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Fazekas FE, Ujfaludi Z, Biró K, Páhi ZG, Buzogány I, Sükösd F, Pankotai T, Beöthe T. Complex treatment of residual metastatic germ cell cancer: A single center experience. J Biotechnol 2024; 389:61-67. [PMID: 38692356 DOI: 10.1016/j.jbiotec.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Testicular 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. OBJECTIVE To assess patient outcomes and complications considering different treatment regimens and clinical characteristics. MATERIALS AND METHODS In 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. RESULTS Standard 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. CONCLUSIONS The 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.
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Affiliation(s)
| | - Zsuzsanna Ujfaludi
- Institute of Pathology, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary; Competence Centre of the Life Sciences Cluster of the Centre of Excellence for Interdisciplinary Research, Development and Innovation, University of Szeged, Dugonics tér, 13, Szeged H-6720, Hungary
| | - Krisztina Biró
- National Institute of Oncology, Dept. of Genitourinary Oncology and Clinical Pharmacology, Budapest, Hungary
| | - Zoltán Gábor Páhi
- Institute of Pathology, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary; Hungarian Centre of Excellence for Molecular Medicine (HCEMM), Genome Integrity and DNA Repair Core Group, Budapesti út 9, Szeged H-6728, Hungary; Competence Centre of the Life Sciences Cluster of the Centre of Excellence for Interdisciplinary Research, Development and Innovation, University of Szeged, Dugonics tér, 13, Szeged H-6720, Hungary
| | - István Buzogány
- Péterfy Sándor Hospital, Dept. of Urology, Budapest, Hungary
| | - Farkas Sükösd
- Institute of Pathology, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Tibor Pankotai
- Institute of Pathology, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary; Hungarian Centre of Excellence for Molecular Medicine (HCEMM), Genome Integrity and DNA Repair Core Group, Budapesti út 9, Szeged H-6728, Hungary; Competence Centre of the Life Sciences Cluster of the Centre of Excellence for Interdisciplinary Research, Development and Innovation, University of Szeged, Dugonics tér, 13, Szeged H-6720, Hungary.
| | - Tamás Beöthe
- Péterfy Sándor Hospital, Dept. of Urology, Budapest, Hungary.
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Kumar R, Sadanala ME, Nagasubramanian S, Joel A, George AJP, Gowri SM, Mukherjee P, Singh A, Mukha RP, Kumar S, Devasia A, Nirmal TJ. 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. Indian J Urol 2024; 40:112-120. [PMID: 38725891 PMCID: PMC11078445 DOI: 10.4103/iju.iju_456_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/28/2024] [Accepted: 02/15/2024] [Indexed: 05/12/2024] Open
Abstract
Introduction Chemotherapy, postchemotherapy retroperitoneal lymph node dissection (pcRPLND), and metastasectomy remain the standard of care for the management of advanced nonseminomatous germ cell tumor (NSGCT). Methods 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. Results 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. Conclusion 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.
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Affiliation(s)
- Rakesh Kumar
- Department of Urology, All India Institute of Medical Sciences, Patna, Bihar, India
- Department of Urology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | | | | | - Anjana Joel
- Department of Medical Oncology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | | | - S Mahasampath Gowri
- Department of Bio-Statistics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Partho Mukherjee
- Department of Urology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Ashish Singh
- Department of Medical Oncology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Rajiv Paul Mukha
- Department of Urology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Santosh Kumar
- Department of Urology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Antony Devasia
- Department of Urology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Thampi John Nirmal
- Department of Urology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Conduit C, Hutchinson AD, Leonard M, O 'Haire S, Moody M, Thomas B, Sim I, Hong W, Ahmad G, Lawrentschuk N, Lewin J, Tran B, Dhillon HM. An exploration of testicular cancer survivors' experience of ejaculatory dysfunction following retroperitoneal lymph node dissection-a sub-study of the PREPARE clinical trial. J Cancer Surviv 2023:10.1007/s11764-023-01489-9. [PMID: 37981616 DOI: 10.1007/s11764-023-01489-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/20/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE Ejaculatory dysfunction secondary to retrograde ejaculation or anejaculation is a complication of retroperitoneal lymph node dissection (RPLND) for survivors of testicular cancer. We explored survivors' experiences of ejaculatory dysfunction following RPLND. METHODS In a sub-study of a single-arm phase 2 clinical trial (ACTRN12622000537752/12622000542796), participants reporting ejaculatory dysfunction ≥ 6 months following RPLND were invited to complete semi-structured interviews. Purposive sampling was used. Interviews continued until thematic saturation occurred, and codebook thematic analysis of interviews was performed. RESULTS Of 58 individuals recruited to the trial, 33 (57%) reported ejaculatory dysfunction. Of these, 32 (97%) agreed to interview and 15 participated. Participants interviewed had median age 34 years (range 24-66), 12 (80%) in a long-term relationship with median time from surgery 36 months (range 11-112). Three overarching themes were identified. The first reflected the value of RPLND despite ejaculatory dysfunction. The second illuminated the impact(s) of ejaculatory dysfunction closely mapped to life stage, with flow-on impacts to fertility, sex, psychological wellbeing and communication. The third reflected information needs. Fertility was a substantial source of concern for some participants. Ejaculatory dysfunction had no effect on sex for some, whilst for others, sex was less pleasurable. Some reported benefits. Few reported ejaculatory dysfunction challenged masculinity, confidence, or self-esteem. CONCLUSIONS Future research should examine interventions to reduce distress related to fertility, challenged masculinity and body image. IMPLICATIONS FOR CANCER SURVIVORS Whilst most participants considered ejaculatory dysfunction to have little impact on their sexual function and relationships, some reported significant difficulties varying by life stage and relationship status.
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Affiliation(s)
- C Conduit
- Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Medical Oncology, University of Melbourne, 305 Grattan St., Melbourne, VIC, Australia
- Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - A D Hutchinson
- Justice & Society, Behaviour-Brain-Body Research Centre, University of South Australia, Magill, Australia
| | - M Leonard
- The Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, Australia
| | - S O 'Haire
- Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - M Moody
- Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - B Thomas
- Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - I Sim
- Endocrinology, Monash Health and Eastern Health, Clayton, VIC, Australia
- Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - W Hong
- Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - G Ahmad
- Andrology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - N Lawrentschuk
- Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
- Urology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - J Lewin
- Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Medical Oncology, University of Melbourne, 305 Grattan St., Melbourne, VIC, Australia
- ONTrac at Peter Mac, Victorian Adolescent and Young Adult Cancer Service, Melbourne, VIC, Australia
| | - B Tran
- Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Sir Peter MacCallum Department of Medical Oncology, University of Melbourne, 305 Grattan St., Melbourne, VIC, Australia.
- Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.
| | - H M Dhillon
- Centre for Medical Psychology and Evidence-Based Decision-Making, School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
- Psycho-Oncology Cooperative Research Group, School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
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Latarius S, Leike S, Erb H, Putz J, Borkowetz A, Thomas C, Baunacke M. Retroperitoneal lymph node dissection for testicular cancer is a demanding procedure: detailed real-life data of complications and additional surgical procedures in 295 cases. World J Urol 2023; 41:2397-2404. [PMID: 37490059 PMCID: PMC10465663 DOI: 10.1007/s00345-023-04516-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/30/2023] [Indexed: 07/26/2023] Open
Abstract
PURPOSE Retroperitoneal lymph node dissection (RPLND) for germ cell tumours is a challenging procedure that may present relevant complications. The purpose was to analyse postoperative complications and identify risk factors for major complications. METHODS This is a retrospective unicentric analysis of a large cohort of 295 RPLNDs from 1992 to 2020. Early complications (30 days) and late complications (31-180 days) were classified according to the Clavien‒Dindo classification. The influence of surgical, patient-specific, and tumour-specific parameters on grade III-V complications was analysed in univariate and multivariate logistic regression models. RESULTS A total of 232 were postchemotherapy RPLNDs, and 63 were primary RPLNDs. Early postoperative complications were found to be grades I-II in 58.6% (173/295), grades III-IV in 9.8% (29/295), and grade V in 0.3% (1/295). In 20% (58/295), additional surgical procedures were needed. Grade III-V complications were associated with ≥ 4 cycles of preoperative chemotherapy (OR 3.7 (1.5-8.9); p = 0.004), RPLND specimen (nonseminoma or immature teratoma) (OR 3.1 (1.4-6.6); p = 0.005), transfusions (OR 2.4 (1.1-5.4); p = 0.03), salvage RPLND (OR 4.1 (1.8-9.3); p < 0.001), and preoperatively elevated AFP (OR 5 (2.2-11.7); p < 0.001). In multivariate analysis, the only independent predictor for grade III-V complications was preoperative AFP elevation (OR 3.3 (1.2-9.2); p = 0.02). Limitations include the retrospective study design. CONCLUSIONS Our results demonstrate that RPLND is a demanding surgical procedure. Patients with a complex tumour history have a higher risk of complications. We recommend treatment of these complex cases in high-volume centres.
