Primary Retroperitoneal Lymph Node Dissection Research Articles

Primary Retroperitoneal Lymph Node Dissection for Clinical Stage II A/B Seminomas: A Systematic Review and Meta-Analysis.

Chemotherapy and radiation therapy are considered standard treatments for stage II seminoma patients; however, these therapies are associated with long-term toxicities. Recently, retroperitoneal lymph node dissection has emerged as an alternative strategy, and the first three phase II trials were published in 2023 with promising results. The present study conducted a systematic review and meta-analysis to evaluate this surgery as an alternative treatment for stage IIA/B seminoma patients. Seminomas are the most common testicular tumors, often affecting young adult males. Standard treatments for stage II seminomas include chemotherapy and radiation therapy, but these therapies are associated with long-term toxicities. Thus, identifying alternative strategies is paramount. Herein, we conducted a systematic review and meta-analysis to appraise the efficacy and safety of retroperitoneal lymph node dissection (RPLND) for treating this condition. We systematically searched the PubMed, Embase, and Cochrane databases for studies evaluating RPLND as a primary treatment for stage II A/B seminomas. Using a random-effects model, single proportion and means and pooled 2-year recurrence-free survival rates with hazard rates and 95% CI were calculated. Seven studies were included, comprising 331 males with stage II seminomas. In the pooled analysis, the recurrence rate was 17.69% (95% CI 12.31-24.75), and the 2-year RFS rate was 81% (95% CI 0.77-0.86). The complication rate was 9.16% (95% CI 6.16-13.42), the Clavien-Dindo > 2 complication rate was 8.83% (95% CI 5.76-13.31), and the retrograde ejaculation rate was 7.01% (95% CI 3.54-13.40). The median operative time was 174.68 min (95% CI 122.17-249.76 min), median blood loss was 105.91 mL (95% CI 46.89-239.22 mL), and patients with no evidence of lymph node involvement ranged from 0-16%. Primary RPLNDs for treating stage IIA/B seminomas have favorable RFS rates, with low complication and recurrence rates. These findings provide evidence that this surgery is a viable alternative therapy for these patients.

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.

Outcomes after primary retroperitoneal lymph node dissection in men with stage 2 non-seminomatous germ cell tumour: A multicenter retrospective cohort study.

516 Background: Based on only smaller retrospective cohort studies, current guidelines recommend primary retroperitoneal lymph node dissection (RPLND) for men with marker-negative stage 2a non-seminomatous germ cell tumor (NSGCT). We aimed to reassess the role of primary RPLND in marker negative stage 2a, explore results in stages 2b/c and/or marker-positive disease, and evaluate surgical methods, recurrence, and adjuvant chemotherapy indications. Methods: Data from 17 institutions were collected, comprising 305 men who underwent primary RPLND for stage 2 NSGCT. Regression analyses were conducted to predict histology in the RPLND specimen and progression-free survival (PFS). Results: A larger retroperitoneal lymph node diameter was associated with pure teratoma in the RPLND specimen (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.09, p-value = 0.02), but it did not correlate with PFS. The 5-year PFS rates were 85% for men with pure teratoma, 94% for men with viable cancer who received adjuvant chemotherapy, and 72% for men with viable cancer who did not receive adjuvant chemotherapy. The number of adjuvant chemotherapy cycles did not significantly affect PFS. Conclusions: Our study suggests considering primary RPLND not only in marker negative clinical stage 2a but also marker negative clinical stage 2b. Further research should identify the efficacy in men in other stages (2C or marker positive) and which patients may benefit from adjuvant chemotherapy and the optimal cycle number.

Anticoagulation prophylaxis patterns following retroperitoneal lymph node dissection for testis cancer

IntroductionRetroperitoneal lymph node dissection (RPLND) is the standard of care for testicular cancer in various disease settings. Deep vein thrombosis (DVT) complications have been reported to occur in <1% of primary RPLND cases and up to 3% of postchemotherapy (PC-RPLND) cases. While prophylactic anticoagulation (AC) has been well-documented to reduce DVT rates in patients undergoing surgery in general, the benefit of prophylactic AC in RPLND has not been assessed. In this retrospective cohort study, we seek to address this unmet need by evaluating the rates and associated risk factors of DVT and pulmonary embolism (PE) with a national and institutional database, assess the changing patterns in DVT prophylaxis with postoperative AC following RPLND, and quantify the potential benefit of prophylactic AC in patients who have undergone RPLND using a risk-stratified approach. MethodsThe National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent RPLND during the 10-year period from 2011 to 2021. An institutional database was queried for all patients undergoing RPLND from 2013 to 2022. Patient characteristics and operative outcomes were compared between the NSQIP and the institutional database. The institutional database was stratified by prior oncologic treatment (i.e., primary RPLND vs. PC-RPLND) and outcomes were compared. Postoperative AC rate was determined and trended by year. The use of postoperative AC and PE events were stratified by clinical stage. The absolute risk reduction (ARR) of AC prophylaxis on PE events and the number needed to treat (NNT) with AC prophylaxis to prevent a single PE event was determined. ResultsIn total, the NSQIP database query resulted in 779 patients and our institutional database query resulted in 188 patients. The rate of DVT and PE was 1.2% and 0.5% vs. 2.1% and 1.6% in the NSQIP and institutional cohort, respectively. The rate of postoperative AC following RPLND in patients from the institutional database increased from 5% in 2013 to 43% in 2022 (P = 0.01). There were no statistically significant differences in complication rates, including bleeding events, chyle leaks, or hospital readmissions amongst patients who were prescribed AC at discharge and those who were not. No stage I patients developed PEs and no stage I patients were prescribed AC. The ARR for AC prophylaxis for development of PE was found to be 0.023 for the clinical stage II and stage III cohorts. The NNT to prevent a single PE with AC was 44 and 43 for the stage II and stage III cohorts, respectively. ConclusionsAC appears beneficial with minimal risk of harm after RPLND, especially in patients with higher risk of developing DVT/PE, highlighting the safety and efficacy of this regimen. There was a significant increase in the rate of AC prophylaxis at discharge amongst patients undergoing RPLND in the institutional database from 2013 to 2022. A risk-stratified protocol of postoperative AC following RPLND appears reasonable, and further prospective trials are warranted to formally confirm this recommendation.

