR) was defined as normalization of serum tumor markers and a ≤1 cm residual mass in the largest axial dimension following chemotherapy. All such patients were surveilled. Outcome measurements and statistical analysisOutcome variables of interest were time to death, time to cancer-specific survival, and time to relapse. Overall survival and relapse-free survival were calculated using the Kaplan-Meier method, and the cumulative incidence of cause-specific survival rates was calculated using competing risk analysis. The impact of risk group and chemotherapy regimen on relapse-free survival was assessed using log-rank test. Results and limitationsDuring the study period, 1429 metastatic germ cell tumor patients were treated with primary chemotherapy. CR was achieved in 191 (18.5%) NSGCT patients. The median age at diagnosis was 27.4 yr, with a median follow-up of 81.1 mo. The majority had American Joint Committee on Cancer stage II at diagnosis (I: 23.8%; II: 49.2%; III: 27%) and International Germ Cell Cancer Collaborative Group good-risk disease (good: 78%; intermediate: 17.8%; poor: 4.2%). Of the 191 patients with a CR, 175 (91.6%) never relapsed and remain disease free. Sixteen (8.4%) patients relapsed after a median of 11.3 mo (range 1–332 mo), with over half (nine patients; 4.7%) relapsing in the retroperitoneum only and salvaged successfully with postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) alone. Of these nine patients, only two (1%) had viable disease in the PC-RPLND specimen. The remaining seven patients had relapses outside the retroperitoneum and received salvage chemotherapy ± postchemotherapy resection. Overall, nine (4.7%) patients have died, but only four (2.1%) from testis cancer. ConclusionsOur data, the largest series to date, confirm that surveillance is safe and effective for men who achieve a CR following chemotherapy for metastatic NSGCTs. Patient summarySurveillance is a safe strategy for patients who achieve a complete response following chemotherapy for metastatic testis cancer.

Overcoming sociodemographic factors in the care of patients with testicular cancer at a safety net hospital.

The objective of this study was to determine whether standardized treatment of germ cell tumors (GCTs) could overcome sociodemographic factors limiting patient care. The records of all patients undergoing primary treatment for GCTs at both a public safety net hospital and an academic tertiary care center in the same metropolitan area were analyzed. Both institutions were managed by the same group of physicians in the context of multidisciplinary cancer care. Patients were grouped by care center; clinicopathologic features and outcomes were analyzed. Between 2006 and 2018, 106 and 95 patients underwent initial treatment for GCTs at the safety net hospital and the tertiary care center, respectively. Safety net patients were younger (29 vs 33years; P=.005) and were more likely to be Hispanic (79% vs 11%), to be uninsured (80% vs 12%; P<.001), to present via the emergency department (76% vs 8%; P<.001), and to have metastatic (stage II/III) disease (42% vs 26%; P=.025). In a multivariable analysis, an absence of lymphovascular invasion (odds ratio [OR], 0.30; P=.008) and an embryonal carcinoma component (OR, 0.36; P=.02) were associated with decreased use of adjuvant treatment for stage I patients; hospital setting was not (OR, 0.67; P=.55). For patients with stage II/III nonseminomatous GCTs, there was no difference in the performance of postchemotherapy retroperitoneal lymph node dissection between the safety net hospital and the tertiary care center (52% vs 64%; P=.53). No difference in recurrence rates was observed between the cohorts (5% vs 6%; P=.76). Sociodemographic factors are often associated with adverse clinical outcomes in the treatment of GCTs; they may be overcome with integrated, standardized management of testicular cancer.

PT375 - Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in patients with testis cancer in the salvage setting

PT375 - Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in patients with testis cancer in the salvage setting

227 - Adjunctive surgery in postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) - is there always an oncologic benefit?

227 - Adjunctive surgery in postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) - is there always an oncologic benefit?

225 - Do patients with advanced germ cell tumors still need Postchemotherapy Retroperitoneal Lymph Node Dissection (PC-RPLND) if the two best models predict a “benign” pathohistology?

225 - Do patients with advanced germ cell tumors still need Postchemotherapy Retroperitoneal Lymph Node Dissection (PC-RPLND) if the two best models predict a “benign” pathohistology?

