Postchemotherapy Retroperitoneal Lymph Node Dissection Research Articles

Orthotopic renal autotransplantation: A step forward during postchemotherapy retroperitoneal lymph node dissection for germ cell tumor

ABSTRACT We present the first and a rare case of orthotopic renal auto-transplantation in the management of postchemotherapy residual retroperitoneal mass encasing the left renal vessels but sparing the parenchyma in a 24-year-old patient with Stage IIIC nonseminomatous germ cell tumor after 4 cycles of chemotherapy. Immediate postoperative and 6 months’ follow-up renograms confirmed the maintained glomerular filtration rate of the transplanted kidney with no residual disease. This case report shows the feasibility of renal autotransplantation in carefully selected patients as they are young and have long-term survival.

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.

A Machine Learning Model to Predict the Histology of Retroperitoneal Lymph Node Dissection Specimens.

While post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) benefits patients with teratoma or viable germ cell tumors (GCT), it becomes overtreatment if necrosis is detected in PC-RPLND specimens. Serum microRNA-371a-3p correctly predicts residual viable GCT with 100% sensitivity; however, prediction of residual teratoma in PC-RPLND specimens using current modalities remains difficult. Therefore, we developed a machine learning model using CT imaging and clinical variables to predict the presence of residual teratoma in PC-RPLND specimens. This study included 58 patients who underwent PC-RPLND between 2005 and 2019 at the University of Tsukuba Hospital. On CT imaging, 155 lymph nodes were identified as regions of interest (ROIs). The ResNet50 algorithm and/or Support Vector Machine (SVM) classification were applied and a nested, 3-fold cross-validation protocol was used to determine classifier accuracy. PC-RPLND specimen analysis revealed 35 patients with necrosis and 23 patients with residual teratoma, while histology of 155 total ROIs showed necrosis in 84 ROIs and teratoma in 71 ROIs. The ResNet50 algorithm, using CT imaging, achieved a diagnostic accuracy of 80.0%, corresponding to a sensitivity of 67.3%, a specificity of 90.5%, and an AUC of 0.84, whereas SVM classification using clinical variables achieved a diagnostic accuracy of 74.8%, corresponding to a sensitivity of 59.0%, a specificity of 88.1%, and an AUC of 0.84. Our machine learning models reliably distinguish between necrosis and residual teratoma in clinical PC-RPLND specimens.

Survival outcomes of postchemotherapy retroperitoneal lymph node dissection for nonseminomatous germ cell tumors: A retrospective cohort study from a single tertiary center in South India.

Chemotherapy, postchemotherapy retroperitoneal lymph node dissection (pcRPLND), and metastasectomy remain the standard of care for the management of advanced nonseminomatous germ cell tumor (NSGCT). We retrospectively studied 73 patients who had pcRPLND at a single tertiary-care center (2003-2022). Surgical and clinicopathological features and oncological outcomes are presented. The mean age was 28.27 years (15-48). Three-fourths had Stage III disease at diagnosis. International Germ Cell Cancer Collaborative Group risk stratification was 54.54% and 21.21% in intermediate risk, and poor risk, respectively. Sixty-two patients had Standard, 7 had Salvage and 4 underwent Desperation pcRPLND. Eleven patients (15.06%) required adjunctive procedures. Thirteen patients (17.8%) had ≥ class 3 Clavien-Dindo complications and postoperative mortality occurred in 5 (6.8%) patients. The histopathologies (HPE) of the pcRPLNDs were necrosis, teratoma, and viable tumor in 39.7%, 45.2%, and 15.1%, respectively. Seven patients underwent metastasectomy. An 85% size reduction in the size of RPLN predicted necrosis. There was 71.4% concordance between pcRPLND and metastasectomy HPEs. The median follow-up was 26.72 months (inter-quartile range - 13.25-47.84). The 2-year recurrence-free survival (RFS) rate was 93% (95% confidence interval [CI]-83%-97%) and the overall survival (OS) rate was 90% (95% CI-80%-95%). This is the largest series of pcRPLND for NSGCT in India to our knowledge. Although most of the cohort belonged to stage III, an RFS and OS rate of >90% at 2 years was achieved. We believe that successful management of postchemotherapy residual masses in NSGCT is contingent on the availability of multidisciplinary expertise and is therefore best done at tertiary-care referral centers.

