Surgical salvage therapy for malignant intrathoracic metastases from nonseminomatous germ cell cancer of testicular origin: Analysis of a single-institution experience

Epigenetic Factors and ncRNAs in Testicular Cancer

Testicular cancer is the most prevalent tumor among males aged 15 to 35, resulting in a significant number of newly diagnosed cases and fatalities annually. Non-coding RNAs (ncRNAs) have emerged as key regulators in various cellular processes and pathologies, including testicular cancer. Their involvement in gene regulation, coding, decoding, and overall gene expression control suggests their potential as targets for alternative treatment approaches for this type of cancer. Furthermore, epigenetic modifications, such as histone modifications, DNA methylation, and the regulation by microRNA (miRNA), have been implicated in testicular tumor progression and treatment response. Epigenetics may also offer critical insights for prognostic evaluation and targeted therapies in patients with testicular germ cell tumors (TGCT). This comprehensive review aims to present the latest discoveries regarding the involvement of some proteins and ncRNAs, mainly miRNAs and lncRNA, in the epigenetic aspect of testicular cancer, emphasizing their relevance in pathogenesis and their potential, given the fact that their specific expression holds promise for prognostic evaluation and targeted therapies.

Pulmonary metastasectomy in germ cell tumors and prostate cancer

Pulmonary oligo-metastases and oligo-recurrences are terms used to define a set of clinical conditions consisting of limited metastatic malignant disease characterized by an intermediate aggressive behavior compared to diffuse metastatic conditions. If the primary tumor has been controlled and extra-thoracic lesions are excluded, there is a suggestion in the medical literature that removal of such lesions could potentially prolong survival. The lungs are a common metastatic spreading site, especially from epithelial malignancies and sarcomas; pulmonary surgical or interventional metastasectomy have been proposed with curative intent in case of limited tumor load (usually less than 5 lesions). There are many series reporting data about colorectal, renal or breast lung metastasectomy, but the absence of multi centric prospective trials determines a lack of definitive evidence, especially for less common tumors such as metastatic germ cell and prostate cancer. They rarely present in the oligo-metastatic form and their management is often based on personal experience. The aim of our article is to review the latest evidence in the treatment of pulmonary metastatic germ cell and prostate tumors. We cover the full range of treatments: from surgery to ablative radiotherapy and combination of local and systemic therapy. Despite the absence of evidence based guidelines, it emerges that pulmonary metastasectomy should always be considered when general criteria for resection have been met. In germ cell tumors surgery should be mainly reserved for residual disease after chemotherapy, whereas in prostate cancer, pulmonary metastasectomy should be preferred to avoid or delay hormonal deprivation therapy and its side effects.

Pathologic concordance of resected metastatic nonseminomatous germ cell tumors in the chest

OBJECTIVE

Men with metastatic nonseminomatous germ cell tumors (NSGCTs) often present with residual chest tumors after chemotherapy. We examined the pathologic concordance of intrathoracic disease and outcomes based on the worst pathology of disease resected at first thoracic surgery.

METHODS

A retrospective analysis was performed of consecutive patients undergoing thoracic resection for metastatic NSGCT in our institution between 2005 and 2018.

RESULTS

Eighty-nine patients (all men) were included. The median age was 29 years (interquartile range [IQR], 23-35 years). Primary sites were testis (n = 84; 94.4%) and retroperitoneum (n = 5; 5.6%). Eighty-seven patients received chemotherapy before undergoing surgery. Nineteen patients (21.3%; group 1) had malignancy resected at first surgery (OR1), and the other 70 patients had benign disease at OR1 (78.7%; group 2). Concordant pathology between lungs was 85.2% in group 1 and 91% in group 2, and between lung and mediastinum was 50% in group 1 and 72.7% in group 2. Despite no teratoma at OR1, 3 patients (15.8%) in group 2 had resection of teratoma (n = 2) or malignancy (n = 1) at future surgery. After a mean follow-up of 65.5 months (IQR, 23.1-89.2 months) for group 1 and 47.7 months (IQR, 13.0-75.1 months) for group 2, overall survival was significantly worse for group 1 (68.4% vs 92.9%; P = .03).

CONCLUSIONS

The wide range of pathology resected in patients with intrathoracic NSGCT metastases requires careful decision making regarding treatment. Pathologic concordance between lungs is better than that between lung and mediastinum in patients with intrathoracic NSGCT metastases. Aggressive surgical management should be considered for all residual disease due to the low concordance between sites and the potential for excellent long-term survival even in patients with chemotherapy-refractory disease.

