Epidemiological pattern and time trends in testicular germ-cell tumors: a single institution 20-year experience

Unilateral post-chemotherapy robot-assisted retroperitoneal lymph node dissection in Stage II non-seminomatous germ cell tumor: A tertiary care experience

Objective

Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) represents an integral component of the management of patients with non-seminomatous germ cell tumor (NSGCT). Modified templates have been proposed to minimize the surgical morbidity of the procedure. Moreover, the implementation of robotic surgery in this setting has been explored. We report our experience with unilateral post-chemotherapy robot-assisted retroperitoneal lymph node dissection (PC-rRPLND) for clinical Stages IIA and IIB NSGCTs.

Methods

A retrospective single institution review was performed including 33 patients undergoing PC-rRPLND for Stages IIA and IIB NSGCTs between January 2015 and February 2019. Following orchiectomy, patients were scheduled for chemotherapy with three cycles of bleomycin-etoposide-cisplatin. Patients with a residual tumor of <5 cm and an ipsilateral metastatic disease on pre- and post-chemotherapy CT scans were eligible for a unilateral template in absence of rising tumor markers. Descriptive statistics were provided for demographics, clinical characteristics, intraoperative and postoperative parameters. Perioperative, oncological, and functional outcomes were recorded.

Results

Overall, 7 (21.2%) patients exhibited necrosis or fibrosis; 14 (42.4%) had mature teratoma; and 12 (36.4%) had viable tumor at final histology. The median lymph node size at surgery was 25 (interquartile range [IQR] 21-36) mm. Median operative time was 180 (IQR 165-215) min and no major postoperative complications were observed. Anterograde ejaculation was preserved in 75.8% of patients. Median follow-up was 26 (IQR 19-30) months and a total of three recurrences were recorded.

Conclusion

PC-rRPLND is a reliable and technically reproducible procedure with safe oncological outcomes and acceptable postoperative ejaculatory function in well selected patients with NSGCTs.

The effect of educational intervention based on health belief model and social support on testicular self-examination in sample of Iranian men

BACKGROUND

Testicular Self-Examination (TSE) causes earlier diagnosis of Testicular cancer (TC). Hence, all men aged between15 to 35 years should perform TSE every month. This study aims to survey the effect of educational intervention based on health belief model and social support on testicular self-examination in men aged between 15 to 35 years of Fasa City, Fars province, Iran.

METHODS

In this quasi-experimental study, 200 men (100 in the experimental group and 100 in the control group) in Fasa City, Fars, Iran, were conducted from June 2018 to August 2019. The educational intervention for the experimental group consisted of six training sessions (testicular cancer, its prevalence and types, its risk factors, symptoms, infected areas, diagnosis, side-effects and its severity, understanding about testicular self-examination and its importance, benefits, and barriers of self-examination and correct way of doing TSE were discussed, role of social support). A questionnaire consisting of demographic information, knowledge, HBM construct, and social support was used to measure testicular self-examination before, 3 months after the intervention, and 6 months later. Data were analyzed using SPSS-22 via chi-squared, independent samples t-test, Mann-Whitney, and repeated measures ANOVA at a significance level of 0.5.

RESULTS

The mean age of the men was 27.26 ± 3.16 years in the experimental group and 27.39 ± 3.12 years in the control group. Three months after the intervention and 6 months after the intervention, the experimental group showed a significant increase in knowledge, perceived susceptibility, perceived severity, perceived benefits, self-efficacy, cues to action, social support, and testicular self-examination performance compared to the control group.

CONCLUSION

This study showed the effectiveness of the intervention based on the HBM constructs and social support in the adoption of testicular self-examination in 3 and 6 months post-intervention in men aged between 15 to 35 years. Hence, these models can act as a framework for designing and implementing educational interventions for testicular self-examination.

Clinical outcome of robot-assisted residual mass resection in metastatic nonseminomatous germ cell tumor

PURPOSE

To evaluate the outcome of robot-assisted residual mass resection (RA-RMR) in nonseminomatous germ cell tumor (NSGCT) patients with residual tumor following chemotherapy.

PATIENTS AND METHODS

Retrospective medical chart analysis of all patients with NSGCT undergoing RA-RMR at two tertiary referral centers between January 2007 and April 2019. Patients were considered for RA-RMR in case of a residual tumor between 10 and 50 mm at cross-sectional computed tomography (CT) imaging located ventrally or laterally from the aorta or vena cava, with normalized tumor markers following completion of chemotherapy, and no history of retroperitoneal surgery.