Contemporary Perioperative Outcomes of Open Retroperitoneal Lymph Node Dissection for Testicular Cancer

Purpose: Retroperitoneal lymph node dissection (RPLND) is an essential component of multimodal treatment of testicular cancer. The latest data on the perioperative outcomes of RPLNDs performed using the open approach (O-RPLND) dates back over a decade. We report our contemporary institutional perioperative outcomes with O-RPLND. Materials and Methods: We retrospectively identified all patients who underwent O-RPLND between 2013 and 2022 across our institution. Clinical and demographic data were reviewed and recorded. Descriptive statistics and univariate analysis were performed with patients stratified according to primary RPLND and post-chemotherapy RPLND (PC-RPLND). Results: Our cohort included a total of 144 men. Seventy-seven percent of all cases were PC-RPLND. The PC-RPLND cohort showed higher preoperative clinical stages (81% vs 26% above cN1, P < .001; 41% vs 1% Stage 3, P < .001). PC-RPLND pathologies were more likely to be teratoma and necrosis or fibrosis (43% vs 6% and 39% vs 33%, P < .001). Estimated blood loss was significantly higher in the PC-RPLND group (291 vs 125 cc, P = .004). Operative time was longer for PC-RPLND (242 vs 196 minutes, P = .011). Length of stay and 30-day readmission rate were not significantly different between groups and averaged 4.3 days and 12%, respectively. Our most common complication was ileus (5%), followed by chyle leak (3%). Conclusions: While PC-RPLND becomes prominent for treating advanced testicular cancer, our recent data suggest positive perioperative results with O-RPLND. With long-term outcome data needed to appropriately select patients for robotic RPLND, O-RPLND in experienced hands continues to improve its outcome and remains the standard approach in the modern era.

Adjunctive Surgery Is Often Without Oncological Benefit at Time of Postchemotherapy Retroperitoneal Lymph Node Dissection.

Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for advanced nonseminomatous germ cell tumors (GCTs) aims to resect all remaining metastatic tissue. Resection of adjacent visceral or vascular organs is commonly performed for complete resection. Resection of organs harboring only necrosis results in relevant overtreatment. The study aimed to describe the frequency of metastatic involvement of resected organs with teratoma or viable cancer and to analyze perioperative complications and relapse-free survival. In a 2-center study, we reviewed a cohort of 1204 patients who underwent PC-RPLND between 2008 and 2021 and identified 242 (20%) cases of adjunctive surgery during PC-RPLND. We analyzed the removed adjacent structures and the pathohistological presence of GCT elements in the resected organs: viable GCT, teratoma, or necrosis/fibrosis. Surgery-associated complications were reported according to the Clavien-Dindo classification. Viable GCT, teratoma, and necrosis were present in 54 (22%), 94 (39%), and 94 (39%), respectively, of all patients with adjunctive resection of adjacent organs. Vascular resections or reconstructions (n = 112; viable: 23%, teratoma: 41%, necrosis: 36%) were performed most frequently, followed by nephrectomies (n = 77; viable: 29%, teratoma: 39%, necrosis: 33%). Perioperative complications of grade ≥ IIIa occurred in 6.6% of all patients, with no difference between the viable GCT and teratoma/necrosis groups (P = .1). A total of 76 patients have been followed without a relapse for at least 36 months. Median follow-up of the whole cohort was 22 months (quartile 7 and 48). Patients with viable GCT/teratoma in the resected specimens had a significantly increased risk of recurrence by 5 years compared to patients with only necrosis (19% vs 59% vs 81%, P < .001). This study shows that 33% to 40% of all resections of adjacent organs do not harbor teratoma or viable GCT. This highlights the need for better patient selection for these complex patients.