Primary Retroperitoneal Lymph Node Dissection for Seminoma Metastatic to the Retroperitoneum.

Primary surgical treatment with retroperitoneal lymph node dissection aims to accurately stage and treat patients with node-positive pure seminoma while avoiding long-term risks of chemotherapy or radiation, traditional standard-of-care treatments. We reported the pathologic and oncologic outcomes of patients with pure seminoma treated with primary retroperitoneal lymph node dissection in a retrospective, single-institution case series over 10 years. The primary outcome was two-year recurrence-free survival stratified by adjuvant management strategy (surveillance versus adjuvant chemotherapy). Forty-five patients treated with primary retroperitoneal lymph node dissection for pure testicular seminoma metastatic to the retroperitoneum were identified. Median size of largest lymph node before surgery was 1.8 cm. Viable germ cell tumor, all of which was pure seminoma, was found in 96% (n=43) of patients. The median number of positive nodes and nodes removed was 2 and 54, respectively. Median positive pathologic node size was 2 cm (IQR 1.4-2.5 cm, range 0.1-5 cm). Four of 29 patients managed with post-operative surveillance experienced relapse; two-year recurrence-free survival was 81%. Median follow-up for those managed with surveillance who did not relapse was 18.5 months. There were no relapses in the retroperitoneum, visceral recurrences, or deaths. Among the 16 patients who received adjuvant treatment, 1 patient experienced relapse in the pelvis at 19 months. Primary retroperitoneal lymph node dissection for pure seminoma with low-volume metastases to the retroperitoneum is safe and effective, allowing most patients to avoid long-term toxicities from chemotherapy or radiation.

Retroperitoneal Lymph Node Dissection in Clinical Stage IIA/B Metastatic Seminoma: Results of the COlogne Trial of Retroperitoneal Lymphadenectomy In Metastatic Seminoma (COTRIMS)

BackgroundRadiation therapy and systemic chemotherapy are recommended treatment options in marker-negative clinical stage (CS) IIA/B seminoma. Despite high cure rates of 82–94%, both therapeutic options are associated with significant long-term toxicities. ObjectiveTo evaluate the feasibility, oncological efficacy, and treatment-associated morbidity of primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) in CS IIA/B seminoma. Design, setting, and participantsA prospective, single-arm, clinical phase 2 trial including CS IIA/B seminoma patients was conducted. InterventionPrimary nerve-sparing retroperitoneal lymphadenectomy. Outcome measurements and statistical analysisRelapse-free and overall survival, surgery-associated complications according to the Clavien-Dindo classification, and Kaplan-Meier methods for survival calculation were assessed. Results and limitationsThirty patients at a mean age of 39.1 (34–52) yr with marker-negative CS IIA and IIB seminomas were recruited. The median follow-up was 22 (8–30) mo. Nineteen (63%) and 11 (36%) patients were diagnosed with stages IIA and B, respectively, at the time of primary diagnosis. Fourteen (47%) and 16 (53%) patients were diagnosed with CS IIA and IIB, respectively, at the time of nsRPLND. Twenty-seven and three patients underwent open and robot-assisted nsRPLND, respectively. The median operating room time was 125 (115–145) min, median blood loss was <150 ml, and median time of hospitalization was 4.5 (3–9) d. Four (13%) patients experienced Clavien-Dindo grade 3a complications. Lymph node histology revealed seminoma in 25 (80%) patients; two and three patients demonstrated embryonal carcinoma and benign disease, respectively. Sixteen patients underwent a serum analysis of miR371 preoperatively, which predicted metastatic disease in 12/13 and benign histology in 3/3 patients. Three of 30 (10%) patients developed an outfield relapse 4, 6, and 9 mo postoperatively and were salvaged by systemic chemotherapy. Limitations are the low patient number and length of follow-up. ConclusionsThe nsRPLND approach results in a high cure rate at midterm follow-up and is associated with a low frequency of treatment-associated morbidities, making this approach a feasible alternative to radiation therapy or systemic chemotherapy. Patient summaryThe standard treatment of clinical stage IIA/B seminomas is radiation therapy or chemotherapy, which results in a significantly increased frequency of long-term toxicity and secondary neoplasms. In this trial, we demonstrate that nerve-sparing retroperitoneal lymph node dissection is a feasible therapeutic approach with low morbidity and high oncological efficacy.