Primary mediastinal germ cell tumors: Survival outcomes and prognostic factors - 10 years experience from a tertiary care institute

Primary Mediastinal Germ Cell Tumor (PMGCT) is a rare and heterogeneous entity. These tumors are typically diagnosed in young adults and carry a poor prognosis. We conducted this study to evaluate the role of radiotherapy on treatment outcomes and prognostic factors in PMGCT that may allow a more adapted treatment strategy to improve survival. Case records of patients who presented with PMGCT over a period of 10-years from January-2009 to December-2019 were retrospectively evaluated. Survival analyses were calculated using Kaplan-Meier (Log-rank) method. Poor prognostic factors for survival were evaluated with Multivariate analysis using Cox-regression method. A total of 46-patients data was analyzed, the majority of the patients were males (95.7%) with a median age of 25-years (range, 17-62). Non-seminomatous histology was predominant (60.9%). Sixteen-patients (34.7%) presented with complications at their initial presentation. Majority of the patients were treated with multimodality approach using chemotherapy, surgery, and/or radiotherapy. At a median follow-up of 40.8 months, the 1, 3, and 5-year overall survival (OS) was 69.6%, 52.2%, and 44.7% respectively. Patients who received radiotherapy in first-line treatment showed significant improvement in 5-year OS (72% vs 30%, p = 0.004) and disease-free survival (70% vs 24%, p = 0.007) in comparison with patients who did not receive. Multivariate analysis revealed that radiotherapy, chemotherapy, surgery, and complications at presentation were independent prognostic factors for OS. PMGCTs are aggressive neoplasms especially in patients presenting with disease-related complications. Dual modality management (radiotherapy as local therapy along with chemotherapy) had shown improvement in survival.

Thoracic Metastasectomy in Germ Cell Tumor Patients Treated With First-line Versus Salvage Therapy

BACKGROUND

Outcomes after thoracic metastasectomy in patients with testicular germ cell tumors (GCTs) who received first-line chemotherapy alone versus salvage chemotherapy remain unexplored.

METHODS

We conducted a retrospective review of patients who underwent thoracic metastasectomy for residual GCT between 1997 and 2019 at a single tertiary center. Factors associated with progression-free survival (PFS) and overall survival (OS) were assessed using multivariable Cox regression.

RESULTS

Of 251 patients, 191 received only first-line chemotherapy (76%) and 60 received salvage chemotherapy (24%). Median follow-up was 3.45 years (interquartile range, 1-7.93 years). Among first-line patients without teratoma in the primary tumor, with necrosis in the retroperitoneal nodes and normalized or decreasing serum tumor markers, 17 of 20 had intrathoracic necrosis (85%). Among first-line and salvage patients, respectively, 5-year OS was 93% (95% confidence interval [CI], 89%-98%) versus 63% (95% CI, 51%-78%; P < .001), and 5-year PFS was 69% (95% CI, 62%-77%) versus 40% (95% CI, 29%-56%; P < .001). On multivariable analysis, multiple lung lesions (hazard ratio [HR] = 3.01; 95% CI, 1.50-6.05; P = .002) and brain metastasis (HR = 4.51; 95% CI, 2.34-8.73; P < .001) at diagnosis, salvage chemotherapy (HR = 1.85; 95% CI, 1.10-3.13; P = .021), teratoma (HR = 2.68; 95% CI, 1.50-4.78; P = .001), and viable malignancy (HR = 4.34; 95% CI, 2.44-7.71; P < .001) were associated with worse PFS.

CONCLUSIONS

Although GCT patients treated with salvage chemotherapy followed by thoracic metastasectomy have more aggressive disease and poorer PFS, they can achieve encouraging OS. Our findings highlight the integral role of aggressive thoracic metastasectomy in the treatment of GCT patients with residual thoracic disease after first line-only or salvage chemotherapy.

Pulmonary Metastasectomy for Germ Cell Tumors

Germ cell tumors (GCTs) are the most common malignancy among young men in the United States. Although prognosis is favorable and response to cisplatin-based chemotherapy regimens is good, 10%–20% of patients with thoracic metastases require surgical management following completion of chemotherapy. Pulmonary metastasectomy (PM) has been employed for GCT patients with lung metastases for several decades. Outcomes have been excellent thus far. However, there have been no randomized controlled trials of PM in GCT and, as new surgical techniques are developed, there is variability in management. This article reviews the existing data on current management of pulmonary metastases in GCT, with attention paid to timing of surgery, surgical approaches, and complications.