The Impact of Enhanced Recovery After Surgery Protocol Implementation on Postoperative Pain Management in the Era of Opioid Crisis: The Post- Chemotherapy Open RPLND Experience.

Enhanced Recovery After Surgery (ERAS) protocols have been proven to optimize postoperative outcomes; however, misuse of opioid analgesics can still hinder postoperative recovery due to related side effects and potential complications. To determine if the implementation of ERAS protocol in post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) patients could help with reducing postoperative pain and opioid use. A case-control study of consecutive testicular cancer patients with indications for PCRLPND, who were offered Conventional Post-operative Management (CPM) or ERAS protocol. Outcomes of interest included Visual Analogue Scale (VAS)-assessed pain level at postoperative days 3, 7, and 30, and Morphine-Equivalent Doses (MEDs)/postoperative day. Intraoperative parameters and postoperative complications were recorded. Parametric and non-parametric tests were used for statistical analysis. In total, 100 opioid-naïve PC-RPLND patients were studied. CPM and ERAS groups (36 and 64 patients, respectively) had similar demographic and baseline clinical characteristics). ERAS group patients had significantly lower blood loss (p = 0.005), blood transfusion rate (p < 0.001), and duration of the procedure (p < 0.001). Post-operative complications were comparable between groups. Nausea and bowel disorders were numerically but not statistically more frequent in the CPM group. ERAS patients had shorter mean hospital stay (5.3 ± 1.4 vs. 7.4 ± 1.6 days, p < 0.001), lower daily MEDs (4.73 ± 2.63 vs. 7.04 ± 2.29, p < 0.001), and lower VAS scores on post-operative day 7 (3.89 ± 1.07 vs. 4.67 ± 1.17, p = 0.001). Post-operative pain was similar between groups on post-operative days 3 and 30. Systematic implementation of ERAS protocol after PC-RPLND improves pain management, optimizes patient recovery, and prevents over-prescription of opioid analgesics.

O11 - Post-chemotherapy retroperitoneal lymph node dissection for metastatic testicular cancer at a national referral center

O11 - Post-chemotherapy retroperitoneal lymph node dissection for metastatic testicular cancer at a national referral center

Radiomics Analyses to Predict Histopathology in Patients with Metastatic Testicular Germ Cell Tumors before Post-Chemotherapy Retroperitoneal Lymph Node Dissection.

The identification of histopathology in metastatic non-seminomatous testicular germ cell tumors (TGCT) before post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) holds significant potential to reduce treatment-related morbidity in young patients, addressing an important survivorship concern. To explore this possibility, we conducted a study investigating the role of computed tomography (CT) radiomics models that integrate clinical predictors, enabling personalized prediction of histopathology in metastatic non-seminomatous TGCT patients prior to PC-RPLND. In this retrospective study, we included a cohort of 122 patients. Using dedicated radiomics software, we segmented the targets and extracted quantitative features from the CT images. Subsequently, we employed feature selection techniques and developed radiomics-based machine learning models to predict histological subtypes. To ensure the robustness of our procedure, we implemented a 5-fold cross-validation approach. When evaluating the models' performance, we measured metrics such as the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, precision, and F-score. Our radiomics model based on the Support Vector Machine achieved an optimal average AUC of 0.945. The presented CT-based radiomics model can potentially serve as a non-invasive tool to predict histopathological outcomes, differentiating among fibrosis/necrosis, teratoma, and viable tumor in metastatic non-seminomatous TGCT before PC-RPLND. It has the potential to be considered a promising tool to mitigate the risk of over- or under-treatment in young patients, although multi-center validation is critical to confirm the clinical utility of the proposed radiomics workflow.

Critical elements of pediatric testicular germ cell tumors surgery

Children, adolescents and young adults with testicular germ cell tumors require appropriate surgical care to insure excellent outcomes. This article presents the most critical elements, and their basis in evidence, for surgery in this population. Specifically, the importance of inguinal radical orchiectomy for malignant tumors, partial orchiectomy for prepubertal tumors and normal serum tumor markers, and the appropriate use of post-chemotherapy retroperitoneal lymph node dissection in those with residual retroperitoneal masses.

Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for seminoma: Limitations of surgical intervention after first-line chemotherapy.

Patients with relapsed seminoma after first-line chemotherapy can be treated with salvage chemotherapy or postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). Based on prior experience, surgical management can have worse efficacy and increased morbidity compared to nonseminomatous germ cell tumor. Our aim was to characterize the surgical efficacy and difficulty in highly selected patients with residual disease after first-line chemotherapy. The Indiana University testis cancer database was queried to identify men who underwent PC-RPLND for seminoma between January 2011 and December 2021. Included patients underwent first-line chemotherapy and had evidence of retroperitoneal disease progression. We identified 889 patients that underwent PC-RPLND, of which only 14 patients were operated on for seminoma. One patient was excluded for lack of follow-up. Out of 13 patients, only 3 patients were disease free with surgery only. Median follow up time was 29.9 months (interquartile ranges : 22.6-53.7). Two patients died of disease. The remaining 8 patients were treated successfully with salvage chemotherapy. During PC-RPLND, 4 patients required nephrectomy, 1 patient required an aortic graft, 2 patients required a partial ureterectomy, and 3 patients required partial or complete caval resection. The decision between salvage chemotherapy and PC-RPLND as second-line therapy can be challenging. Salvage chemotherapy is effective but is associated with short and long-term morbidity. Surgical efficacy in this setting seems to be limited, but careful selection of patients may lead to surgical success without affecting the ability to receive any systemic salvage therapies if necessary or causing life-threating morbidity.

Risk Factors for Relapse in Nonseminomatous Testicular Cancer After Postchemotherapy Retroperitoneal Lymph Node Dissection With Viable Residual Cancer.

No consensus exists on the management of men with nonseminoma and viable nonteratomatous germ cell tumor in the postchemotherapy retroperitoneal lymph node dissection (pcRPLND) specimen after first-line chemotherapy. We analyzed surveillance versus different adjuvant chemotherapy regimens and the influence of time to pcRPLND on oncologic outcomes. Data on 117 men treated with cisplatin-based first-line chemotherapy between 1990 and 2018 were collected from 13 institutions. All patients had viable nonteratomatous germ cell tumor in the pcRPLND specimen. Surgery was performed after a median of 57 days, followed by either surveillance (n = 64) or adjuvant chemotherapy (n = 53). Primary end points were progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS). After controlling for International Germ Cell Cancer Cooperative Group risk group and percent of viable malignant cells found at RPLND, no difference was observed between men managed with surveillance or adjuvant chemotherapy regarding PFS (hazard ratio [HR], 0.72 [95% CI, 0.32 to 1.6]; P = .4), CSS (HR, 0.69; 95% CI, 0.20 to 2.39; P = .6), and OS (HR, 0.78 [95% CI, 0.25 to 2.44]; P = .7). No statistically significant differences for PFS, CSS, or OS were observed on the basis of chemotherapy regimen or in men treated with pcRPLND ≤57 versus >57 days after first-line chemotherapy. Residual disease with <10% versus ≥10% viable cancer cells were associated with a longer PFS (HR, 3.22 [95% CI, 1.29 to 8]; P = .012). Relapse in the retroperitoneum was observed in 34 (29%) men. Men with a complete resection at pcRPLND and <10% viable cells have favorable outcomes without further treatment. Complete retroperitoneal resection seems more important than early pcRPLND.

Sexual function using the EORTC QLQ-TC26 in testicular cancer survivors: A multi-institutional, cross-sectional study.