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Affiliation(s)
- Stefanie Latarius
- Department of Urology, Medical Faculty Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Steffen Leike
- Department of Urology, Medical Faculty Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Holger Erb
- Department of Urology, Medical Faculty Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Juliane Putz
- Department of Urology, Medical Faculty Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Angelika Borkowetz
- Department of Urology, Medical Faculty Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Christian Thomas
- Department of Urology, Medical Faculty Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Martin Baunacke
- Department of Urology, Medical Faculty Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Germany
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Evmorfopoulos K, Chasiotis G, Barbatis A, Zachos I, Kouvelos G, Bareka M, Vlachostergios PJ, Arnaoutoglou E, Tzortzis V, Matsagkas M. Complete Vascular Replacement of the Infrarenal Inferior Vena Cava and Abdominal Aorta during Post-Chemotherapy Retroperitoneal Lymph Node Dissection for a Non-Seminomatous Germ Cell Tumor. Curr Oncol 2023; 30:5448-5455. [PMID: 37366895 DOI: 10.3390/curroncol30060412] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/27/2023] [Accepted: 06/02/2023] [Indexed: 06/28/2023] Open
Abstract
Testicular germ cell tumors (TGCTs) are the leading cause of cancer-related death in males between the ages of 20 and 40. In the advanced stages, the combination of cisplatin-based chemotherapy and surgical excision of the remaining tumor can cure many of these patients. Vascular procedures may be required during retroperitoneal lymph node dissection (RPLND) in order to achieve the complete excision of all residual retroperitoneal masses. Careful assessment of pre-operative imaging and the identification of patients who could benefit from additional procedures are important for minimizing peri- and postoperative complications. We report on a case of a 27-year-old patient with non-seminomatous TGCT, who successfully underwent post-chemotherapy RPLND with additional infrarenal inferior vena cava (IVC) and complete abdominal aorta replacement using synthetic grafts.
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Affiliation(s)
- Konstantinos Evmorfopoulos
- Department of Urology, School of Health Sciences, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, 41110 Larissa, Greece
| | - Georgios Chasiotis
- Department of Urology, School of Health Sciences, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, 41110 Larissa, Greece
| | - Alexandros Barbatis
- Department of Vascular Surgery, School of Health Sciences, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, 41110 Larissa, Greece
| | - Ioannis Zachos
- Department of Urology, School of Health Sciences, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, 41110 Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, School of Health Sciences, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, 41110 Larissa, Greece
| | - Metaxia Bareka
- Department of Anesthesiology, School of Health Sciences, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, 41110 Larissa, Greece
| | - Panagiotis J Vlachostergios
- Department of Urology, School of Health Sciences, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, 41110 Larissa, Greece
- Department of Medical Oncology, IASO Thessalias Hospital, 41500 Larissa, Greece
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Eleni Arnaoutoglou
- Department of Anesthesiology, School of Health Sciences, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, 41110 Larissa, Greece
| | - Vassilios Tzortzis
- Department of Urology, School of Health Sciences, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, 41110 Larissa, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, School of Health Sciences, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, 41110 Larissa, Greece
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Fournier C, Leguillette C, Leblanc E, Le Deley MC, Carnot A, Pasquier D, Escande A, Taieb S, Ceugnart L, Lebellec L. Diagnostic Value of the Texture Analysis Parameters of Retroperitoneal Residual Masses on Computed Tomographic Scan after Chemotherapy in Non-Seminomatous Germ Cell Tumors. Cancers (Basel) 2023; 15:cancers15112997. [PMID: 37296963 DOI: 10.3390/cancers15112997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
After chemotherapy, patients with non-seminomatous germ cell tumors (NSGCTs) with residual masses >1 cm on computed tomography (CT) undergo surgery. However, in approximately 50% of cases, these masses only consist of necrosis/fibrosis. We aimed to develop a radiomics score to predict the malignant character of residual masses to avoid surgical overtreatment. Patients with NSGCTs who underwent surgery for residual masses between September 2007 and July 2020 were retrospectively identified from a unicenter database. Residual masses were delineated on post-chemotherapy contrast-enhanced CT scans. Tumor textures were obtained using the free software LifeX. We constructed a radiomics score using a penalized logistic regression model in a training dataset, and evaluated its performance on a test dataset. We included 76 patients, with 149 residual masses; 97 masses were malignant (65%). In the training dataset (n = 99 residual masses), the best model (ELASTIC-NET) led to a radiomics score based on eight texture features. In the test dataset, the area under the curve (AUC), sensibility, and specificity of this model were respectively estimated at 0.82 (95%CI, 0.69-0.95), 90.6% (75.0-98.0), and 61.1% (35.7-82.7). Our radiomics score may help in the prediction of the malignant nature of residual post-chemotherapy masses in NSGCTs before surgery, and thus limit overtreatment. However, these results are insufficient to simply select patients for surgery.
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Affiliation(s)
- Clémence Fournier
- Department of Medical Oncology, Centre Hospitalier de Roubaix, 59100 Roubaix, France
| | | | - Eric Leblanc
- Department of Surgical Oncology, Centre Oscar Lambret, 59000 Lille, France
| | | | - Aurélien Carnot
- Department of Medical Oncology, Centre Oscar Lambret, 59000 Lille, France
| | - David Pasquier
- Academic Department of Radiation Oncology, Centre Oscar Lambret, 59000 Lille, France
- Univ. Lille, CNRS, Centrale Lille, UMR 9189-CRIStAL, 59000 Lille, France
| | - Alexandre Escande
- Univ. Lille, CNRS, Centrale Lille, UMR 9189-CRIStAL, 59000 Lille, France
- Department of Radiotherapy, Clinique Léonard de Vinci, 59187 Dechy, France
| | - Sophie Taieb
- Department of Radiology, Centre Oscar Lambret, 59000 Lille, France
| | - Luc Ceugnart
- Department of Radiotherapy, Clinique Léonard de Vinci, 59187 Dechy, France
| | - Loïc Lebellec
- Department of Medical Oncology, Centre Oscar Lambret, 59000 Lille, France
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Notarfrancesco M, Fankhauser CD, Lorch A, Ardizzone D, Helnwein S, Hoch D, Hermanns T, Thalmann G, Beyer J. 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. Swiss Med Wkly 2023; 153:40053. [PMID: 37080191 DOI: 10.57187/smw.2023.40053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND 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. AIMS To assess perioperative complications and oncological outcomes at two major referral centres in Switzerland. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Marco Notarfrancesco
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Anja Lorch
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Davide Ardizzone
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Simon Helnwein
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Dennis Hoch
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Thomas Hermanns
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - George Thalmann
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Jörg Beyer
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Abstract
Testicular cancer is a curable cancer. The success of physicians in curing the disease is underpinned by multidisciplinary advances. Cisplatin-based combination chemotherapy and the refinement of post-chemotherapy surgical procedures and diagnostic strategies have greatly improved long term survival in most patients. Despite such excellent outcomes, several controversial dilemmas exist in the approaches to clinical stage I disease, salvage chemotherapy, post-chemotherapy surgical procedures, and implementing innovative imaging studies. Relapse after salvage chemotherapy has a poor prognosis and the optimal treatment is not apparent. Recent research has provided insight into the molecular mechanisms underlying cisplatin resistance. Phase 2 studies with targeted agents have failed to show adequate efficacy; however, our understanding of cisplatin resistant disease is rapidly expanding. This review summarizes recent advances and discusses relevant issues in the biology and management of testicular cancer.