Comparison of laparoscopic, robotic, and open retroperitoneal lymph node dissection for non-seminomatous germ cell tumor: a single-center retrospective cohort study

PurposeTo compare the perioperative outcomes of L-RPLND, R-RPLND and O-RPLND, and determine which one can be the mainstream option.MethodsWe retrospectively reviewed medical records of 47 patients undergoing primary RPLND by three different surgical techniques for stage I–II NSGCT between July 2011 and April 2022 at our center. Standard open and laparoscopic RPLND was performed with usual equipment, and robotic RPLND was operated with da Vinci Si system.ResultsForty-seven patients underwent RPLND during 2011–2022, and 26 (55.3%) of them received L-RPLND, 14 (29.8%) were operated with robot, while 7 (14.9%) were performed O-RPLND. The median follow-up was 48.0 months, 48.0 months, and 60.0 months, respectively. The oncological outcomes were comparable among all groups. In L-RPLND group, there were 8 (30.8%) cases of low grade (Clavien I–II) complications, and 3 (11.5%) cases of high-grade (Clavien III–IV) complications. In R-RPLND group, one (7.1%) low-grade complication and four (28.6%) high-grade complications were observed. In O-RPLND group, there were 2 (28.5%) cases of low-grade complications and one case (14.2%) of high-grade one. The operation duration of L-RPLND was the shortest. In O-RPLND group, the number of positive lymph nodes were higher than other two groups. Patients undergoing open surgery had lower (p < 0.05) red blood cell count, hemoglobin level, and higher (p < 0.05) estimated blood loss, white blood cell count than those receiving either laparoscopic or robotic surgery.ConclusionAll three surgical techniques are comparable in safety, oncological, andrological, and reproductive outcomes under the circumstance of not using primary chemotherapy. L-RPLND might be the most cost-effective option.

Primary retroperitoneal lymph node dissection (RPLND) in seminoma stage IIA-IIC ≤3cm: Combined results of the SWENOTECA (Swedish Norwegian Testicular Cancer Group) and Cologne.

Background: Chemotherapy or radiotherapy have been standard treatment for stage II seminomas with excellent survival but are associated with significant long-term treatment-related toxicities. Several prospective trials have shown primary retroperitoneal lymph node dissection (RPLND) to be an effective and safe alternative. The current SWENOTECA treatment program recommends primary RPLND in seminoma stage IIA to IIB ≤ 3 cm with 1-2 metastatic nodes as the standard treatment modality. We present preliminary results combined with data from Cologne. Methods: Within SWENOTECA, RPLND is centralized to 5 hospitals and Cologne is a tertiary centre for patients recruited from different parts of Germany. Both patients with recurrence after initial stage I disease and patients with primary stage IIA and IIB at diagnosis were included. We collected information on operation time, bleeding, peri- and postoperative complications. We also analyzed histologic outcome and whether adjuvant chemotherapy was given. We followed the patients for any recurrence of disease. Results: We have included 94 patients operated from May 2018 to November 2022. The number of operations per site varied from 4 to 28. The mean age of patients at time of RPLND was 41.8 years (range 21-79). Overall, 54 patients had recurrence after initial stage I disease and 40 patients had primary stage IIA/IIB disease at diagnosis (one missing data). At time of RPLND 62 patients had IIA-disease and 31 stage IIB-disease (one missing data). The histology from RPLND showed seminoma in 83 patients, benign/necrosis in eight patients, vital non-seminomatous GCT in one patient, teratoma only in one patient and lymphoma in one patient. Mean number of resected nodes was 19, and mean number of positive nodes were 1.5. Twenty-six patients (28%) were operated with robotic laparoscopic technique. Ten patients (10.6%) had a Clavien-Dindo postoperative complication &gt; 2. Twenty-three of the patients were given adjuvant oncological treatment after RPLND, most of them one course of BEP. The patients have been followed for in median 18 months (range 2-59). Nine patients (9.6 %) have had recurrences, all but one in the first year after RPLND. Conclusions: Our early results of primary RPLND of seminomas IIA-IIB ≤ 3 cm are promising. Longer follow-up is required to ensure this as a safe treatment option.

The role of primary retroperitoneal lymph node dissection in the treatment of stage II seminoma.