To evaluate sexual function after treatment using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Testicular Cancer 26 (EORTC QLQ-TC26) questionnaire in Japanese testicular cancer (TC) survivors in a multi-institutional, cross-sectional study. This study enrolled TC survivors who visited any of eight high-volume institutions in Japan from 2018 to 2019. After obtaining informed consent, participants completed the EORTC QLQ-TC26 questionnaires. We evaluated sexual function after treatment for TC using the EORTC QLQ-TC26 and analyzed the impact of treatment on sexual function in TC survivors. A total of 567 TC survivors responded to the EORTC QLQ-TC26. Median age at the time of response was 43 years (interquartile range [IQR] 35-51 years), and median follow-up period after treatment was 5.2 years (IQR 2.2-10.0 years). Sexual function, particularly ejaculatory function, was significantly lower after post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) than after Surveillance or Chemotherapy groups (p < 0.05). In the PC-RPLND group, nerve-sparing procedure preserved postoperative ejaculatory function after RPLND compared with the non-nerve-sparing and offered improved ejaculatory function with time. On multivariate analysis, RPLND was a significant predictor of post-treatment ejaculatory dysfunction, particularly without nerve-sparing (odds ratio 3.0, 95% CI 1.2-7.7, p < 0.05). In addition, TC survivors with nerve-sparing RPLND had higher sexual activity than those without. This survey of the EORTC QLQ-TC26 showed that sexual function and activity in TC survivors after RPLND was reduced in the absence of nerve-sparing techniques.

Testicular Radiomics To Predict Pathology At Time of Postchemotherapy Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Tumor

IntroductionTesticular germ cell tumors are the most common malignancy in young adult males. Patients with metastatic disease receive standard of care chemotherapy followed by retroperitoneal lymph node dissection for residual masses >1cm. However, there is a need for better preoperative tools to discern which patients will have persistent disease after chemotherapy given low rates of metastatic germ cell tumor after chemotherapy. The purpose of this study was to use radiomics to predict which patients would have viable germ cell tumor or teratoma after chemotherapy at time of retroperitoneal lymph node dissection. Patients and MethodsPatients with nonseminomatous germ cell tumor undergoing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) between 2008 and 2019 were queried from our institutional database. Patients were included if prechemotherapy computed tomography (CT) scan and postchemotherapy imaging were available. Semiqualitative and quantitative features of residual masses and nodal regions of interest and radiomic feature extractions were performed by 2 board certified radiologists. Radiomic feature analysis was used to extract first order, shape, and second order statistics from each region of interest. Post-RPLND pathology was compared to the radiomic analysis using multiple t-tests. Results45 patients underwent PC-RPLND at our institution, with the majority (28 patients) having stage III disease. 24 (53%) patients had teratoma on RPLND pathology, while 2 (4%) had viable germ cell tumor. After chemotherapy, 78%, 53%, and 33% of patients had cystic regions, fat stranding, and local infiltration present on imaging. After radiomic analysis, first order statistics mean, median, 90th percentile, and root mean squares were significant. Strong correlations were observed between these 4 features;a lower signal was associated with positive pathology at RPND. ConclusionsTesticular radiomics is an emerging tool that may help predict persistent disease after chemotherapy.

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.

Perioperative complications and oncological outcomes of post-chemotherapy retroperitoneal lymph node dissection in patients with germ cell cancer at two high-volume university centres in Switzerland – a retrospective chart review

Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is an integral part of the management of patients with metastatic non-seminoma and residual masses >1 cm after chemotherapy. To assess perioperative complications and oncological outcomes at two major referral centres in Switzerland. This was a retrospective chart review of 136 patients with non-seminoma who underwent PC-RPLND between 2010 and 2020 at the university hospitals of Bern and Zürich. Patient, treatment and tumour characteristics as well as the types and frequencies of intra- and postoperative complications were registered and compared using the chi-square test. Oncological outcomes consisted of the time and location of relapses as well as progression-free and overall survival, which were compared using the log-rank test. Overall, 70 patients from Bern and 66 patients from Zürich were included; 5 patients had a previous retroperitoneal lymph node dissection (RPLND) (2 Bern, 3 Zürich). Vascular injuries were the most frequent intraoperative complication, occurring in 27/136 (19.9%) patients. Postoperative complications were observed in 42/136 (30.9%) patients, ileus being the most common. Perioperative mortality was 2.2%. A retroperitoneal mass ≥50 mm was significantly associated with intraoperative complications (p = 0.004) and increased resource demands (p = 0.021). Postoperative morbidity was higher according to age at post-chemotherapy retroperitoneal lymph node dissection ≥40 years (p = 0.028) and retroperitoneal mass ≥20 mm (p = 0.005). The median follow-up time was 37 months (interquartile range [IQR] 18-64 months). The median progression-free survival at 5 years was 76% (95% confidence interval [CI]: 64-85%) in Bern and 69% (95% CI: 54-80%) in Zürich (p = 0.464). The median overall survival at 5 years was 88% (95% CI: 76-94%) in Bern and 77% (95% CI: 60-87%) in Zürich (p = 0.335). Patients with progressive disease or a tumour marker increase before retroperitoneal lymph node dissection had significantly inferior progression-free and overall survival compared to non-progressing patients. The presence of teratoma in resected specimens did not confer inferior survival probabilities compared to necrosis only, whereas the presence of vital undifferentiated tumour conferred inferior progression-free and overall survival. Patients with a previous retroperitoneal lymph node dissection and patients operated for late relapses >2 years after chemotherapy also had significantly inferior progression-free and overall survival. We found a relevant rate of severe perioperative complications at PC-RPLND at even experienced high-volume centres. The oncological outcomes at two major university urological centres in Switzerland were similar and determined by preoperative risk factors and intraoperative histology.