Postchemotherapy retroperitoneal lymph node dissection in patients presenting with very high HCG levels

PurposeChoriocarcinoma germ cell tumors are rare and usually present with significantly elevated human chorionic gonadotropin (hCG) levels. When curable, it is felt to be largely a result of chemotherapy. We sought to determine the histologic characteristics for those undergoing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) and compare them with metastatic nonseminomatous germ cell tumor (NSGCT) patients with similarly elevated hCG levels. MethodsWe reviewed medical records of men undergoing PC-RPLND between 1988 and 2017 with postorchiectomy, preinduction chemotherapy hCG levels greater than 50,000 mIU/ml. They were stratified by primary tumor histology: Pure choriocarcinoma and mixed NSGCT. Clinical, pathologic, and serologic data were reported and logistic regression was used to assess for predictors of necrosis in the PC-RPLND specimen. ResultsOur cohort consisted of 108 men. The mixed group (n = 91) had a median hCG of 165,177 mIU/ml, a postchemotherapy node size of 4.7 cm, of whom 19.8% also received salvage chemotherapy prior to RPLND. The pure choriocarcinoma group (n = 17) had a median hCG of 170,267 mIU/ml, a node size of 5.1 cm, of whom 17.6% received salvage chemotherapy. 88.2% of patients with choriocarcinoma had necrosis in the PC-RPLND specimen compared with 29.7% of the mixed NSGCT group (P = <0.0001). Controlling for salvage chemotherapy use, prechemotherapy hCG, node size and marker status, choriocarcinoma patients were 20 fold more likely to have necrosis on RPLND specimen (Odds ratio 20.68 [95% confidence interval 5.279–81.114]). ConclusionWhile PC-RPLND is appropriate in patients with residual masses after chemotherapy, patients with pure choriocarcinoma presenting with significantly elevated hCG levels represent a unique patient population where necrosis is found more often than anticipated.

Additional surgical procedures and perioperative morbidity in post-chemotherapy retroperitoneal lymph node dissection for metastatic testicular cancer in two intermediate volume hospitals

PurposeTo evaluate the perioperative morbidity of PC-RPLND in two intermediate volume centers and to identify predictors of high morbidity.MethodsRetrospective analysis of 124 patients treated with open PC-RPLND at two tertiary referral centers between 2001 and 2018. Perioperative morbidity was determined by analyzing additional surgical procedures, intra-operative blood loss, and postoperative complications.ResultsAn additional procedure was necessary for 33 patients (26.6%). The risk was higher in patients with IGCCCG intermediate/poor prognosis (OR 3.56; 95% CI 1.33–9.52) and residual tumor size > 5 cm (OR 3.53; 95% CI 1.39–8.93). Blood loss was higher in patients with IGCCCG intermediate/poor prognosis (β = 0.177; p = 0.029), large residual tumor (β = 0.570; p < 0.001), an additional intervention (β = 0.342; p < 0.001) and teratoma on retroperitoneal histology (β = − 0.19; p = 0.014). Thirty-one patients had a postoperative complication Clavien-Dindo Grade ≥ 2 (25.0%). Complication risk was highest in patients undergoing an additional intervention (OR 3.46; 95% CI 1.03–11.60; p = 0.044).ConclusionsThe rate of additional interventions in our series is comparable to what has been reported in high-volume centers. IGCCCG intermediate/poor prognosis patients with high-volume disease and patients undergoing an additional surgical procedure can be classified as high-risk patients.

National management trends in clinical stage IIA nonseminomatous germ cell tumor (NSGCT) and opportunities to avoid dual therapy

IntroductionFor marker-negative clinical stage (CS) IIA nonseminomatous germ cell tumor (NSGCT), National Comprehensive Cancer Network and American Urological Association guidelines recommend either retroperitoneal lymph node dissection (RPLND) or induction chemotherapy. The goal is cure with one form of therapy. We evaluated national practice patterns in the management of CSIIA NSGCT and utilization of secondary therapies. MethodsThe National Cancer Data Base was used to identify 400 men diagnosed with marker negative CSIIA NSGCT between 2004 and 2014 treated with RPLND or chemotherapy. Trends in the utilization of initial and adjuvant treatment (chemotherapy only, RPLND only, RPLND with adjuvant chemotherapy, and postchemotherapy RPLND) were analyzed. ResultsOf the 400 cases, 233 (58%) underwent induction chemotherapy with surveillance, 51 (20%) underwent RPLND with surveillance, 89 (22%) underwent RPLND followed by adjuvant chemotherapy, and 14 (4%) underwent induction chemotherapy followed by RPLND. Thirty percent of patients received dual therapy. After RPLND with pN1 staging, 43 (61%) underwent adjuvant chemotherapy. The pN0 rate after primary RPLND was 22%. Five year overall survival ranged from 95% to 100% based on initial treatment choice. ConclusionsFor marker negative CS IIA nonseminoma, dual, therapy, and treatment with chemotherapy is common. With low volume retroperitoneal disease resected at RPLND, adjuvant chemotherapy was frequently administered but has debatable therapeutic value. These data highlight opportunities to decrease treatment burden in patients with CS IIA nonseminoma.