RESULTS

A total of 45 patients were included in the analysis. The Royal Marsden stage before chemotherapy was IIA in 13 (28.9%), IIB in 16 (35.6%), IIC in 3 (6.7%) and IV in 13 patients (28.9%). The median residual tumor size was 1.9 cm (interquartile range [IQR] 1.4-2.8; range 1.0-5.0). Five procedures (11.1%) were converted to an open procedure due to a vascular injury (n = 2), technical difficulty (n = 2) or tumor debris leakage (n = 1). A postoperative adverse event occurred in two patients (4.4%). Histopathology showed teratoma, necrosis and viable cancer in 29 (64.4%), 14 (31.1%), and two patients (4.4%), respectively. After a median follow-up of 41 months (IQR 22-70), one patient (2.2%) relapsed in the retroperitoneum. The one- and 2-year recurrence-free survival rate was 98%.

CONCLUSION

RA-RMR is an appropriate treatment option in selected patients, potentially providing excellent cure rates with minimal morbidity. Long-term outcome data are needed to further support this strategy and determine inclusion and exclusion criteria.

The Novel Biomarker of Germ Cell Tumours, Micro-RNA-371a-3p, Has a Very Rapid Decay in Patients with Clinical Stage 1

BACKGROUND

Accumulating evidence suggests serum levels of microRNA (miR)-371a-3p to be a novel tumour marker of testicular germ cell tumours (GCTs). Presently, there is only limited information regarding the velocity of decline of serum levels in response to treatment.

PATIENTS AND METHODS

Twenty-four patients with testicular GCT (20 seminoma, 4 nonseminoma, median age 40 years) with clinical stage 1 had measurements of serum levels of miR-371a-3p preoperatively and repeatedly on the following 3 days. Three had additional tests done within 24 h after surgery. Measurement results were analysed using descriptive statistical methods.

RESULTS

Serum levels dropped to 2.62, 1.27, and 0.47% of the preoperative level within 1, 2, and 3 days, respectively. The computed half-life amounts to 3.7-7 h. The velocity of decay is significantly associated with tumour size.

CONCLUSIONS

Serum-levels of miR-371a-3p have a short half-life of less than 12 h. The rapid decay after treatment represents a valuable feature confirming the usefulness of miR-371a-3p as a valuable serum biomarker of GCT.

Testicular Germ-Cell Tumours: A Descriptive Analysis of Clinical Characteristics at First Presentation

INTRODUCTION

Clinical characteristics of testicular germ cell tumours (GCTs) apparently change over time, and some vary geographically. The aim of this study is to document the clinical profile of contemporary GCT patients.

PATIENTS AND METHODS

Four hundred twenty-two Caucasian GCT-patients treated in one German centre during 2000-2017, were analysed in terms of patient-age, laterality, histology, tumour-size, clinical stages (CS), pathological (pT)-stages and serum biomarker expression. The results were analysed descriptively and compared with the literature.

RESULTS

Median age was 36 years and 60.2% had seminoma. Βeta-human chorionic gonadotropin was expressed in 37.9% and alpha Fetoprotein in 25.6%. CS1 presenting stage was 66.6% of all GCT patients, 79.1% in seminoma, and 47.6% in nonseminoma. Tumour size was significantly associated with pT-stages and CS. Patients >50 years had significantly more seminoma (77.6%) than younger ones (57.9%). Comparison with literature data revealed a shifting towards higher age, lower CS, higher proportion of seminoma and striking differences of characteristics among geographic regions.

CONCLUSIONS

A typical contemporary clinical profile of testicular GCTs is presented in this study. Median age, relative incidence of seminoma and proportion of CS1 appear to be increasing over time. Striking differences among ethnic groups regarding the characteristics of GCT require further investigation.

During twenty years of Cisplatin-based therapy the face of nonseminomatous testicular germ cell tumors is still changing: an evaluation of presentation, management, predictive factors and survival

PURPOSE

To assess the changing presentation and treatment of nonseminomatous testicular germ cell tumors (NSGCT) and to investigate predictive factors for the status of metastasis at diagnosis and on relapse and death.

MATERIALS AND METHODS

Retrospective record review of 147 patients that underwent inguinal orchiectomy from 1987-2007. Follow-up data was available for 102 patients (median follow-up: 80 months (0-243); 96 patients alive).