Stage II seminoma is responsive to chemo- or radiotherapy with a progression-free survival of 87-95% at 5 years but at the cost of short- and long-term toxicity. After evidence about these long-term morbidities emerged, four surgical cohorts investigating the role of retroperitoneal lymph node dissection (RPLND) as a treatment option for stage II disease were initiated. Currently, two RPLND series have been published as a complete report, while data from other series have only been published as congress abstracts. In series without adjuvant chemotherapy, recurrence rates ranged from 13% to 30% after follow-ups of 21-32 months. In those receiving RPLND and adjuvant chemotherapy, the recurrence rate was 6% after a mean follow-up of 51 months. Across all trials, recurrent disease was treated with systemic chemotherapy (22/25), surgery (2/25), and radiotherapy (1/25). The rate of pN0 disease after RPLND varied between 4% and 19%. Postoperative complications were reported in 2-12%, while antegrade ejaculation was maintained in 88-95% of patients. Median length of stay ranged from 1 to 6 days. In men with clinical stage II seminoma, RPLND is a safe and promising treatment option. Further research is needed to determine the risk of relapse and to personalize treatment options based on patient-specific risk factors.

MP50-09 CONTEMPORARY OUTCOMES OF PRIMARY EXTRAPERITONEAL RETROPERITONEAL LYMPH NODE DISSECTION FOR STAGE II GERM CELL TUMORS

You have accessJournal of UrologyCME1 Apr 2023MP50-09 CONTEMPORARY OUTCOMES OF PRIMARY EXTRAPERITONEAL RETROPERITONEAL LYMPH NODE DISSECTION FOR STAGE II GERM CELL TUMORS Muhannad Alsyouf, Arman Ashrafi, Sanam Ladi Seyedian, Erika L. Wood, Antoin Douglawi, Hamed Ahmadi, Madeleine Burg, Alireza Ghoreifi, Sumeet Bhanvadia, Anne Schuckman, Hooman Djaladat, and Siamak Daneshmand Muhannad AlsyoufMuhannad Alsyouf More articles by this author , Arman AshrafiArman Ashrafi More articles by this author , Sanam Ladi SeyedianSanam Ladi Seyedian More articles by this author , Erika L. WoodErika L. Wood More articles by this author , Antoin DouglawiAntoin Douglawi More articles by this author , Hamed AhmadiHamed Ahmadi More articles by this author , Madeleine BurgMadeleine Burg More articles by this author , Alireza GhoreifiAlireza Ghoreifi More articles by this author , Sumeet BhanvadiaSumeet Bhanvadia More articles by this author , Anne SchuckmanAnne Schuckman More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , and Siamak DaneshmandSiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003298.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with germ cell tumors (GCT) and clinically low volume retroperitoneal adenopathy have multiple treatment options offering excellent oncologic outcomes. Primary retroperitoneal lymph node dissection (RPLND) is a treatment option that avoids the long term side effects of systemic therapies, however, can be associated with short term morbidity. The objective of this study was to evaluate the perioperative and oncologic outcomes of GCT patients who underwent a primary RPLND via an open extraperitoneal approach (EP RPLND) for the management of clinical stage II (CSII) GCT. METHODS: All GCT patients with marker negative, CSII who underwent a primary EP-RPLND between 2010-2021 were reviewed. The study population included patients with clinical stage (CS)I with retroperitoneal relapse & de-novo CSII patients. Perioperative, ejaculatory function, & oncologic outcomes were evaluated including recurrence rates and patterns. RESULTS: Overall, 45/170 EP-RPLND were performed in the primary setting (20 seminoma, 45 NSGCT). Median radiologic disease size was 1.7cm(IQR 1.3-2.3). Median number of lymph nodes resected was 35(IQR 23–46.5). Three patients (6.7%) experienced a 90-day complication. There were no cases of postoperative ileus, and median hospital stay was 2(IQR 1-3) days. In patients who underwent nerve sparing, 40/44 (91%) maintained antegrade ejaculatory function. pN+ rate was 90% in seminoma and 68% in NSGCT. In seminoma patients, 20 underwent a primary EP-RPLND. At a follow-up of 37.4 months, only 2 patients (10%) with stage IIA developed recurrence: 1 in-field (at 33.3 months follow-up) and 1 outside-field recurrence (at 42.7 months). Both were successfully managed with subsequent surgical resection, with an overall survival (OS) and systemic treatment free survival (STFS) of 100%. In 25 NSGCT patients with a median follow-up of 20.9 months, there were 6 recurrences (24%, 3 stage IIA, 3 stage IIB) at a median time of 3.1 months. All of these recurrences were successfully managed with chemotherapy (OS 100%, STFS 76%). CONCLUSIONS: In CSII GCT, a primary EP RPLND is safe, associated with short hospitalization, and offers excellent oncologic outcomes while minimizing patients morbidity. In this series, all seminoma patients and 76% of NSGCT patients avoided systemic therapy. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e688 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Muhannad Alsyouf More articles by this author Arman Ashrafi More articles by this author Sanam Ladi Seyedian More articles by this author Erika L. Wood More articles by this author Antoin Douglawi More articles by this author Hamed Ahmadi More articles by this author Madeleine Burg More articles by this author Alireza Ghoreifi More articles by this author Sumeet Bhanvadia More articles by this author Anne Schuckman More articles by this author Hooman Djaladat More articles by this author Siamak Daneshmand More articles by this author Expand All Advertisement PDF downloadLoading ...