MP50-08 POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION (PC-RPLND) FOR SEMINOMA: IS SURGERY EFFECTIVE?

You have accessJournal of UrologyCME1 Apr 2023MP50-08 POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION (PC-RPLND) FOR SEMINOMA: IS SURGERY EFFECTIVE? Isamu Tachibana, Andre Alabd, Rumeal Whaley, Jacob Mcfadden, Alex Piroozi, Sean Kern, Nabil Adra, Richard Foster, Lawrence Einhorn, Clint Cary, and Timothy Masterson Isamu TachibanaIsamu Tachibana More articles by this author , Andre AlabdAndre Alabd More articles by this author , Rumeal WhaleyRumeal Whaley More articles by this author , Jacob McfaddenJacob Mcfadden More articles by this author , Alex PirooziAlex Piroozi More articles by this author , Sean KernSean Kern More articles by this author , Nabil AdraNabil Adra More articles by this author , Richard FosterRichard Foster More articles by this author , Lawrence EinhornLawrence Einhorn More articles by this author , Clint CaryClint Cary More articles by this author , and Timothy MastersonTimothy Masterson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003298.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with relapsed seminoma after first-line chemotherapy can be treated with salvage chemotherapy or post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND). Based on prior reported experience, surgical management can have worse efficacy and increased morbidity compared to non-seminomatous germ cell tumor. Our aim was to characterize the surgical efficacy and difficulty in a specific cohort of patients with definite progression but minimal disease burden. METHODS: The Indiana University testis cancer database was queried to identify men who underwent PC-RPLND for seminoma between January 2011 to December 2021. Included patients only underwent first-line chemotherapy and could not have any evidence of non-seminomatous elements on orchiectomy or have elevated serum alpha-fetoprotein (AFP). All patient demonstrated high suspicion of retroperitoneal disease prior to PC-RPLND was based on increasing size of tumor on standard CT imaging, progression of FDG avidity on PET imaging, or elevated tumor markers. RESULTS: We identified 889 patients that underwent PC-RPLND, of which only 14 patients were operated on for seminoma. One patient was excluded for lack of meaningful follow-up. Out of 13 patients, only 3 patients were disease free with surgery and did not have to undergo salvage chemotherapy. Median follow up time was 29.9 months (IQR: 22.6-53.7). Two patients died due to testicular cancer. The remaining 8 patients were treated successfully with salvage chemotherapy. For additional procedures, 4 patients required a nephrectomy, 1 patient required an aortic graft, 2 patients required a partial ureterectomy, and 3 patients required partial or complete caval resection CONCLUSIONS: The decision between salvage chemotherapy and PC-RPLND as second-line therapy can be challenging. Salvage chemotherapy is effective but is associated with short and long-term morbidity. Surgical efficacy in this setting seems to be limited, but careful selection of patients may lead to surgical success without life threatening morbidity or adjunctive procedures that may compromise the ability to receive salvage chemotherapy. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e687 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Isamu Tachibana More articles by this author Andre Alabd More articles by this author Rumeal Whaley More articles by this author Jacob Mcfadden More articles by this author Alex Piroozi More articles by this author Sean Kern More articles by this author Nabil Adra More articles by this author Richard Foster More articles by this author Lawrence Einhorn More articles by this author Clint Cary More articles by this author Timothy Masterson More articles by this author Expand All Advertisement PDF downloadLoading ...