RESULTS

Mean patients age increased (p = 0.015) and more patients were diagnosed in clinical stage I (CSI) (p = 0.040). The fraction of yolk sac (YS) elements inclined (p = 0.030) and pT2 tumors increased (p < 0.001). Retroperitoneal lymph node dissection (RPLND) declined whereas more patients were treated with chemotherapy (p < 0.001; p = 0.004). There was an increase in relapse free (RFS) and cancer specific survival (CSS) due to an improvement in patients with disseminated disease (p = 0.014; p < 0.001). The presence of YS and teratoma elements showed a reduction in the odds ratio (OR) for metastasis at diagnosis (p = 0.002, OR: 0.262; p = 0.009, OR: 0.428) whereas higher pT-stage was associated to their presence (p = 0.039). Patients with disseminated disease (CS > I) showed a declined CSS compared to CSI patients (p = 0.055). The presence of YS elements was associated to an improved RFS (p = 0.038).

CONCLUSIONS

In our single institution study the face of NSGCT markedly changed over 20 years even after the introduction of Cisplatin-based chemotherapy. These changes were accompanied by an improvement in RFS and CSS. When dealing with NSGCT patients such observations now and in the future should be taken into account.

Factors associated with testicular self-examination among unaffected men from multiple-case testicular cancer families

Background

The lifetime testicular cancer (TC) risk in the general population is relatively low (~1 in 250), but men with a family history of TC are at 4 to 9 times greater risk than those without. Some health and professional organizations recommend consideration of testicular self-examination (TSE) for certain high-risk groups (e.g. men with a family history of TC). Yet little is known about factors associated with TSE behaviors in this at-risk group.

Methods

We collected information on this subject during an on-going NCI multidisciplinary, etiologically-focused, cross-sectional Familial Testicular Cancer (FTC) study. We present the first report specifically targeting TSE behaviors among first- and second-degree relatives (n = 99) of affected men from families with ≥ 2 TC cases. Demographic, medical, knowledge, health belief, and psychological factors consistent with the Health Belief Model (HBM) were evaluated as variables related to TSE behavior, using chi-square tests of association for categorical variables, and t-tests for continuous variables.

Results

For men in our sample, 46% (n = 46) reported performing TSE regularly and 51% (n = 50) reported not regularly performing TSE. Factors associated (p < .05) with regularly performing TSE in multivariate analysis were physician recommendation and testicular cancer worry. This is the first study to examine TSE in unaffected men from FTC families.

Conclusion

The findings suggest that, even in this high-risk setting, TSE practices are sub-optimal. Our data provide a basis for further exploring psychosocial issues that are specific to men with a family history of TC, and formulating intervention strategies aimed at improving adherence to TSE guidelines.

Postchemotherapy retroperitoneal lymph node dissection in advanced testicular cancer: radical or modified template resection

BACKGROUND

The anatomical extent of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) has been discussed controversially for many years.

OBJECTIVE

To evaluate the necessity of PC-RPLND with modified or radical template resection in patients with advanced nonseminomatous germ-cell tumors (NSGCT) and residual masses following systemic chemotherapy.

DESIGN, SETTING, AND PARTICIPANTS

The charts of 152 consecutive patients who were treated at two tertiary referral centers were retrospectively reviewed.

INTERVENTION

All patients underwent PC-RPLND, with 54 and 98 patients undergoing a radical template resection and 98 patients undergoing a modified template resection. Modified template resection was performed if the location of the residual mass corresponded to the primary landing zone of testis cancer and the residual mass measured < or = 5 cm in diameter. In all other cases a full bilateral PC-RPLND was chosen.

MEASUREMENTS

The following data were analyzed: location of the residual mass, extent of surgery, length of surgery, treatment-associated complications, nerve-sparing approach, adjunctive surgical procedures, postoperative morbidity, duration of hospital stay, early and late complications, relapse rates, cancer-specific survival rates, and overall survival rates.

RESULTS AND LIMITATIONS

Overall, 84 patients (55.2%) had necrosis/fibrosis, 45 (29.6%) had mature teratoma, and 23 (15.1%) had vital cancer in the surgical specimens. Antegrade ejaculation was preserved in 85% and 25% of patients undergoing modified and bilateral PC-RPLND (p=0.02), respectively. Eight recurrences (5.2%) were observed after a mean follow-up of 39 mo (range 6-105 mo): one patient had an in-field relapse following modified PC-RPLND, and seven patients had recurrences outside the boundaries of full bilateral PC-RPLNDs. The 2-yr disease-free survival rates were 78.6% and 92.8% for bilateral and modified PC-RPLND, respectively. The limitations of this study were a short follow-up, a limited number of patients, and the retrospective nature of the study.

CONCLUSIONS

Full bilateral PC-RPLND is the standard approach to extensive residual masses. In well-defined masses a modified template PC-RPLND does not interfere with oncologic outcome but decreases treatment-associated morbidity.