MP33-04 THE EARLY RESULTS OF THE SWENOTECA (SWEDISH NORWEGIAN TESTICULAR CANCER GROUP) INTRODUCTION OF PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION (RPLND) IN SEMINOMA STAGE IIA-IIB ≤ 3cm

You have accessJournal of UrologyCME1 Apr 2023MP33-04 THE EARLY RESULTS OF THE SWENOTECA (SWEDISH NORWEGIAN TESTICULAR CANCER GROUP) INTRODUCTION OF PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION (RPLND) IN SEMINOMA STAGE IIA-IIB ≤ 3cm Anna Thor, Axel Gerdtsson, Bjarte Almas, Dag Halvorsen, Gabriella Cohn Cedermark, Helene Neegaard, Ingrid Glimelius, Hege Sagstuen Haugnes, Asa Karlsdottir, Olof Stahl, Signe Melsen Larsen, Anna Grenabo Bergdahl, Torgrim Tandstad, and Anders Kjellman Anna ThorAnna Thor More articles by this author , Axel GerdtssonAxel Gerdtsson More articles by this author , Bjarte AlmasBjarte Almas More articles by this author , Dag HalvorsenDag Halvorsen More articles by this author , Gabriella Cohn CedermarkGabriella Cohn Cedermark More articles by this author , Helene NeegaardHelene Neegaard More articles by this author , Ingrid GlimeliusIngrid Glimelius More articles by this author , Hege Sagstuen HaugnesHege Sagstuen Haugnes More articles by this author , Asa KarlsdottirAsa Karlsdottir More articles by this author , Olof StahlOlof Stahl More articles by this author , Signe Melsen LarsenSigne Melsen Larsen More articles by this author , Anna Grenabo BergdahlAnna Grenabo Bergdahl More articles by this author , Torgrim TandstadTorgrim Tandstad More articles by this author , and Anders KjellmanAnders Kjellman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003266.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Chemotherapy or radiotherapy have been the standard treatment for stage II seminomas with excellent results for survival but associated with significant long-term treatment-related toxicities. Several prospective trials have shown primary retroperitoneal lymph node dissection (RPLND) to be effective and safe as an alternative treatment. These results made us change the guidelines in the latest update of the SWENOTECA treatment program making surgery with RPLND the primary treatment modality in seminoma stage IIA to IIB ≤ 3 cm with 1-2 metastatic nodes. We have done an update of the result of the patients treated by the new management program. METHODS: The RPLND surgery in Sweden and Norway are centralised to 5 hospitals all participating in this study. In the study we included both patients with recurrence after initial stage I disease and patients with stage IIA and B at diagnosis. The patients were operated between 2019 and 2022. We collected information on operation time, bleeding, peri- and postoperative complications. We also analysed the histology and if adjuvant chemotherapy was given. We followed the patients for any recurrence of disease. RESULTS: We have included 61 patients operated from January 2019 to September 2022. The number of operations per site varied from 4 to 22. The mean age of patients at time of RPLND was 42.6 years (range 25-79). 38 patients had stage I disease at diagnosis and a recurrence. 23 patients had stage IIA or IIB disease at diagnosis. At time of RPLND 46 patients had IIA-disease and 14 stage IIB-disease (one missing data). The histology from RPLND showed seminoma in 56 patients, necrosis in two patients, teratoma in one patient (two missing data). 24 patients were operated with robotic laparoscopic technique. Seven patients out of 61 had a Clavien-Dindo postoperative complication > 2. The patients have been followed for a median of 17 months (range 2-45). Five patients have had recurrences, three in operated template and two outside templates. CONCLUSIONS: Our early results of primary RPLND of seminomas IIA-IIB ≤ 3 cm, show promising results. Longer follow-up is required to fully ensure that this is a safe treatment option. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e451 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anna Thor More articles by this author Axel Gerdtsson More articles by this author Bjarte Almas More articles by this author Dag Halvorsen More articles by this author Gabriella Cohn Cedermark More articles by this author Helene Neegaard More articles by this author Ingrid Glimelius More articles by this author Hege Sagstuen Haugnes More articles by this author Asa Karlsdottir More articles by this author Olof Stahl More articles by this author Signe Melsen Larsen More articles by this author Anna Grenabo Bergdahl More articles by this author Torgrim Tandstad More articles by this author Anders Kjellman More articles by this author Expand All Advertisement PDF downloadLoading ...