PD19-05 DOES PERCENTAGE OF SEMINOMA AT ORCHIECTOMY IMPACT PATIENT MORBIDITY AND PATHOLOGIC OUTCOMES AT POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION FOR MIXED GERM CELL TUMOR?

INTRODUCTION AND OBJECTIVE: Post-chemotherapy retroperitoneal lymph node dissections (PC-RPLND) for pure seminoma are widely considered to have an increased potential for surgical complexity and morbidity secondary to increased post-chemotherapy desmoplastic changes. This places patients at increased risk, often with pathologic findings only revealing necrosis. We sought to determine if the percentage of seminoma in the orchiectomy specimen predicts necrosis on PC-RPLND for non-seminomatous germ cell tumors (NSGCT) and the associated impact on patient morbidity. METHODS: Patients with seminoma in the orchiectomy specimen who underwent PC-RPLND for NSGCT at Indiana University from 2009-2019 were identified to assess pathologic findings, required ancillary procedures at the time of PC-RPLND, and post-operative outcomes. Patients were categorized into quartiles to assess if increasing percentage of seminoma predicted necrosis. RESULTS: Of the 109 patients identified, pathologic analysis revealed necrosis in 30/109 (27.5%), malignancy 17/109 (15.6%), and teratoma 62/109 (56.9%). As percent seminoma increased by quartile, necrosis was more prevalent (23.7%, 25%, 33.3%, 41.7%), as was the radiographic size decrease in post-chemotherapy retroperitoneal masses. For patients with greater than 90% seminoma, necrosis was found 50% of the time. The incidence of concurrent nephrectomy, need for intra-operative vascular repair, and estimated blood loss during PC-RPLND was greatest in the 4th quartile. There was no significant difference in pre-operative serum tumor markers, patient age, body mass index, pre-operative comorbidities, length of stay, or post-operative Clavien-Dindo classification outcomes. CONCLUSIONS: As percent seminoma in the orchiectomy specimen increased, the incidence of necrosis, surgical complexity, and the need for concurrent ancillary procedures increased. However, it did not seem to change the hospital course or post-operative morbidity. Unfortunately, these results show that PC-RPLND cannot be eliminated even in patients with very high orchiectomy seminoma percentages as over half of these patients had teratoma or viable malignant elements in the retroperitoneum. Source of Funding: None

MP76-05 VALIDATION OF THE BEST MODELS TO PREDICT PATHOHISTOLOGY IN GERM CELL TUMOR PATIENTS UNDERGOING POSTCHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION

You have accessJournal of UrologyPenile & Testicular Cancer: Penile & Testicular Cancer III (MP76)1 Apr 2020MP76-05 VALIDATION OF THE BEST MODELS TO PREDICT PATHOHISTOLOGY IN GERM CELL TUMOR PATIENTS UNDERGOING POSTCHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION Tim Nestler*, Pia Paffenholz, Bettina Baeßler, Martin Hellmich, Andreas Hiester, Alessandro Nini, David Pfister, Peter Albers, and Axel Heidenreich Tim Nestler*Tim Nestler* More articles by this author , Pia PaffenholzPia Paffenholz More articles by this author , Bettina BaeßlerBettina Baeßler More articles by this author , Martin HellmichMartin Hellmich More articles by this author , Andreas HiesterAndreas Hiester More articles by this author , Alessandro NiniAlessandro Nini More articles by this author , David PfisterDavid Pfister More articles by this author , Peter AlbersPeter Albers More articles by this author , and Axel HeidenreichAxel Heidenreich More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000962.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The aim of our study was to validate and evaluate the two currently best performing prediction models (Vergouwe and Leao) for final pathohistology in NSGCT patients undergoing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) and we introduce a new radiomics approach. METHODS: We performed a retrospective analysis including 496 patients who underwent a PC-RPLND between 2008 and 2018 to validate the two prediction models using published formulas and thresholds. ROC were plotted and AUC was calculated. We determined the optimal cut point and used bootstrapping (1,000 replications) to estimate its variability. For radiomics, lymph nodes of 80 patients were identified on CT images, semiautomatically segmented with 93 radiographic features (pyRadiomics package). A linear support vector machine algorithm was applied to analyze reproducible radiomics features. A continuous reduction of features analyzed was performed using Random Forest algorithms and ROC analysis. RESULTS: In our validation cohort, the Vergouwe model had a significantly better AUC compared to Leao model (0.749 [CI 0.706-0.792] vs. 0.689 [0.642-0.736], p = 0.004) to predict benign histology. At a threshold of > 70% for the probability of benign disease, the Leao model would have avoided PC-RPLND in 8.6% with benign disease with an error rate of 5.6% for viable tumor. The Vergouwe model would avoid PC-RPLND in 23.4% with benign disease with an error rate of 12.7% for viable tumor/teratoma. Of the 93 radiomic features analyzed, 51 features were reproducible. Applying the trained algorithm on the training dataset resulted in an accuracy of 0.96 (93% sensitivity, 100% specificity, 100% PPV), on an independent validation cohort the accuracy was 0.81 (88% sensitivity, 72% specificity, 78% PPV). CONCLUSIONS: According to our data, the discriminatory accuracy of both models is not sufficient to safely select patients for surveillance strategy instead of PC-RPLND. The radiomics model is promising but needs prospective validation. Further studies including new biomarkers are needed to optimize the accuracy of potential prediction models. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1153-e1153 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tim Nestler* More articles by this author Pia Paffenholz More articles by this author Bettina Baeßler More articles by this author Martin Hellmich More articles by this author Andreas Hiester More articles by this author Alessandro Nini More articles by this author David Pfister More articles by this author Peter Albers More articles by this author Axel Heidenreich More articles by this author Expand All Advertisement PDF downloadLoading ...

PD19-06 LOCATION AND HISTOLOGY OF RETROPERITONEAL METASTASES IN POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION FOR NON-SEMINOMA GERM CELL TUMOUR

INTRODUCTION AND OBJECTIVE: Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) in patients with metastatic non-seminoma germ cell tumour (NSGCT) is a procedure with high complication rate and risk of permanent retrograde ejaculation. The current Swedish and Norwegian Testicular Cancer Group (SWENOTECA) modified unilateral template results in a low complication rate, but a relatively high proportion of patients experiences permanent retrograde ejaculation. The objective was to evaluate the histology of the resected nodes in specific areas and outcome of patients, to identify which patients that safely could benefit from a more restricted unilateral template without resection on the contralateral side of the aorta. METHODS: All NSGCT patients within the SWENOTECA network with post-chemotherapy residual tumour of 10-50mm in the largest axial diameter, treated with PC-RPLND between 2007 and 2014 were evaluated in this prospective population-based study. A modified unilateral PC-RPLND could be selected in patients with residual tumour located in the template of a unilateral PC-RPLND (areas 1-5,7,9 for a right-sided NSGCT and 2,3,6,8,10 for a left-sided NSGCT). Laterality of the testicular NSGCT, location of pathological lymph nodes on the CT scan pre chemotherapy and pre-PC-RPLND, areas dissected and the histology for each area was recorded. Follow-up until end of 2016. RESULTS: There were 113 right and 107 left-sided NSGCT. A black dot represents each patient in each area with a postitive node pre-chemotherapy and pre-PC-RPLND, if the area was dissected and teratoma/cancer at histology was found. A red dot represents each patient with negative nodes pre-PC-RPLND and teratoma/cancer was found. In right-sided and left-sided NSGCT respectively 4/6 and 4/5 patients that had a red dot in a contralateral area of the aorta, had positive nodes on CT in an other contralateral area. During follow-up of median 69 months, 4 patients had an in-field recurrence CONCLUSIONS: If the residual mass is located in the unilateral template of the affected testicle (areas 1,2,4,5,7,9 for a right-sided NSGCT and areas 3,6,8,10 for a left-sided NSGCT) and residual tumour size is 10-50mm, a unilateral template is sufficient to remove all teratoma/vital cancer. If the pre or post chemotherapy CT scan shows a pathological lymph node outside of a unilateral template an extended template is recommendedSource of Funding: none

Primary and post-chemotherapy robotic retroperitoneal lymph node dissection for testicular cancer: a review.