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Affiliation(s)
- Michal Chovanec
- 2nd Department of Oncology, Faculty of Medicine, Comenius University, National Cancer Institute, Bratislava, Slovakia
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School of Brown University, Lifespan Academic Medical Center, Providence, RI, USA
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9
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Murez T, Fléchon A, Branger N, Savoie PH, Rocher L, Camparo P, Neuville P, Ferretti L, Van Hove A, Roupret M. French AFU Cancer Committee Guidelines - Update 2022-2024: testicular germ cell cancer. Prog Urol 2022; 32:1066-1101. [DOI: 10.1016/j.purol.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022]
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10
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Conduit C, Hong W, Martin F, Thomas B, Lawrentschuk N, Goad J, Grimison P, Ahmadi N, Tran B, Lewin J. A meta-analysis of clinicopathologic features that predict necrosis or fibrosis at post-chemotherapy retroperitoneal lymph node dissection in individuals receiving treatment for non-seminoma germ cell tumours. Front Oncol 2022; 12:931509. [PMID: 36059636 PMCID: PMC9428700 DOI: 10.3389/fonc.2022.931509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Post-chemotherapy retroperitoneal lymph node dissection (pcRPLND) for residual nodal masses is a critical component of care in metastatic testicular germ cell tumour (GCT). However, the procedure is not of therapeutic value in up to 50% of individuals in whom histopathology demonstrates post-treatment necrosis or fibrosis alone. Improved diagnostic tools and clinicopathologic features are needed to separate individuals who benefit from pcRPLND and avoid surgery in those who do not. Methods A prospectively registered meta-analysis of studies reporting clinicopathologic features associated with teratoma, GCT and/or necrosis/fibrosis at pcRPLND for metastatic non-seminoma GCT (NSGCT) was undertaken. We examined the effect of various clinicopathologic factors on the finding of necrosis/fibrosis at pcRPLND. The log odds ratios (ORs) of each association were pooled using random-effects models. Results Using the initial search strategy, 4,178 potentially eligible abstracts were identified. We included studies providing OR relating to clinicopathologic factors predicting pcRPLND histopathology, or where individual patient-level data were available to permit the calculation of OR. A total of 31 studies evaluating pcRPLND histopathology in 3,390 patients were eligible for inclusion, including two identified through hand-searching the reference lists of eligible studies. The following were associated with the presence of necrosis/fibrosis at pcRPLND: absence of teratomatous elements in orchidectomy (OR 3.45, 95% confidence interval [CI] 2.94-4.17); presence of seminomatous elements at orchidectomy (OR 2.71, 95% CI 1.37-5.37); normal pre-chemotherapy serum bHCG (OR 1.96, 95% CI 1.62-2.36); normal AFP (OR 3.22, 95% CI 2.49–4.15); elevated LDH (OR 1.72, 95% CI 1.37-2.17); >50% change in mass during chemotherapy (OR 4.84, 95% CI 3.94-5.94); and smaller residual mass size (<2 cm versus >2 cm: OR 3.93, 95% CI 3.23-4.77; <5 cm versus >5 cm: OR 4.13, 95% CI 3.26-5.23). Conclusions In this meta-analysis, clinicopathologic features helped predict the presence of pcRPLND necrosis/fibrosis. Collaboration between centres that provide individual patient-level data is required to develop and validate clinical models and inform routine care to direct pcRPLND to individuals most likely to derive benefits. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD42021279699
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Affiliation(s)
- Ciara Conduit
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
- Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Wei Hong
- Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Department of Medical Oncology, St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Felicity Martin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Benjamin Thomas
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Nathan Lawrentschuk
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jeremy Goad
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Peter Grimison
- Department of Medical Oncology, Chris O’Brien Lifehouse, Camperdown, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Nariman Ahmadi
- Department of Urology, Chris O’Brien Lifehouse, Camperdown, NSW, Australia
| | - Ben Tran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
- Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Jeremy Lewin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
- ONTrac at Peter Mac, Victorian Adolescence and Young Adult Cancer Service, Melbourne, VIC, Australia
- *Correspondence: Jeremy Lewin,
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11
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Yaegashi H, Nohara T, Shigehara K, Izumi K, Kadono Y, Makino T, Yamashita K, Ohtsubo K, Ikeda H, Mizokami A. Survival Outcomes of Patients With Primary Mediastinal Germ Cell Tumors: A Retrospective Single-institutional Experience. CANCER DIAGNOSIS & PROGNOSIS 2022; 2:352-359. [PMID: 35530648 PMCID: PMC9066546 DOI: 10.21873/cdp.10116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 02/25/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND/AIM Primary mediastinal non-seminomatous germ cell tumors (PMNSGCTs) are occasionally complicated by a hematologic malignancy, as with somatic-type malignant tumors called germ cell tumors with somatic-type malignancy (GCTSTM) and are known to have a poor prognosis. PATIENTS AND METHODS Data obtained between September 1997 and February 2020 for patients with mediastinal germ cell tumor at our institution were retrospectively analyzed. Key outcome measures included survival rates and the clinical features of non-seminoma cases. RESULTS Of 16 patients, 9 had pure seminoma, and 7 had non-seminoma. At the median follow-up of 56.2 months, the 5-year survival rate was significantly higher in patients with seminoma (100%) than in those with non-seminoma (37%) (log-rank test, p=0.0153). Regarding PMNSGCT, two patients evolved into GCTSTM and three had concomitant hematological malignancies. CONCLUSION Patients with PMNSGCTs, GCTSTM complications, and hematologic malignancies showed poor survival, suggesting the need for the development of treatment strategies.
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Affiliation(s)
- Hiroshi Yaegashi
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Takahiro Nohara
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Kazuyoshi Shigehara
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Kouji Izumi
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Yoshifumi Kadono
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Tomoyuki Makino
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
- Department of Urology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Kaname Yamashita
- Division of Medical Oncology, Cancer Research Institute, Kanazawa University, Kanazawa, Japan
| | - Koushiro Ohtsubo
- Division of Medical Oncology, Cancer Research Institute, Kanazawa University, Kanazawa, Japan
| | - Hiroko Ikeda
- Department of Pathology, Kanazawa University Hospital, Kanazawa, Japan
| | - Atsushi Mizokami
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
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12
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Nini A, Boschheidgen M, Hiester A, Winter C, Antoch G, Schimmöller L, Albers P. Preoperative clinical and radiographic predictors of major vascular surgery in patients with testicular cancer undergoing post-chemotherapy residual tumor resection (PC-RPLND). World J Urol 2021; 40:349-354. [PMID: 34731264 DOI: 10.1007/s00345-021-03870-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 10/21/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To evaluate the probability to correctly predict major vascular surgery (MVS) in patients undergoing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for testicular cancer. METHODS From a database of 504 RPLNDs performed in 434 patients (2008-2018), 78 patients submitted to PC-RPLND for non-seminoma germ-cell cancer after cisplatin-based chemotherapy with available preoperative CT scans were identified. Second PC-PLNDs (Re-Dos), salvage RPLNDs, or RPLNDs for late-relapse were excluded as well as thoraco-abdominal approaches. Preoperative imaging was reviewed by a urologist and a radiologist blinded to operative details. RESULTS Of 78 patients, 16 (20.5%) underwent MVS (caval and/or aortic replacement or reconstruction). On univariable analyses, transversal diameter, sagittal diameter, tumor volume, aorta- and cava-tumor contact angle, poor IGCCCG score, clinical stage III and preoperative positive markers were predictors of MVS (all p values ≤ 0.01). At multivariable analyses aorta- (cut-off 64°) and cava-tumor contact angle (cut-off 98°) and poor IGCCCG score represented the three most important predictors of MVS (all p values ≤ 0.05). The model constructed has a PPV 100%, NPV 87% and an accuracy of 88%. CONCLUSIONS Presence of aorta-tumor contact angle ≥ 64°, cava-tumor contact angle ≥ 98° and poor IGCCCG score identify correctly 9 out of 10 patients requiring MVS at the time of first PC-RPLND.