MP50-14 A MULTICENTER EVALUATION OF THE PROGNOSTIC UTILITY OF CHANGES IN TREATMENT-ASSOCIATED BODY COMPOSITION IN MEN WITH GERM CELL TUMORS (GCT) OF THE TESTIS: IMPLICATIONS FOR ADVERSE EVENTS AND COMPLICATIONS

You have accessJournal of UrologyCME1 Apr 2023MP50-14 A MULTICENTER EVALUATION OF THE PROGNOSTIC UTILITY OF CHANGES IN TREATMENT-ASSOCIATED BODY COMPOSITION IN MEN WITH GERM CELL TUMORS (GCT) OF THE TESTIS: IMPLICATIONS FOR ADVERSE EVENTS AND COMPLICATIONS Claire Buxton, Benjamin N. Schmeusser, Sarah K. Holt, Datta Patil, Anthea Phuong, J. Peter Marquardt, Ryan O'malley, Grace Laidlaw, George R. Schade, Daniel W. Lin, Michael T. Schweizer, Todd Yezefski, Evan Y. Yu, Bruce Montgomery, Florian J. Fintelmann, Sophia Chahine, Viraj A. Master, and Sarah P. Psutka Claire BuxtonClaire Buxton More articles by this author , Benjamin N. SchmeusserBenjamin N. Schmeusser More articles by this author , Sarah K. HoltSarah K. Holt More articles by this author , Datta PatilDatta Patil More articles by this author , Anthea PhuongAnthea Phuong More articles by this author , J. Peter MarquardtJ. Peter Marquardt More articles by this author , Ryan O'malleyRyan O'malley More articles by this author , Grace LaidlawGrace Laidlaw More articles by this author , George R. SchadeGeorge R. Schade More articles by this author , Daniel W. LinDaniel W. Lin More articles by this author , Michael T. SchweizerMichael T. Schweizer More articles by this author , Todd YezefskiTodd Yezefski More articles by this author , Evan Y. YuEvan Y. Yu More articles by this author , Bruce MontgomeryBruce Montgomery More articles by this author , Florian J. FintelmannFlorian J. Fintelmann More articles by this author , Sophia ChahineSophia Chahine More articles by this author , Viraj A. MasterViraj A. Master More articles by this author , and Sarah P. PsutkaSarah P. Psutka More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003298.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Skeletal muscle mass is associated with oncologic outcomes and treatment-associated toxicity across malignancies. However, men with GCT are younger and less likely to suffer baseline age-related muscle loss. As such, the prognostic utility of body composition metrics in GCT is undefined. We aimed to quantify changes in body composition following cytotoxic chemotherapy (CC) for GCT and evaluate associations between these changes and rates of CC-associated adverse events (AEs) and post-retroperitoneal lymphadenectomy (RPLND) complications. METHODS: This retrospective study included 216 patients with GCT (N=152 from Fred Hutchinson Cancer Center/ University of Washington; N=64 from Emory University Hospital) treated with CC and/or RPLND, with CT scans within 75 days before initiation and after completion of treatment. We analyzed L3 axial CT scans for skeletal muscle index (SMI), subcutaneous adipose index (SAI), and visceral adipose index (VAI). Logistic regression was used to evaluate associations between body composition metrics and grade 3+ AEs and Clavien 3+ post-RPLND complications. RESULTS: Median age for the cohort was 30 years (IQR 25-39) of whom, 47% of men had nonseminomatous GCT (Stage IS, II, and III in 17%, 39%, and 42%, respectively). 182 men received CC including BEP (67%), EP (19%), and VIP (7%), with a median of 3 cycles while 34 men (33%) and 69 men underwent primary and post-CC RPLND, respectively. Median time between CTs was 114 days. Median change in SMI, VAI, and SAI was -6% (Figure 1), +13%, and +11%, respectively. Overall, 79 men (43%) experienced grade 3+ AEs, and 24 men (23%) experienced Clavien 3+ post-RPLND complications. On regression analysis, higher baseline VAI (p=0.048), lower post-CC SMI (p=0.008), and decreased SMI (p=0.047) were associated with increased risk of grade 3+ AE. No baseline body composition metrics or changes therein during CC predicted risk of post-RPLND complications. CONCLUSIONS: We observed a decline in skeletal muscle and an increase in adipose tissue following CC in men with GCT. Both skeletal muscle and adipose tissue metrics were associated with the incidence of chemotherapy-associated adverse events and may have the potential for use in risk evaluation. Source of Funding: None © 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 Claire Buxton More articles by this author Benjamin N. Schmeusser More articles by this author Sarah K. Holt More articles by this author Datta Patil More articles by this author Anthea Phuong More articles by this author J. Peter Marquardt More articles by this author Ryan O'malley More articles by this author Grace Laidlaw More articles by this author George R. Schade More articles by this author Daniel W. Lin More articles by this author Michael T. Schweizer More articles by this author Todd Yezefski More articles by this author Evan Y. Yu More articles by this author Bruce Montgomery More articles by this author Florian J. Fintelmann More articles by this author Sophia Chahine More articles by this author Viraj A. Master More articles by this author Sarah P. Psutka More articles by this author Expand All Advertisement PDF downloadLoading ...

Trial in progress: PRESTIGE—Primary retroperitoneal lymph node dissection (RPLND) for clinical stage II (CSII) testicular germ cell tumour (TGCT) and its impact on health-related quality of life (HRQoL) compared to chemotherapy or radiotherapy.