Management of extraretroperitoneal masses in germ cell tumor

PURPOSE OF REVIEW

Management of extraretroperitoneal (ERP) germ cell tumor (GCT) is a complex clinical scenario faced by urologic oncologists. This article reviews the indications and approach to management of ERP GCT masses.

RECENT FINDINGS

ERP GCT management starts with chemotherapy, and for any residual masses, a careful consideration of surgical intervention versus salvage chemotherapy. Decision-making regarding residual ERP masses hinges on tumor markers, and also the anatomical location. These factors should be contextualized by the patient's risk for teratoma or active GCT, which will impact outcome and thus weigh on decision-making conversations with patients who have advanced disease. Technical challenges of surgical management in the postchemotherapy setting also apply in ERP mass resection. The risks of surgical management in the lung and liver, in particular, add special considerations for morbidity. Surgical resection is often the only recourse for a patient who may have chemoresistant disease and may be an important step in achieving cure.

SUMMARY

Surgical management of ERP GCT requires multidisciplinary input, and the urologic oncologist can help guide management with particular emphasis on the indication, timing, and approach to surgical resection.

Role of radiotherapy in treating patients with primary malignant mediastinal non-seminomatous germ cell tumor: A 21-year experience at a single institution

Background

The aim of this study was to investigate the clinical characteristics and outcomes of patients with primary malignant mediastinal non-seminomatous germ cell tumor (MMNSGCT) by comparing the efficacies of different treatment modalities.

Methods

The charts of 62 consecutive patients with MMNSGCT between 1990 and 2010 were reviewed. Analyses included Kaplan-Meier survival and Cox multivariate regression.

Results

There was sufficient data of 61 patients for inclusion in the study. The median age was 25 years. At diagnosis, 35 patients had tumors located in the mediastinum, 26 had lung and/or distant metastases. At a median follow-up of 47.2 months, 32 patients had died and 43 had developed progressive disease. The one, three, and five-year overall survival (OS) and progression-free survival (PFS) rates were 72.1%, 50.8%, 49.2% and 47.5%, 32.8%, 32.8%, respectively. Patients who received radiotherapy in the primary treatment regimen showed improved five-year OS (68.2% vs. 38.5%, P = 0.043), PFS (45.5% vs. 20.5%, P = 0.023), and local recurrence-free survival (LRFS) (77.3% vs. 38.5%, P = 0.003) compared with those who did not receive radiotherapy. Multivariate analysis revealed that radiotherapy was an independent prognostic factor of five-year OS (hazard ratio [HR] 0.39, P = 0.037), PFS (HR 0.42, P = 0.017), and LRFS (HR 0.31, P = 0.019).

Conclusion

Radiotherapy in a chemotherapy-based treatment regimen could significantly reduce local recurrence and improve survival of MMNGCT patients.

Survival after resection for metastatic testicular nonseminomatous germ cell cancer to the lung or mediastinum

BACKGROUND

Since the advent of cisplatin-based chemotherapy, nonseminomatous germ cell tumors (NSGCT) have been considered one of the most curable solid neoplasms and a model for multimodality cancer therapy. We undertook an institutional review of testicular NSGCT patients who underwent operations to remove lung or mediastinal metastases after chemotherapy in the cisplatin era to determine outcomes.

METHODS

From 1980 to 2006, 431 patients underwent 640 postchemotherapy surgical procedures to remove lung (n = 159, 36.8%), mediastinal (n = 136, 31.6%), or both lung and mediastinal (n = 136, 31.6%) metastases within 2 years of chemotherapy. Multiple variables potentially predictive of survival were analyzed.

RESULTS

The overall median survival was 23.4 years, with 295 (68%) patients alive and well after an average follow-up of 5.6 years. There was no survival difference in patients who underwent removal of lung or mediastinal metastases. Pathologic categories of resected residual disease were necrosis (21.5%), teratoma (52.7%), persistent NSGCT (15.0%), and degenerative non-germ cell cancer (10.1%). Multivariable analysis identified older age at time of diagnosis (p = 0.001), non-germ cell cancer in testes specimen (p = 0.004), and pathology of residual disease (p < 0.001) as significantly predictive of survival.

CONCLUSIONS

Patients who undergo resection of residual lung or mediastinal disease for metastatic testicular NSGCT as a planned approach after cisplatin-based chemotherapy have overall excellent long-term survival. Survival is equivalent comparing hematogenous and lymphatic routes of metastases but depends on the pathology of the resected disease. These results justify an aggressive surgical approach, particularly to remove residual teratoma in the lung or mediastinum after chemotherapy, including multiple surgical procedures if necessary.