MP50-15 TESTICULAR RADIOMICS CORRELATED WITH PATHOLOGY AT TIME OF POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION FOR NON-SEMINOMATOUS GERM CELL TUMOR

You have accessJournal of UrologyCME1 Apr 2023MP50-15 TESTICULAR RADIOMICS CORRELATED WITH PATHOLOGY AT TIME OF POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION FOR NON-SEMINOMATOUS GERM CELL TUMOR Nikit Venishetty, Jacob Taylor, Yin Xi, Jeffrey Howard, Yeeseng Ng, and Aditya Bagrodia Nikit VenishettyNikit Venishetty More articles by this author , Jacob TaylorJacob Taylor More articles by this author , Yin XiYin Xi More articles by this author , Jeffrey HowardJeffrey Howard More articles by this author , Yeeseng NgYeeseng Ng More articles by this author , and Aditya BagrodiaAditya Bagrodia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003298.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Testicular germ cell tumors are the most commonly diagnosed malignancy in men aged 20 to 39 years old, as a third of patients will have metastatic disease on presentation. Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is performed to treat patients with metastatic non-seminomatous germ cell tumor (NSGCT). Although 50% of patients will viable GCT or teratoma, there is no accurate measurement to predict pre-operatively which patients will have residual disease after chemotherapy. Our aim was to use testicular radiomics data, a method that collects quantitative tumor imaging data from conventional imaging, to predict pathology after PC-RPLND. METHODS: Radiomics, clinical, and pathologic data were extracted from 45 patients with metastatic NSGCT undergoing PC-RPLND. An abdominal radiologist drew regions of interest (ROI) around metastatic notes, and PyRadiomics was used to extract first order, shape, and second order statistics from each ROI. T-Tests were performed to differentiate radiomics features between binary pathology type. P values were adjusted using the BH method to control false discovery rate. Python 3.7 and R 4.2.0 used for additional statistical analyses. RESULTS: There were 16 clinical stage II patients and 28 clinical stage III. 42% of patients had necrosis on PC-RPLND pathology, while 53% and 4% patients had teratoma and viable germ cell tumor, respectively. First order statistics mean, median, 90th percentile, and root mean squares were significant (Table 1). No significant differences was observed in other first order, shape, or texture features. We also show that the first order statistics above as significant, while the other radiomic statistics were not significant. CONCLUSIONS: Testicular radiomics is a tool that can help predict which patients with metastatic NSGCT are at higher risk of persistent disease after chemotherapy. We found relatively few first-order radiomic variables that were correlated with post-operative pathology. Results may have also been less predictive given small number of patients (4%) with residual GCT at time of RPLND. Further precision of extraction of the radiomics data may improve clinical decision-making in patients with metastatic NSGCT after chemotherapy prior to RPLND. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e690 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nikit Venishetty More articles by this author Jacob Taylor More articles by this author Yin Xi More articles by this author Jeffrey Howard More articles by this author Yeeseng Ng More articles by this author Aditya Bagrodia More articles by this author Expand All Advertisement PDF downloadLoading ...