TPS433 Background: As cure rates for patients with advanced TGCT improve, there is increasing focus on quality of survival. Increasingly, primary RPLND is being used as an alternative to chemotherapy (and radiotherapy) as primary treatment for selected individuals, due to the development of low morbidity surgical techniques (robot-assisted and extraperitoneal approaches), and recognition of acute and long-term toxicity of chemotherapy and radiotherapy. We hypothesise that primary RPLND compared to chemotherapy and radiotherapy will have less detrimental impact on HRQoL with comparable oncological outcomes. Methods: PRESTIGE is a prospective cohort study among adults with histologically confirmed advanced TGCT planned for primary RPLND, chemotherapy or radiotherapy. Eligible patients may have de novo advanced disease, or relapse within two- (NSGCT) or three-years (seminoma) following orchidectomy, without prior chemotherapy or radiotherapy (including adjuvant), and able to complete HRQoL questionnaires in English. See table for cohort-specific eligibility. Surgical approach (modality, template, adjuvant chemotherapy), chemotherapy regimen and radiotherapy dose will be administered at physician discretion and captured in Australia’s national multi-centre TGCT registry, iTestis, with clinical data in follow-up. Participants will complete HRQoL questionnaires focusing on physical, social, emotional, and functional domains commencing prior to treatment and continuing for 24 months. Questionnaires include EORTC QLQ-C30, EORTC QLQ-TC26, Brief Male Sexual Function Inventory and specific questions focusing on retrograde ejaculation and fertility. Patients undergoing RPLND will also have miR-371 evaluation pre-operatively and serially for 12 months after surgery. The primary outcome is change in EORTC QLQ-C30 global health status over 24 months for participants undergoing primary RPLND. Key secondary outcomes are changes in HRQoL, patterns of recurrence, surgical complications, retrograde ejaculation, and infertility. A sample size of 90 participants (30 for RPLND, 60 for chemotherapy) provides &gt;80% power to detect a mean difference of 28% in global health status at 0.05 significance favouring RPLND. Up to 30 individuals receiving radiotherapy may also be enrolled. The first site was activated 4-Aug-22; 2 of 3 study sites are active and 5 out of a planned 120 (4%) participants have enrolled. [Table: see text]

Low rate of teratoma in primary retroperitoneal lymph node dissection for non-seminoma csiia marker negative patients – a population-based study from the swedish and norwegian testicular cancer group

Low rate of teratoma in primary retroperitoneal lymph node dissection for non-seminoma csiia marker negative patients – a population-based study from the swedish and norwegian testicular cancer group

The early results of the SWENOTECA (Swedish Norwegian Testicular Cancer Group) introduction of primary Retroperitoneal Lymph Node Dissection (RPLND) in seminoma stage IIA-IIb ≤ 3cm

The early results of the SWENOTECA (Swedish Norwegian Testicular Cancer Group) introduction of primary Retroperitoneal Lymph Node Dissection (RPLND) in seminoma stage IIA-IIb ≤ 3cm

PRIMETEST II – trial to test new predictors of recurrence in CS II A/B seminoma patients treated with primary robot-assisted retroperitoneal lymph node dissection

PRIMETEST II – trial to test new predictors of recurrence in CS II A/B seminoma patients treated with primary robot-assisted retroperitoneal lymph node dissection

Twenty Years' Experience in Retroperitoneal Lymph Node Dissection for Testicular Cancer in a Tertiary Referral Center.

Background and Objectives: The aim of this article is to present a single-surgeon, open retroperitoneal lymph node dissection (RPLND) series for testicular cancer in a high-volume center. Materials and Methods: We reviewed data from patients who underwent RPLND performed by an experienced surgeon at our institution between 2000 and 2019. We evaluated surgical and perioperative outcomes, complications, Recurrence-Free Survival (RFS), Overall Survival (OS), and Cancer-Specific Survival (CSS). Results: RPLND was performed in primary and secondary settings in 21 (32%) and 44 (68%) patients, respectively. Median operative time was 180 min. Median hospital stay was 6 days. Complications occurred in 23 (35%) patients, with 9 (14%) events reported as Clavien grade ≥ 3. Patients in the primary RPLND group were significantly younger, more likely to have NSGCT, had higher clinical N0 and M0, and had higher nerve-sparing RPLND (all p ≤ 0.04) compared to those in the secondary RPLND group. In the median follow-up of 120 (56-180) months, 10 (15%) patients experienced recurrence. Finally, 20-year OS, CSS, and RFS were 89%, 92%, and 85%, respectively, with no significant difference in survival rates between primary vs. secondary RPLND subgroups (p = 0.64, p = 0.7, and p = 0.31, respectively). Conclusions: Open RPLND performed by an experienced high-volume surgeon achieves excellent oncological and functional outcomes supporting the centralization of these complex procedures.