Open retroperitoneal lymph node dissection (RPLND) is the gold standard for surgical management of the retroperitoneum in patients with testicular cancer, and is associated with excellent oncologic outcomes and significant morbidity including length of stay. Minimally invasive RPLND, starting with laparoscopic retroperitoneal lymph node dissection in 1992 and now robotic retroperitoneal lymph node dissection in 2006, endeavor to decrease the morbidity of open RPLND while maintaining excellent oncologic outcomes. This review surveys the literature regarding both primary and post-chemotherapy robotic RPLND, emphasizing that while early outcomes are promising, much work needs to be done before widespread use of this technique is implemented.

Re: Surgical Complications in Postchemotherapy Retroperitoneal Lymph Node Dissection for Nonseminoma Germ Cell Tumour: A Population-Based Study from the Swedish Norwegian Testicular Cancer Group.

Re: Surgical Complications in Postchemotherapy Retroperitoneal Lymph Node Dissection for Nonseminoma Germ Cell Tumour: A Population-Based Study from the Swedish Norwegian Testicular Cancer Group.

Prognostic Value of Teratoma in Primary Tumor and Postchemotherapy Retroperitoneal Lymph Node Dissection Specimens in Patients With Metastatic Germ Cell Tumor.

Presence of teratoma in patients with metastatic testicular germ cell tumor (GCT) is of unknown prognostic significance. We report survival outcomes of patients with or without teratoma in primary tumor and postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) specimen and assess impact on prognosis. Patients with metastatic nonseminomatous GCT (NSGCT) who were evaluated at Indiana University between 1990 and 2016 and had primary testicular tumor specimen from orchiectomy (ORCH) were included. All patients were treated with cisplatin-based combination chemotherapy. The cohort was divided into 2 groups according to presence or absence of teratoma in ORCH specimen. Survival data were correlated with histopathologic findings. Differences in progression-free (PFS) and overall survival (OS) were evaluated using log-rank tests and Cox proportional hazards models to adjust for known adverse prognostic factors. We identified 1,224 consecutive patients evaluated at Indiana University between 1990 and 2016 who met inclusion criteria. Median age was 27 years (range, 13-71 years); 689 patients had teratoma in ORCH specimen, and 535 did not. With median follow-up of 2.3 years, 5-year PFS was 61.9% (95% CI, 57.1% to 66.2%) for those with teratoma versus 63.1% (95% CI, 58.0% to 67.8%) for those without (P = .66); 5-year OS was 82.2% (95% CI, 77.9% to 85.8%) versus 81.4% (95% CI, 76.5% to 85.3%; P = .91), respectively. A total of 473 patients underwent PC-RPLND; 5-year PFS for patients with pure teratoma in PC-RPLND specimen versus necrosis only was 65.9% versus 79.1% (P = .06), and 5-year OS was 90.3% versus 93.4% (P = .21), respectively. Presence of teratoma in ORCH and PC-RPLND specimens was not a prognostic factor in this large retrospective study of patients with NSGCT.

Predictive capacity of miRNA-375 in identifying teratoma in post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND).

416 Background: Traditional tumor markers for testicular germ cell tumor (TGCT), lactate dehydrogenase (LDH), beta-human chorionic gonadotropin (hCG), and alpha-fetoprotein (AFP), have limited sensitivity in detecting residual tumor on PC-RPLND. Micro-RNAs (miRNA) have emerged as a promising serum markers to predict residual TGCT on RPLND. Previous reports have suggested high levels of miRNA-375 in teratoma. The purpose of this study was to evaluate serum miRNA-375 as a tumor marker for PC-RPLND teratoma. Methods: We prospectively collected pre-surgical serum samples from consecutive GCT patients undergoing PC-RPLND. Serum miRNA-375-3p and -5p expression was validated and quantified by qPCR. Receiver operating characteristic (ROC) analysis and logistic regression were utilized to evaluate test characteristics and predictors of teratoma. Results: 40 patients underwent PC-RPLND. 18 had benign pathology, 2 viable TGCT, 19 teratoma, and 1 embryonal rhabdomyosarcoma. 3 miRNA specimens were excluded as outliers. miRNA-375-5p was undetectable in all samples examined. ROC analysis of miRNA-375-3p revealed an area under the curve of 0.503. Of 19 patients with teratoma, 16 had elevated miRNA-375-3p (84.2% sensitivity). 6/17 with benign pathology had normal mi-RNA-375-3p (35.3% specificity). 16/27 with positive tests harbored teratoma (59.3% positive predictive value). 6/9 with negative miRNA-375-3p had benign disease (66.7% negative predictive value). Univariate analysis demonstrated that clinical stage, pre-RPLND LDH, AFP, hCG, N/L ratio, and miRNA-375-3p were not significant predictors of teratoma. Conclusions: miRNA-375 does not predict teratoma on PC-RPLND. Tissue expression of miRNA-375 did not translate to serum expression in our study. Reliable predictors of teratoma on PC-RPLND remain elusive.