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Affiliation(s)
- Alessandro Nini
- Department of Urology and Pediatric Urology, Saarland University Medical Center, Universitätsklinikum des Saarlandes, Saarland University, 66421, Homburg/Saar, Germany. .,Division of Experimental Oncology/Unit of Urology, Department of Urology, URI, IRCCS San Raffaele Scientific Hospital, Milan, Italy. .,Department of Urology, Medical Faculty, University Hospital, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
| | - Matthias Boschheidgen
- Institute for Diagnostic and Interventional Radiology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Andreas Hiester
- Department of Urology, Medical Faculty, University Hospital, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian Winter
- Department of Urology, Medical Faculty, University Hospital, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Gerald Antoch
- Institute for Diagnostic and Interventional Radiology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Lars Schimmöller
- Institute for Diagnostic and Interventional Radiology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Peter Albers
- Department of Urology, Medical Faculty, University Hospital, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
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13
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Conduit C, Tran B. Improving outcomes in germ cell cancers using miRNA. Ther Adv Med Oncol 2021; 13:17588359211027826. [PMID: 34262617 PMCID: PMC8252353 DOI: 10.1177/17588359211027826] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/07/2021] [Indexed: 11/30/2022] Open
Abstract
Owing to advances in treatment paradigms across the last five decades, testicular cancer is now eminently curable. However, current serum tumour and imaging biomarkers lack adequate sensitivity, specificity, and predictive value. Subsequently, their utility in detecting active malignancy and informing treatment decisions is minimal in a large proportion of men with testicular cancer. Micro-ribonucleic acids (miRNA), pertinently miR-371a-3p, offer a new tool, which based on early data, appears to fill many of the gaps that existing biomarkers leave. This paper reviews the evolution of the technology, potential limitations, and discusses the clinical relevance of miRNA as it moves towards the clinic.
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Affiliation(s)
- Ciara Conduit
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Ben Tran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Locked Bag 1, A’Beckett St, Melbourne, VIC 8006, Australia
- Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
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14
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Abstract
PURPOSE OF REVIEW This review aims to summarize the latest evidence of medical and surgical treatment options for patients with relapsing testicular germ cell tumors. RECENT FINDINGS Depending on International Germ Cell Cancer Classification Group risk classification 10-50% of patients with metastatic TGCT develop relapse which needs further multimodality treatment. With regard to therapy, early relapses are stratified according to their prognostic risk profile which results in a 3-year overall survival between 6% in the very high to 77% in the very low risk group. Prognostic risk score dictates systemic therapy which might be second line chemotherapy (TIP, PEI) or high dose chemotherapy. Any residual masses following salvage chemotherapy need to be completely resected due the presence of viable cancer and/or teratoma in more than 50% of cases. Targeted therapy in men with druggable mutations is for individualized cases only. Patients with late relapses developing more than 2 years after first-line chemotherapy are best managed by surgery. Desperation surgery is reserved for those patients with rising markers during or immediately after chemotherapy and good risk factors such as rising alpha-fetoprotein, <3 metastatic sites and complete resectability. Multimodality treatment will result in long-term cure of 25% to 60%. Due to the complexity of treatment, chemotherapy as well as surgery should be performed in highly experienced centres only. SUMMARY Multimodality treatment to salvage relapsing patients with metastatic testis cancer requires extensive experience for both systemic therapy and surgery. If done properly, it will result in moderate to high cure rates. Personalized therapeutic options are currently evaluated in clinical trials.
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15
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Torres L, Ramos JG, Varela R, Cabrera M, Orrego PA, Mosquera AV, Vecino SVP. Complicaciones de la linfadenectomía retroperitoneal postquimioterapia en pacientes con tumor germinal de origen testicular: Experiencia de 12 años en un centro de referencia en Colombia. Rev Urol 2021. [DOI: 10.1055/s-0040-1721327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Resumen
Objetivo El objetivo de este estudio, fue describir las complicaciones intraoperatorias y postoperatorias, así como la necesidad de cirugías concomitantes en la linfadenectomía retroperitoneal postquimioterapia en un centro de referencia de manejo de cáncer.
Métodos Se recolectaron datos de una cohorte retrospectiva de pacientes con diagnóstico de tumor germinal de origen testicular que hubiesen recibido quimioterapia y en quienes se documentó tumor residual retroperitoneal y fueron sometidos a LRP-PC durante 12 años en un centro de referencia de manejo de cáncer.
Resultados Se practicó LRP-PC a 64 pacientes. La edad promedio al momento de la cirugía fue 28,1 años (18-47 años). El tamaño promedio de la masa retroperitoneal post quimioterapia fue 6,7 (1–28 cm). La estancia hospitalaria promedio fue 7,9 días (rango 1-99 días), la tasa de cirugías adicionales fue del 20%. La tasa de complicaciones mayores fue de 7,8%. Tener seminoma en la histología testicular inicial se asoció con un mayor sangrado y el tamaño de la masa retroperitoneal residual se asoció con la necesidad de cirugías concomitantes.
Conclusiones La LRP-PC es una cirugía de alto nivel de complejidad que se asocia a complicaciones mayores y a la necesidad de cirugías concomitantes. Esta cohorte de pacientes muestra desenlaces similares a los descritos en la literatura, recalcando el hecho de que esta cirugía, debería ser realizada en centros de referencia de manejo del cáncer.
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Affiliation(s)
- Lynda Torres
- Pontificia Universidad Javeriana, Centro Policlínico Olaya, Bogotá, Colombia
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16
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Murez T, Fléchon A, Savoie PH, Rocher L, Camparo P, Morel-Journel N, Ferretti L, Méjean A. [French ccAFU guidelines - update 2020-2022: testicular germ cell tumors]. Prog Urol 2020; 30:S280-S313. [PMID: 33349427 DOI: 10.1016/s1166-7087(20)30754-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE - To update French guidelines concerning testicular germ cell cancer. MATERIALS AND METHODS - Comprehensive Medline search between 2018 and 2020 upon diagnosis, treatment and follow-up of testicular germ cell cancer and treatments toxicities. Level of evidence was evaluated. RESULTS - Testicular Germ cell tumor diagnosis is based on physical examination, biology tests (serum tumor markers AFP, hCGt, LDH) and radiological assessment (scrotal ultrasound and chest, abdomen and pelvis computerized tomography). Total inguinal orchiectomy is the first-line treatment allowing characterization of the histological type, local staging and identification of risk factors for micrometastases. In case of several therapeutic options, one must inform his patient balancing risks and benefits. Surveillance is usually chosen in stage I seminoma compliant patients as the evolution rate is low between 15 to 20%. Carboplatin AUC7 is an alternative option. Radiotherapy indication should be avoided. In stage I non seminomatous patients, either surveillance or risk-adapted strategy can be applied. Staging retroperitoneal lymphadenectomy has restricted indications. Metastatic germ cell tumors are usually treated by PEB chemotherapy according to IGCCCG prognostic classification. Lombo-aortic radiotherapy is still a standard treatment for stage IIA. Residual masses should be evaluated by biological and radiological assessment 3 to 4 weeks after the end of chemotherapy. Retroperitoneal lymphadenectomy is advocated for every non seminomatous residual mass more than one cm. 18FDG uptake should be evaluated for each seminoma residual mass more than 3 cm. CONCLUSIONS - A rigorous use of classifications is mandatory to define staging since initial diagnosis. Applying treatments based on these classifications leads to excellent survival rates (99% in CSI, 85% in CSII+).
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Affiliation(s)
- T Murez
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie et de transplantation rénale, CHU Lapeyronie, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier Cedex 5, France.
| | - A Fléchon
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Centre Léon-Bérard, 28, rue Laennec, 69008 Lyon, France
| | - P-H Savoie
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de chirurgie urologique, hôpital d'instruction des armées Sainte-Anne, BP 600, 83800 Toulon Cedex 09, France
| | - L Rocher
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de radiologie, hôpital Antoine-Béclère, AP-HP, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France; Université Paris Saclay, BIOMAPS, 63, avenue Gabriel-Péri, 94270 Le Kremlin-Bicêtre, France
| | - P Camparo
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Institut de pathologie des Hauts-de-France, 51, rue Jeanne-d'Arc, 80000 Amiens, France
| | - N Morel-Journel
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, CHU de Lyon, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France
| | - L Ferretti
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; MSP Bordeaux Bagatelle, 203, route de Toulouse, 33401 Talence, France
| | - A Méjean
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie et transplantation rénale, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
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17
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Kozakova K, Mego M, Cheng L, Chovanec M. Promising novel therapies for relapsed and refractory testicular germ cell tumors. Expert Rev Anticancer Ther 2020; 21:53-69. [PMID: 33138660 DOI: 10.1080/14737140.2021.1838279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Germ cell tumors (GCTs) are the most common solid malignancies in young men. The overall cure rate of GCT patients in metastatic stage is excellent, however; patients with relapsed or refractory disease have poor prognosis. Attempts to treat refractory disease with novel effective treatment to improve prognosis have been historically dismal and the ability to predict prognosis and treatment response in GCTs did not sufficiently improve in the last three decades. AREAS COVERED We performed a comprehensive literature search of PubMed/MEDLINE to identify original and review articles (years 1964-2020) reporting on current improvement salvage treatment in GCTs and novel treatment options including molecularly targeted therapy and epigenetic approach. Review articles were further searched for additional original articles. EXPERT OPINION Despite multimodal treatment approaches the treatment of relapsed or platinum-refractory GCTs remains a challenge. High-dose chemotherapy (HDCT) regimens with autologous stem-cell transplant (ASCT) from peripheral blood showed promising results in larger retrospective studies. Promising results from in vitro studies raised high expectations in molecular targets. So far, the lacking efficacy in small and unselected trials do not shed a light on targeted therapy. Currently, wide inclusion of patients into clinical trials is highly advised.