[The surgery after. . . retroperitoneal lymph node dissection and surgery of the residual masses after chemotherapy for advanced testicular cancer]

Thirty-six cases of retroperitoneal lymph node dissections for residual mass after chemotherapy for testicular cancer are reported. In a reference center, the recruitment is modified by the severity of the situations related to very big masses, tumors of poor prognosis and resistant tumors. Lymph node dissection is often atypical and surgery of metastatic residual masses is frequent (13 operations). The 8-year global survival remains stable, over 90%. The 5-year cumulated risk of recurrence is 20%, but these situations can be overtaken.

Thoracic metastasectomy for nonseminomatous germ cell tumors

Pulmonary metastases are common in patients after resection for nonseminomatous germ cell tumor of the testis. There is solid evidence that resection for residual pulmonary disease, after adjuvant chemotherapy, can provide patients with a long-term survival. This article addresses the issues of patient selection and prognostic factors with the current review of pulmonary metastasectomy in metastatic nonseminomatous germ cell tumors retrieved from retrospective studies. In summary, there is a substantial body of evidence demonstrating that resection of residual lesions after chemotherapy can be performed safely with a low mortality rate. For a subset of patients with viable malignant tumor cells after chemotherapy, the overall results of a 5-year actuarial survival rate ranged between 42 and 61%. However, no presurgical algorithm had proven effective at predicting histologic outcome and, similar to that in pulmonary metastasectomy in general, no prospective randomized trials have been conducted to define the role of surgery versus a nonsurgical treatment regimen.

Indications and approach to surgical resection of lung metastases

Pulmonary metastasectomy is a curative option for selected patients with cancer spread to the lungs. Complete surgical removal of pulmonary metastases can improve survival and is recommended under certain criteria. Specific issues that require consideration in a multidisciplinary setting when planning pulmonary metastasectomy include: adherence to established indications for resection, the surgical strategy including the use of minimally invasive techniques, pulmonary parenchyma preservation, and the role of lymphadenectomy.

[Surgery for thoracic metastases from urological malignancies]

Surgery of thoracic metastases from urological malignancies essentially concerns renal carcinoma and non seminomatous testicular germ cell tumors (NSGCT). Complete resection of renal cell cancer lung metastases can be done with low mortality and an appreciable long survival rate, especially for single lesion with a long free interval. For NSGCT, resection of all pulmonary lesions and mediastinal residual masses after chemotherapy affords a very high long term survival rate. In the case of multiple lesions, surgical approaches must be carefully chosen.

Surgical treatment of metastatic disease to the lung

The presence of distant metastases usually implies disease not amenable to cure through surgical resection. In such cases, chemotherapy is the mainstay of treatment, with surgery or radiation reserved for palliative measures. However, metastases limited to the lung may be resected with resultant prolonged patient survival compared to unresectable, widely disseminated metastases. Isolated pulmonary metastases should therefore not be considered untreatable. In this review, we discuss the pathophysiology of pulmonary metastases. We outline prognostic factors associated with metastases, and propose criteria to help select patients for metastasectomy. Surgical approaches, including various open techniques and video-assisted thoracoscopy, are covered. Surgical issues, including the need for unilateral versus bilateral exploration, the extent of resection to achieve cure, the need for lymph node dissection, and the benefit of repeat operations, are discussed. Finally, we review some of the more common tumors that metastasize to the lungs, and the role of metastasectomy in their treatment. Resection of pulmonary metastases confers a survival benefit to a select group of patients so long as the primary tumor is controlled, metastases are limited to the lungs, the patient can tolerate the operation from a cardiopulmonary standpoint, and the metastases are completely resected.

Pediatric pulmonary tumors: primary and metastatic

Pediatric pulmonary tumors are rare. There is often a significant delay in diagnosis of pulmonary tumors secondary to their rarity and nonspecific presenting physiologic and radiographic findings. A high index of suspicion in pediatric patients with recurrent or persistent pulmonary symptoms is of paramount importance in diagnosing pulmonary tumors at an early stage. Malignant pulmonary tumors are more frequently diagnosed than benign lesions, with metastatic cancers being the most common. Complete surgical resection remains the basis of therapy for primary lesions, and its role in secondary cancers is becoming more established. Adjuvant therapies are frequently employed depending on the precise tumor involved. Mortality rates vary greatly depending on tumor location, stage, and type.