MP50-16 ONCOLOGICAL OUTCOMES FOLLOWING ROBOTIC POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION FOR TESTICULAR CANCER: A WORLDWIDE MULTICENTER STUDY

You have accessJournal of UrologyCME1 Apr 2023MP50-16 ONCOLOGICAL OUTCOMES FOLLOWING ROBOTIC POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION FOR TESTICULAR CANCER: A WORLDWIDE MULTICENTER STUDY Alireza Ghoreifi, Anirban Mitra, Ashish Khanna, Jordan Rich, George McClintock, Fady Baky, Zachary Mcdowell, Matthew Ho, Jacob Roberts, Farshad Sheybaee Moghaddam, Taseen Haque, Inderbir Gill, Scott Eggener, James Porter, Nariman Ahmadi, Reza Mehrazin, John Sfakianos, Aditya Bagrodia, Sudhir Rawal, John Ward, and Hooman Djaladat Alireza GhoreifiAlireza Ghoreifi More articles by this author , Anirban MitraAnirban Mitra More articles by this author , Ashish KhannaAshish Khanna More articles by this author , Jordan RichJordan Rich More articles by this author , George McClintockGeorge McClintock More articles by this author , Fady BakyFady Baky More articles by this author , Zachary McdowellZachary Mcdowell More articles by this author , Matthew HoMatthew Ho More articles by this author , Jacob RobertsJacob Roberts More articles by this author , Farshad Sheybaee MoghaddamFarshad Sheybaee Moghaddam More articles by this author , Taseen HaqueTaseen Haque More articles by this author , Inderbir GillInderbir Gill More articles by this author , Scott EggenerScott Eggener More articles by this author , James PorterJames Porter More articles by this author , Nariman AhmadiNariman Ahmadi More articles by this author , Reza MehrazinReza Mehrazin More articles by this author , John SfakianosJohn Sfakianos More articles by this author , Aditya BagrodiaAditya Bagrodia More articles by this author , Sudhir RawalSudhir Rawal More articles by this author , John WardJohn Ward More articles by this author , and Hooman DjaladatHooman Djaladat More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003298.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The feasibility and safety of robotic approach for post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) has been previously shown by our group. The aim of this study is to evaluate the oncological outcomes of robotic PC-RPLND. METHODS: In this retrospective study, we included patients who underwent robotic PC-RPLND at nine academic centers across the world between 2011 and 2022. Patients’ characteristics, pathological findings, and oncological outcomes were reviewed. RESULTS: A total of 137 patients with a median age of 29 (IQR 25, 36) years were included. The baseline features and clinicopathological findings are shown in Table 1. BEP (bleomycin, etoposide, cisplatin) was the main chemotherapy regimen (80%) and 12 patients (9%) received salvage chemotherapy. Twelve cases (9%) were electively converted to open. Median estimated blood loss, operative time, and length of hospital stay were 100 mL, 5 hours, and 2 days, respectively. Final pathology revealed necrosis/fibrosis in 59 (43%), pure teratoma in 64 (47%), and viable germ cell tumor in 14 (10%) patients. Among patients with residual viable tumor, those with pN2,3 non-seminoma received chemotherapy and the others were followed closely. With a median follow-up of 21 (IQR 8, 49) months, seven patients (5%) had disease recurrence, of whom 3 (2%) were in-field (Table 2). 2-year recurrence free survival was 93%. Median time to recurrence was 11 months. No port-site recurrence or carcinomatosis was identified. Two (1.5%) cancer-related deaths were recorded. CONCLUSIONS: At centers with expertise in testicular cancer and minimally invasive surgery, in appropriately selected patients robotic PC-RPLND is associated with comparable short-term oncological outcomes to the open approach. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e691 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alireza Ghoreifi More articles by this author Anirban Mitra More articles by this author Ashish Khanna More articles by this author Jordan Rich More articles by this author George McClintock More articles by this author Fady Baky More articles by this author Zachary Mcdowell More articles by this author Matthew Ho More articles by this author Jacob Roberts More articles by this author Farshad Sheybaee Moghaddam More articles by this author Taseen Haque More articles by this author Inderbir Gill More articles by this author Scott Eggener More articles by this author James Porter More articles by this author Nariman Ahmadi More articles by this author Reza Mehrazin More articles by this author John Sfakianos More articles by this author Aditya Bagrodia More articles by this author Sudhir Rawal More articles by this author John Ward More articles by this author Hooman Djaladat More articles by this author Expand All Advertisement PDF downloadLoading ...