Phase 2 Single-arm Trial of Primary Retroperitoneal Lymph Node Dissection in Patients with Seminomatous Testicular Germ Cell Tumors with Clinical Stage IIA/B (PRIMETEST)

BackgroundPrimary retroperitoneal lymph node dissection (RPLND) for clinical stage (CS) IIA/B seminoma without adjuvant treatment is an experimental treatment to avoid radiotherapy- or chemotherapy-related toxicity from standard treatment. ObjectiveThe PRIMETEST trial aimed to prospectively evaluate the oncological efficacy and surgical safety of primary RPLND. Design, setting, and participantsPRIMETEST is a single-arm, single-center prospective phase 2 trial. Patients with seminoma, unilateral retroperitoneal lymph node metastases <5 cm, and human chorionic gonadotropin levels <5 mU/ml were included. Patients with CS IIA/B seminoma at initial diagnosis, and recurrence under active surveillance or following adjuvant carboplatin for CS I disease were eligible. Outcome measurements and statistical analysisUnilateral open or robot-assisted primary RPLND was performed. The primary endpoint of the study was progression-free survival (PFS) after 36 mo. The trial was considered positive if <30% of patients experienced a recurrence. Results and limitationsBetween 2016 and 2021, 33 patients were accrued (nine with primary CS IIA/B, 19 recurrences during active surveillance, and five recurrences following adjuvant carboplatin). Thirteen and 20 patients had CS IIA and IIB, respectively. Open and robot-assisted RPLND procedures were performed in 14 (42%) and 19 (58%) patients, respectively. After a median follow-up of 32 mo (interquartile range 23–46), ten recurrences were detected (30%, 95% confidence interval: 16–49%); thus, the primary endpoint was not met. Infield recurrences occurred in three of ten patients. The current analysis of risk factors could not identify the predictors of recurrence. Three of 33 patients (9%) presented with pN0. ConclusionsThe PRIMETEST trial did not meet its primary endpoint. Nevertheless, PFS of 70% after a median follow-up of 32 mo suggests this approach to be of interest for highly selected patients. Selection criteria, however, need to be defined and validated in a larger prospective cohort of patients. Until then, surgery alone for the treatment of patients with CS IIA/B seminoma cannot be recommended outside of a clinical trial setting. Patient summaryIn this study, we investigated primary surgery as an alternative to conventional treatment (chemotherapy or radiation therapy) in patients with metastatic seminoma. The primary objective of the study, to prevent at least 30% of patients from recurrence, was not met. However, certain patients may benefit from this approach and thereby avoid chemotherapy or radiation therapy. Predictive factors need to be analyzed to better select patients for this surgery-only approach.

Evaluation of miR-371a-3p to predict viable germ cell tumor in patients with pure seminoma receiving retroperitoneal lymph node dissection.

Conventional serum tumor markers (STMs) for testicular germ cell tumors (GCTs) offer limited performance with particularly poor sensitivity in cases of minimal residual disease and pure seminoma. While growing evidence has indicated miR-371a-3p to be a superior biomarker, its utility in detecting pure seminoma at recurrence has not been extensively explored. This study's objective was to explore miR-371a-3p's utility in detecting metastatic pure seminoma at retroperitoneal lymph node dissection (RPLND). RNA was isolated from patient serum samples collected pre-RPLND. Fifteen patients were assigned to our 'benign' (n = 6) or 'seminoma' (n = 9) group based on pathological confirmation of viable seminoma. Five of the patients received chemotherapy before RPLND (PC-RPLND), and 10 were chemotherapy naïve. MiR-371a-3p expression was quantified via RT-quantitative polymerase chain reaction. The Cq values were statistically evaluated to obtain performance measurements. Median relative expression of miR-371a-3p was higher in the Seminoma group than the Benign, but this difference was not statistically significant (Rq = 3705 and 241, respectively, p = 0.2844). Of the 10 chemotherapy naïve patients, nine had viable seminoma at RPLND, and seven had elevated miR-371a-3p expression. Among the five postchemotherapy (PC) patients, zero had viable GCT at RPLND, and two had elevated miR-371a-3p expression. The primary RPLND group presented 78% sensitivity and 100% specificity. Specificity in the PC-RPLND group was 60%. An optimal Rq threshold of 28.62 was determined by Youden's J statistic, yielding 78% sensitivity and 67% specificity. Receiver operating characteristic analysis provided an AUC of 0.704 (95% CI: 0.43-0.98, p = 0.1949). Despite modest performance, miR-371a-3p exhibited improved sensitivity and specificity compared with conventional STMs. MiR-371a-3p outperformed STMs in the primary RPLND settings. However, miR-371a-3p was not a robust predictor of pathology in the PC setting. These results suggest that pure seminoma at RPLND is a clinical context, wherein the miRNA assay may require further refinement.

P123 - Treatment outcomes of men with stage 2 non-seminomatous germ cell tumours treated with primary retroperitoneal lymph node dissection: A systematic review

P123 - Treatment outcomes of men with stage 2 non-seminomatous germ cell tumours treated with primary retroperitoneal lymph node dissection: A systematic review