Evaluation of the oncologic benefit of adjunctive surgery at time of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND).

388 Background: PC-RPLND for advanced nonseminomatous germ cell tumors aims to resect all remaining metastatic tissue. The resection of adjacent visceral or vascular organs is commonly performed to achieving complete resection of the residual masses. However, the frequency of metastatic involvement of those organs with teratoma or vital cancer is currently unknown. Methods: We reviewed a cohort of 1181 patients who underwent PC-RPLND between 2008 and 2018 as a 2-center study and identified 235 (20%) cases of adjunctive surgery during PC-RPLND. We analysed the pathohistological presence of germ cell tumor elements in the resected organs: viable tumor (V), teratoma (T) or necrosis / fibrosis (N). Surgery associated complications were reported according to the Clavien-Dindo classification. Outcomes of subgroups were compared by using log-rank test. Results: V, T, N was present in 51 (21%), 91 (39%) and 93 (40%) of all patients with adjunct resected organs. In 235 patients, 316 adjunct organs were resected with 64 (27%) of these patients receiving a resection of multiple organs. The kidney was the most often resected organ (n = 74; V: 27% T: 39% N: 34%), followed by V. Cava (n = 66; V: 24% T: 36%, N: 40%) and partial liver resections (n = 48; V: 15%, T: 31%, N: 54%). Intraoperative complications occurred in 21% of patients (VT 32% vs N 17%, p = 0.021). Postoperative complications occurred in 35% of which 22% were Clavien Grad III-V showing no significant differences between VTN p = 0.093. 27% of all patients suffered from a relapse during a median follow-up of 22 months [0-180]. Patients with T or V in the resected specimens had a significantly reduced 5-year RFS compared to patients with only N (39%, 81%, p &lt; 0.001). Conclusions: This study shows for the first time that 40% of all resections of adjunct organs are oncologically unnecessary due to the presence of N only in the pathological specimens. In case of doubt we propose an organ safe procedure with multiple intraoperative frozen section to avoiding oncologically unnecessary adjunctive surgeries especially nephrectomies and vascular resections. Additionally, a more accurate presurgical workup is required to spare patients with N from PC-RPLND.

Validation of the two best models to predict “benign” pathohistology in patients with advanced nonseminomatous germ cell tumors (NSGCT) undergoing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND).

389 Background: The aim of our study is to validate and evaluate the two currently best performing prediction models (Vergouwe and Leao) for final pathohistology in NSGCT patients undergoing PC-RPLND and we introduce a new radiomics approach. Methods: We performed a retrospective analysis including 496 patients who underwent a PC-RPLND between 2008 and 2018 to validate the two prediction models using published formulas and thresholds. ROC were plotted and AUC was calculated. We determined the optimal cut point and used bootstrapping (1,000 replications) to estimate its variability. For radiomics, lymph nodes of 80 patients were identified on CT images, semiautomatically segmented with 93 radiographic features (pyRadiomics package). A linear support vector machine algorithm was applied to analyze reproducible radiomics features. A continuous reduction of features analyzed was performed using Random Forest algorithms and ROC analysis. Results: In our validation cohort, the Vergouwe model had a significantly better AUC compared to Leao model (0.749 [CI 0.706-0.792] vs. 0.689 [0.642-0.736], p=0.004) to predict benign histology. At a threshold of &gt; 70% for the probability of benign disease, the Leao model would have avoided PC-RPLND in 8.6% with benign disease with an error rate of 5.6% for viable tumor. The Vergouwe model would avoid PC-RPLND in 23.4% with benign disease with an error rate of 12.7% for viable tumor/teratoma. Of the 93 radiomic features analyzed, 51 features were reproducible. Applying the trained algorithm on the training dataset resulted in an accuracy of 0.96 (93% sensitivity, 100% specificity, 100% PPV), on an independent validation cohort the accuracy was 0.81 (88% sensitivity, 72% specificity, 78% PPV). Conclusions: According to our data, the discriminatory accuracy of both models is not sufficient to safely select patients for surveillance strategy instead of PC-RPLND. The radiomics model is promising but needs prospective validation. Further studies including new biomarkers are needed to optimize the accuracy of potential prediction models.