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Affiliation(s)
- Kristyna Kozakova
- Department of Anesthesiology and Intensive Care Medicine, National Cancer Institute , Bratislava, Slovakia.,2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute , Bratislava, Slovakia
| | - Michal Mego
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute , Bratislava, Slovakia.,Division of Hematology Oncology, Indiana University Simon Cancer Center , Indianapolis, IN, USA
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine , Indianapolis, IN, USA.,Department of Urology, Indiana University School of Medicine , Indianapolis, IN, USA
| | - Michal Chovanec
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute , Bratislava, Slovakia.,Division of Hematology Oncology, Indiana University Simon Cancer Center , Indianapolis, IN, USA
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18
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Shaikh F, Stark D, Fonseca A, Dang H, Xia C, Krailo M, Pashankar F, Rodriguez-Galindo C, Olson TA, Nicholson JC, Murray MJ, Amatruda JF, Billmire D, Stoneham S, Frazier AL. Outcomes of adolescent males with extracranial metastatic germ cell tumors: A report from the Malignant Germ Cell Tumor International Consortium. Cancer 2020; 127:193-202. [PMID: 33079404 DOI: 10.1002/cncr.33273] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/13/2020] [Accepted: 09/21/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Adolescents with extracranial metastatic germ cell tumors (GCTs) are often treated with regimens developed for children, but their clinical characteristics more closely resemble those of young adult patients. This study was designed to determine event-free survival (EFS) for adolescents with GCTs and compared them with children and young adults. METHODS An individual patient database of 11 GCT trials was assembled: 8 conducted by pediatric cooperative groups and 3 conducted by an adult group. Male patients aged 0 to 30 years with metastatic, nonseminomatous, malignant GCTs of the testis, retroperitoneum, or mediastinum who were treated with platinum-based chemotherapy were included. The age groups were categorized as children (0 to <11 years), adolescents (11 to <18 years), and young adults (18 to ≤30 years). The study compared EFS and adjusted for risk group by using Cox proportional hazards analysis. RESULTS From a total of 2024 individual records, 593 patients met the inclusion criteria: 90 were children, 109 were adolescents, and 394 were young adults. The 5-year EFS rate was lower for adolescents (72%; 95% confidence interval [CI], 62%-79%) than children (90%; 95% CI, 81%-95%; P = .003) or young adults (88%; 95% CI, 84%-91%; P = .0002). The International Germ Cell Cancer Collaborative Group risk group was associated with EFS in the adolescent age group (P = .0020). After adjustments for risk group, the difference in EFS between adolescents and children remained significant (hazard ratio, 0.30; P = .001). CONCLUSIONS EFS for adolescent patients with metastatic GCTs was similar to that for young adults but significantly worse than for that children. This finding highlights the importance of coordinating initiatives across clinical trial organizations to improve outcomes for adolescents and young adults. LAY SUMMARY Adolescent males with metastatic germ cell tumors (GCTs) are frequently treated with regimens developed for children. In this study, a large data set of male patients with metastatic GCTs across different age groups has been built to understand the outcomes of adolescent patients in comparison with children and young adults. The results suggest that adolescent males with metastatic GCTs have worse results than children and are more similar to young adults with GCTs. Therefore, the treatment of adolescents with GCTs should resemble therapeutic approaches for young adults.
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Affiliation(s)
- Furqan Shaikh
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Stark
- Institute for Medical Research, University of Leeds, Leeds, United Kingdom
| | - Adriana Fonseca
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ha Dang
- Children's Oncology Group, Monrovia, California
| | - Caihong Xia
- Children's Oncology Group, Monrovia, California
| | - Mark Krailo
- Children's Oncology Group, Monrovia, California
| | | | | | - Thomas A Olson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - James C Nicholson
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Matthew J Murray
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - James F Amatruda
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, California
| | | | - Sara Stoneham
- Children's and Young Persons Cancer Services, University College London Hospital Trusts, London, United Kingdom
| | - A Lindsay Frazier
- Dana-Farber Cancer Institute, Boston, Massachusetts.,Boston Children's Hospital, Boston, Massachusetts
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19
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Umbreit EC, McIntosh AG, Suk-Ouichai C, Segarra LA, Holland LC, Fellman BM, Williams SB, Thomas AZ, Tu SM, Pettaway CA, Pisters LL, Ward JF, Wood CG, Karam JA. Intraoperative and early postoperative complications in postchemotherapy retroperitoneal lymphadenectomy among patients with germ cell tumors using validated grading classifications. Cancer 2020; 126:4878-4885. [PMID: 32940929 DOI: 10.1002/cncr.33051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/13/2020] [Accepted: 02/21/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Postchemotherapy retroperitoneal lymphadenectomy (PC-RPLND) is an essential, yet potentially morbid, therapy for the management of patients with advanced germ cell tumors. In the current study, the authors sought to define the complication profile of PC-RPLND using validated grading systems for intraoperative adverse events (iAEs) and early postoperative complications. METHODS Between 2000 and 2018, all patients who underwent PC-RPLND were analyzed for iAEs and early postoperative complications using the Kaafarani and Clavien-Dindo classifications, respectively. Logistic regression models were conducted to assess patient and tumor factors associated with iAEs and postoperative complications. RESULTS Of the 453 patients identified, 115 patients (25%) and 252 patients (56%), respectively, experienced an iAE and postoperative complication. Major iAEs (grade ≥3) were observed in 15 patients (3%) and major postoperative complications (grade ≥3) were noted in 80 patients (18%). The most common iAE was vascular injury (112 of 132 events; 85%), which occurred in 92 patients (20%), and the most frequent postoperative complication was ileus, which occurred in 121 patients (27%). Original and postchemotherapy retroperitoneal mass size, nonretroperitoneal metastases, intermediate and/or poor International Germ Cell Cancer Collaborative Group classification, previous RPLND, elevated tumor markers at the time of RPLND, and anticipated adjuvant surgical procedures increased the risk of both iAEs and postoperative complications. Patients who experienced an iAE were significantly more likely to experience a postoperative complication (odds ratio, 2.50; 95% confidence interval, 1.58-3.97 [P < .001]). CONCLUSIONS In what to the authors' knowledge is the first analysis of PC-RPLND using validated classifications for both iAEs and postoperative complications, advanced disease and surgical complexity significantly increased the risks of major iAEs and postoperative complications. Standardized reporting of adverse perioperative events allows providers and patients to appreciate the consequences of PC-RPLND during counseling and decision making.
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Affiliation(s)
- Eric C Umbreit
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew G McIntosh
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chalairat Suk-Ouichai
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Luis A Segarra
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Levi C Holland
- McGovern Medical School, University of Texas, Houston, Texas
| | - Bryan M Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen B Williams
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Division of Urology, Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Arun Z Thomas
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Urology, Tallaght Hospital, Dublin, Ireland.,Department of Surgery, Trinity College, Dublin, Ireland
| | - Shi-Ming Tu
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Curtis A Pettaway
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Louis L Pisters
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John F Ward
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher G Wood
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jose A Karam
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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20
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Nason GJ, Jewett MAS, Bostrom PJ, Goldberg H, Hansen AR, Bedard PL, Sturgeon J, Warde P, Chung P, Anson-Cartwright L, Sweet J, Atenafu EG, O'Malley M, Hamilton RJ. Long-term Surveillance of Patients with Complete Response Following Chemotherapy for Metastatic Nonseminomatous Germ Cell Tumor. Eur Urol Oncol 2020; 4:289-296. [PMID: 32907779 DOI: 10.1016/j.euo.2020.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 07/13/2020] [Accepted: 08/18/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is controversy regarding the management of patients with normal markers and residual masses (≤1 cm) after chemotherapy for nonseminomatous germ cell tumors (NSGCTs). OBJECTIVE To determine long-term outcomes of a surveillance strategy in such patients. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of our multidisciplinary testicular cancer database was performed. All patients who underwent primary chemotherapy for metastatic NSGCTs were identified between 1981 and 2016. A complete response (CR) was defined as normalization of serum tumor markers and a ≤1 cm residual mass in the largest axial dimension following chemotherapy. All such patients were surveilled. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Outcome variables of interest were time to death, time to cancer-specific survival, and time to relapse. Overall survival and relapse-free survival were calculated using the Kaplan-Meier method, and the cumulative incidence of cause-specific survival rates was calculated using competing risk analysis. The impact of risk group and chemotherapy regimen on relapse-free survival was assessed using log-rank test. RESULTS AND LIMITATIONS During the study period, 1429 metastatic germ cell tumor patients were treated with primary chemotherapy. CR was achieved in 191 (18.5%) NSGCT patients. The median age at diagnosis was 27.4 yr, with a median follow-up of 81.1 mo. The majority had American Joint Committee on Cancer stage II at diagnosis (I: 23.8%; II: 49.2%; III: 27%) and International Germ Cell Cancer Collaborative Group good-risk disease (good: 78%; intermediate: 17.8%; poor: 4.2%). Of the 191 patients with a CR, 175 (91.6%) never relapsed and remain disease free. Sixteen (8.4%) patients relapsed after a median of 11.3 mo (range 1-332 mo), with over half (nine patients; 4.7%) relapsing in the retroperitoneum only and salvaged successfully with postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) alone. Of these nine patients, only two (1%) had viable disease in the PC-RPLND specimen. The remaining seven patients had relapses outside the retroperitoneum and received salvage chemotherapy ± postchemotherapy resection. Overall, nine (4.7%) patients have died, but only four (2.1%) from testis cancer. CONCLUSIONS Our data, the largest series to date, confirm that surveillance is safe and effective for men who achieve a CR following chemotherapy for metastatic NSGCTs. PATIENT SUMMARY Surveillance is a safe strategy for patients who achieve a complete response following chemotherapy for metastatic testis cancer.
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Affiliation(s)
- Gregory J Nason
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Michael A S Jewett
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Peter J Bostrom
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Hanan Goldberg
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Aaron R Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Philippe L Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jeremy Sturgeon
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Padraig Warde
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Peter Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Lynn Anson-Cartwright
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Joan Sweet
- Department of Pathology and Lab Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Martin O'Malley
- Division of Abdominal Imaging, Joint Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada.
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21
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John P, Albers P, Hiester A, Heidenreich A. [Retroperitoneal lymph node dissection in testicular germ cell tumours: indications, complications and special cases]. Aktuelle Urol 2020; 51:475-481. [PMID: 32557448 DOI: 10.1055/a-1176-9796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
ZusammenfassungDie retroperitoneale Lymphadenektomie ist integraler Bestandteil der stadienadaptierten Therapie von testikulären Keimzelltumoren. Verschiedene Ansätze der retroperitonealen Lymphadenektomie werden auf Basis unterschiedlicher Indikationen durchgeführt.Die nervschonende retroperitoneale Lymphadenektomie als primäre Therapieoption bei nicht seminomatösen Keimzelltumoren im klinischen Stadium I sollte risikoadaptiert erfolgen. Geringfügige perioperative Komplikationen wie Wundinfekte, Lymphozelen und paralytischer Ileus treten bei in etwa 14 % der Patienten auf. Schwerwiegendere Komplikationen wie chylärer Aszites und Lungenarterienembolien treten bei ca. 5,4 % der Patienten auf. Die häufigste Langzeitkomplikation ist hierbei das Auftreten einer Retrograden Ejakulation. Der Erhalt der antegraden Ejakulation kann jedoch bei weit über 90 % der Patienten erreicht werden.Die postchemotherapeutische retroperitoneale Lymphadenektomie ist integraler Bestandteil der multimodalen Therapie bei retroperitonealen Residualbefunden. Bei residuellen Befunden > 3 cm beim fortgeschrittenen Seminom dient das FDG PET als zuverlässige Entscheidungshilfe zur Durchführung einer retroperitonealen Lymphadenektomie.Bei ca. 30 % der Patienten mit nicht seminomatösen Keimzelltumoren finden sich residuelle retroperitoneale Tumorbefunde. Diese sollten unabhängig von der Größe der Befunde bei negativen Serumtumormarkern oder Serumtumormarkern im Plateau komplett reseziert werden. Die postchemotherapeutische retroperitoneale Lymphadenektomie stellt einen herausfordernden Eingriff dar und sollte primär an ausgewiesenen Zentren durchgeführt werden. Bei bis zu 25 % der Patienten ist im Rahmen der postchemotherapeutischen retroperitonealen Lymphadenektomie die Resektion umgebender Strukturen indiziert. Eine Beteiligung der aorta abdominalis liegt in 6 – 10 % der Fälle vor, eine Beteiligung der vena cava in ca. 2 % der Fälle. Komplikationsraten liegen bei der postchemotherapeutischen retroperitonealen Lymphadenektomie höher als bei der primären nervschonenenden Lymphadenektomie mit signifikant höherem intraoperativen Blutverlust und signifikant höherer Transfusionsrate. Mit einer Wahrscheinlichkeit von 2 – 7 % tritt chylärer Aszites nach postchemotherapeutischer retroperitonealer Lymphadenektomie häufiger auf. Jedoch kann auch im Rahmen der postchemotherapeutischen Lymphadenektomie bei bis zu 85 % der Erhalt der antegraden Ejakulation erreicht werden. Entscheidend für den Erhalt der antegraden Ejakulation und einer Verbesserung der Morbidität insgesamt ist auch hier das nach Möglichkeit das Anstreben eines nervsparenden Vorgehens durch Anpassung der Felder.
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22
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Gilligan T, Lin DW, Aggarwal R, Chism D, Cost N, Derweesh IH, Emamekhoo H, Feldman DR, Geynisman DM, Hancock SL, LaGrange C, Levine EG, Longo T, Lowrance W, McGregor B, Monk P, Picus J, Pierorazio P, Rais-Bahrami S, Saylor P, Sircar K, Smith DC, Tzou K, Vaena D, Vaughn D, Yamoah K, Yamzon J, Johnson-Chilla A, Keller J, Pluchino LA. Testicular Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 17:1529-1554. [PMID: 31805523 DOI: 10.6004/jnccn.2019.0058] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Testicular cancer is relatively uncommon and accounts for <1% of all male tumors. However, it is the most common solid tumor in men between the ages of 20 and 34 years, and the global incidence has been steadily rising over the past several decades. Several risk factors for testicular cancer have been identified, including personal or family history of testicular cancer and cryptorchidism. Testicular germ cell tumors (GCTs) comprise 95% of malignant tumors arising in the testes and are categorized into 2 main histologic subtypes: seminoma and nonseminoma. Although nonseminoma is the more clinically aggressive tumor subtype, 5-year survival rates exceed 70% with current treatment options, even in patients with advanced or metastatic disease. Radical inguinal orchiectomy is the primary treatment for most patients with testicular GCTs. Postorchiectomy management is dictated by stage, histology, and risk classification; treatment options for nonseminoma include surveillance, systemic therapy, and nerve-sparing retroperitoneal lymph node dissection. Although rarely occurring, prognosis for patients with brain metastases remains poor, with >50% of patients dying within 1 year of diagnosis. This selection from the NCCN Guidelines for Testicular Cancer focuses on recommendations for the management of adult patients with nonseminomatous GCTs.
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Affiliation(s)
- Timothy Gilligan
- 1Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Daniel W Lin
- 2University of Washington/Seattle Cancer Care Alliance
| | | | | | | | | | | | | | | | | | | | | | | | - Will Lowrance
- 14Huntsman Cancer Institute at the University of Utah
| | | | - Paul Monk
- 16The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Joel Picus
- 17Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | | | | | - Daniel Vaena
- 24St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - David Vaughn
- 25Abramson Cancer Center at the University of Pennsylvania
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23
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Blok JM, Meijer RP, van der Poel HG, Bex A, van Vooren J, van Urk JJ, Horenblas S, Bosch JLHR. Additional surgical procedures and perioperative morbidity in post-chemotherapy retroperitoneal lymph node dissection for metastatic testicular cancer in two intermediate volume hospitals. World J Urol 2020; 39:839-846. [PMID: 32372160 PMCID: PMC7969692 DOI: 10.1007/s00345-020-03229-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/24/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose To evaluate the perioperative morbidity of PC-RPLND in two intermediate volume centers and to identify predictors of high morbidity. Methods Retrospective analysis of 124 patients treated with open PC-RPLND at two tertiary referral centers between 2001 and 2018. Perioperative morbidity was determined by analyzing additional surgical procedures, intra-operative blood loss, and postoperative complications. Results An additional procedure was necessary for 33 patients (26.6%). The risk was higher in patients with IGCCCG intermediate/poor prognosis (OR 3.56; 95% CI 1.33–9.52) and residual tumor size > 5 cm (OR 3.53; 95% CI 1.39–8.93). Blood loss was higher in patients with IGCCCG intermediate/poor prognosis (β = 0.177; p = 0.029), large residual tumor (β = 0.570; p < 0.001), an additional intervention (β = 0.342; p < 0.001) and teratoma on retroperitoneal histology (β = − 0.19; p = 0.014). Thirty-one patients had a postoperative complication Clavien-Dindo Grade ≥ 2 (25.0%). Complication risk was highest in patients undergoing an additional intervention (OR 3.46; 95% CI 1.03–11.60; p = 0.044). Conclusions The rate of additional interventions in our series is comparable to what has been reported in high-volume centers. IGCCCG intermediate/poor prognosis patients with high-volume disease and patients undergoing an additional surgical procedure can be classified as high-risk patients. Electronic supplementary material The online version of this article (10.1007/s00345-020-03229-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joost M Blok
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands. .,Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Richard P Meijer
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Henk G van der Poel
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Axel Bex
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jeanette van Vooren
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Japke J van Urk
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Simon Horenblas
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J L H Ruud Bosch
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands
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24
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Nason GJ, Donahoe L, de Perrot M, Aditya I, Jewett MAS, Bedard PL, Hansen AR, Chung P, Warde P, Anson-Cartwright L, Sweet J, O'Malley M, Atenafu EG, Hamilton RJ. Simultaneous Vs Sequential Retroperitoneal, Thoracic and Cervical Resection of Post Chemotherapy Residual Masses in Patients With Metastatic Nonseminomatous Germ Cell Tumors of the Testis. Urology 2020; 138:69-76. [PMID: 32004556 DOI: 10.1016/j.urology.2019.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare a simultaneous vs sequential approach to residual post chemotherapy mass resections in metastatic testis cancer. METHODS A retrospective review was performed of patients who underwent retroperitoneal and thoracic/cervical resection of post chemotherapy residual masses between 2002 and 2018. Group 1: "Simultaneous" (Combined Retroperitoneal and Thoracic/Cervical resections on the same date); Group 2: "Sequential" (Retroperitoneal and Thoracic/Cervical resections at separate dates). RESULTS During the study period, 35 simultaneous and 17 sequential resections were performed. The median age at surgery was 28 years (Range 16-61). The median follow-up from last surgical procedure was 62.7 months (Range 0.4-194). Histology revealed teratoma in 38 (73.1%) patients, necrosis in 8 (15.4%) and viable tumor in 6 (11.5%). Discordant pathology findings between thoracic/cervical and abdominal resections were noted in 16 (30.8%) patients. No differences were observed between the simultaneous vs sequential groups in median operating time (585 minutes vs 545 minutes, P = .64), blood loss (1300 vs 1300 mls, P = .42), or length of stay (9 vs 11 days, P = .14). There was no difference between the 5-year (65.7% vs 68.6%) relapse-free survival between the 2 groups (P = .84) or the 5-year (88.6% vs 100%) overall and disease-specific survival (P = .25). CONCLUSION Simultaneous resection of retroperitoneal and thoracic/cervical post chemotherapy metastases is a feasible in some patients. It requires multidisciplinary collaboration and a longer primary procedure.
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Affiliation(s)
- Gregory J Nason
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Ishan Aditya
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Michael A S Jewett
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Philip L Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Aaron R Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Padraig Warde
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Lynn Anson-Cartwright
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Joan Sweet
- Department of Pathology and Lab Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Martin O'Malley
- Division of Abdominal Imaging, Joint Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada.
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25
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Amend G, Palvolgyi R, Rodriguez VM, Bold RJ, Evans CP. A Case Series of Preoperative Endovascular Stenting in Patients Undergoing Postchemotherapy Resection of Complex Oncologic Masses. Eur Urol Oncol 2020; 3:1-6. [PMID: 31892469 DOI: 10.1016/j.euo.2019.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
Abstract
The incidence of complications for postchemotherapy (PC) resections is high. Severe intraoperative hemorrhage during retroperitoneal lymph node dissection is of significant concern. The safety and efficacy of endovascular technology in vascular surgery have been demonstrated, but no studies have incorporated endovascular stenting in preoperative planning. We present a case series of four patients with nonseminomatous germ cell tumors who underwent preoperative endovascular stenting to identify and protect major vascular structures encased by complex PC tumors. We measured operative time, estimated blood loss, intraoperative transfusion requirement, length of stay, and postoperative complications. In all cases, surgery progressed without full continuous identification of the major vascular structures and their branches because of the assurance that hemorrhage would be controlled should they be breached. PATIENT SUMMARY: Preoperative endovascular stenting may be an effective approach for minimizing intraoperative hemorrhage and operative time in patients undergoing bulky postchemotherapy dissection. Additional studies are needed to better clarify patient selection criteria and quantify the efficacy and adverse consequences.
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Affiliation(s)
- Gregory Amend
- Department of Urologic Surgery, University of California at Davis, Sacramento, CA, USA
| | - Roland Palvolgyi
- Department of Urologic Surgery, University of California at Davis, Sacramento, CA, USA
| | - Victor M Rodriguez
- Department of Vascular Surgery, University of California at Davis, Sacramento, CA, USA
| | - Richard J Bold
- Department of Surgical Oncology, University of California at Davis, Sacramento, CA, USA
| | - Christopher P Evans
- Department of Urologic Surgery, University of California at Davis, Sacramento, CA, USA.
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Baessler B, Nestler T, Pinto Dos Santos D, Paffenholz P, Zeuch V, Pfister D, Maintz D, Heidenreich A. Radiomics allows for detection of benign and malignant histopathology in patients with metastatic testicular germ cell tumors prior to post-chemotherapy retroperitoneal lymph node dissection. Eur Radiol 2019; 30:2334-2345. [PMID: 31828413 DOI: 10.1007/s00330-019-06495-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/29/2019] [Accepted: 10/04/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To evaluate whether a computed tomography (CT) radiomics-based machine learning classifier can predict histopathology of lymph nodes (LNs) after post-chemotherapy LN dissection (pcRPLND) in patients with metastatic non-seminomatous testicular germ cell tumors (NSTGCTs). METHODS Eighty patients with retroperitoneal LN metastases and contrast-enhanced CT were included into this retrospective study. Resected LNs were histopathologically classified into "benign" (necrosis/fibrosis) or "malignant" (viable tumor/teratoma). On CT imaging, 204 corresponding LNs were segmented and 97 radiomic features per LN were extracted after standardized image processing. The dataset was split into training, test, and validation sets. After stepwise feature reduction based on reproducibility, variable importance, and correlation analyses, a gradient-boosted tree was trained and tuned on the selected most important features using the training and test datasets. Model validation was performed on the independent validation dataset. RESULTS The trained machine learning classifier achieved a classification accuracy of 0.81 in the validation dataset with a misclassification of 8 of 36 benign LNs as malignant and 4 of 25 malignant LNs as benign (sensitivity 88%, specificity 72%, negative predictive value 88%). In contrast, a model containing only the LN volume resulted in a classification accuracy of 0.68 with 64% sensitivity and 68% specificity. CONCLUSIONS CT radiomics represents an exciting new tool for improved prediction of the presence of malignant histopathology in retroperitoneal LN metastases from NSTGCTs, aiming at reducing overtreatment in this group of young patients. Thus, the presented approach should be combined with established clinical biomarkers and further validated in larger, prospective clinical trials. KEY POINTS • Patients with metastatic non-seminomatous testicular germ cell tumors undergoing post-chemotherapy retroperitoneal lymph node dissection of residual lesions show overtreatment in up to 50%. • We assessed whether a CT radiomics-based machine learning classifier can predict histopathology of lymph nodes after post-chemotherapy lymph node dissection. • The trained machine learning classifier achieved a classification accuracy of 0.81 in the validation dataset with a sensitivity of 88% and a specificity of 78%, thus allowing for prediction of the presence of viable tumor or teratoma in retroperitoneal lymph node metastases.
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Affiliation(s)
- Bettina Baessler
- Institute of Diagnostic and Interventional Radiology, University Hospital of Cologne, Cologne, Germany. .,Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland.
| | - Tim Nestler
- Department of Urology, University Hospital of Cologne, Cologne, Germany
| | - Daniel Pinto Dos Santos
- Institute of Diagnostic and Interventional Radiology, University Hospital of Cologne, Cologne, Germany
| | - Pia Paffenholz
- Department of Urology, University Hospital of Cologne, Cologne, Germany
| | - Vikram Zeuch
- Department of Urology, University Hospital of Aachen, Aachen, Germany
| | - David Pfister
- Department of Urology, University Hospital of Cologne, Cologne, Germany
| | - David Maintz
- Institute of Diagnostic and Interventional Radiology, University Hospital of Cologne, Cologne, Germany
| | - Axel Heidenreich
- Department of Urology, University Hospital of Cologne, Cologne, Germany
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27
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Murez T, Fléchon A, Savoie PH, Rocher L, Camparo P, Morel-Journel N, Ferretti L, Sèbe P, Méjean A. [French ccAFU guidelines - Update 2018-2020: Testicular germ cell tumors]. Prog Urol 2019; 28 Suppl 1:R149-R166. [PMID: 31610870 DOI: 10.1016/j.purol.2019.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To update French guidelines concerning testicular germ cell cancer. METHODS Comprehensive Medline search between 2016 and 2018 upon diagnosis, treatment and follow-up of testicular germ cell cancer and treatments toxicities. Level of evidence was evaluated. RESULTS Testicular Germ cell tumor diagnosis is based on physical examination, biology tests (serum tumor markers AFP, hCGt, LDH) and radiological assessment (scrotal ultrasound and chest, abdomen and pelvis computerized tomography). Total inguinal orchiectomy is the first- line treatment allowing characterization of the histological type, local staging and identification of risk factors for micrometastases. In case of several therapeutic options, one must inform his patient balancing risks and benefits. Surveillance is usually chosen in stage I seminoma compliant patients as the evolution rate is low between 15 to 20 %. Carboplatin AUC7 is an alternative option. Radiotherapy indication should be avoided. In stage I non-seminomatous patients, either surveillance or risk-adapted strategy can be applied. Staging retroperitoneal lymphadenectomy has restricted indications. Metastatic germ cell tumors are usually treated by PEB chemotherapy according to IGCCCG prognostic classification. Lombo-aortic radiotherapy is still a standard treatment for stage IIA. Residual masses should be evaluated by biological and radiological assessment 3 to 4 weeks after the end of chemotherapy. Retroperitoneal lymphadenectomy is advocated for every non-seminomatous residual mass more than one cm. 18FDG uptake should be evaluated for each seminoma residual mass more than 3cm. CONCLUSIONS A rigorous use of classifications is mandatory to define staging since initial diagnosis. Applying treatments based on these classifications leads to excellent survival rates (99 % in CSI, 85 % in CSII+).
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Affiliation(s)
- T Murez
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, CHRU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France.
| | - A Fléchon
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'oncologie médicale, centre Léon-Bérard, 28, rue Laennec, 69008 Lyon, France
| | - P-H Savoie
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital d'instruction des armées Sainte-Anne, BP 600, 83800 Toulon cedex 09, France
| | - L Rocher
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de radiologie, CHU Paris Sud, site Kremlin-Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France
| | - P Camparo
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Centre de pathologie, 51, rue de Jeanne-D'Arc, 80000 Amiens, France
| | - N Morel-Journel
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, centre hospitalier Lyon Sud (Pierre Bénite), HCL groupement hospitalier du Sud, 69495 Pierre Bénite cedex, France
| | - L Ferretti
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, MSP de Bordeaux-Bagatelle, 203, route de Toulouse, BP 50048, 33401 Talence cedex, France
| | - P Sèbe
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, groupe hospitalier Diaconesses Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France
| | - A Méjean
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital européen Georges-Pompidou, université Paris Descartes, AP-HP, 75015 Paris, France
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Groeben C, Koch R, Nestler T, Kraywinkel K, Borkowetz A, Wenzel S, Baunacke M, Thomas C, Huber J. Centralization tendencies of retroperitoneal lymph node dissection for testicular cancer in Germany? A total population-based analysis from 2006 to 2015. World J Urol 2019; 38:1765-1772. [PMID: 31605195 DOI: 10.1007/s00345-019-02972-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 09/27/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Retroperitoneal lymph node dissection (RPLND) is a standard treatment in the management of metastatic testicular cancer. Due to modified treatment algorithms, it is becoming less frequent. MATERIALS AND METHODS We analyzed data from the nationwide German hospital billing database covering 2006-2015. Cases with a testicular cancer diagnosis combined with RPLND were included. We assessed the length of hospital stay (LOS), blood transfusion, and in-hospital mortality stratified for surgical approach, hospital characteristics, and annual caseload. Annual hospital caseload categories were defined as low (< 4), medium (4-10), and high (> 10). We supplemented tumor incidence and staging data from the German cancer registry (60% of population). RESULTS 4926 cases were included with decreasing annual caseload numbers from 623 in 2006 to 382 in 2015. The incidence of testicular cancer and higher tumor stages remained stable. High-volume hospitals performed 19.4%, medium-volume hospitals 43.7%, and low-volume hospitals 36.8% RPLNDs. Low- abd medium-volume hospitals declined, while high-volume hospitals (n = 5) maintained their annual caseload. Overall in-hospital mortality was 0.47%. Blood transfusion rates were higher in high-volume centers assumedly due to selection of more complex cases. However, high-volume hospitals showed a shorter LOS with 10.5 vs. 11.2 (medium volume), and 12.7 days (low volume). CONCLUSION Total numbers of RPLND have declined from 2006 to 2015, while tumor incidences and stages remained fairly stable. Constant reduction of indication in guidelines contributes to this finding. High-volume hospitals achieve shorter hospital stays in spite of assumedly more complex and extensive cases. There is a modest trend towards unregulated centralization.
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Affiliation(s)
- Christer Groeben
- Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Rainer Koch
- Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Tim Nestler
- Department of Urology, University Hospital of Cologne, Cologne, Germany
- Department of Urology, Federal Armed Services Hospital Koblenz, Koblenz, Germany
| | - Klaus Kraywinkel
- National Center for Cancer Registry Data, Robert Koch Institute, Berlin, Germany
| | - Angelika Borkowetz
- Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Stefanie Wenzel
- Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Martin Baunacke
- Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Christian Thomas
- Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Johannes Huber
- Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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Paffenholz P, Nestler T, Hoier S, Pfister D, Hellmich M, Heidenreich A. External validation of 2 models to predict necrosis/fibrosis in postchemotherapy residual retroperitoneal masses of patients with advanced testicular cancer. Urol Oncol 2019; 37:809.e9-809.e18. [PMID: 31540832 DOI: 10.1016/j.urolonc.2019.07.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 07/12/2019] [Accepted: 07/25/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Nonseminomatous testicular germ cell tumors with residual retroperitoneal lesions >1 cm are treated with postchemotherapy retroperitoneal lymph node dissection (pcRPLND). However, up to 50% of patients are overtreated since the histology shows only residual necrosis/fibrosis. We aim to validate the 2 currently best performing prediction models (Vergouwe and Leao) for postchemotherapy residual mass histology. METHODS AND MATERIALS We performed a retrospective analysis including 402 patients who underwent a pcRPLND from 2008 to 2015. The study cohort was used to validate the 2 prediction models by Vergouwe and Leao using the published formulas and thresholds. RESULTS Using our validation cohort, the Vergouwe model reached a significantly better area under the curve compared to the Leao model (0.760 (confidence interval 0.713-0.807) vs. 0.692 (0.640-0.744), P = 0.002) in the prediction of benign histology. At a threshold of >70% for the predicted probability of benign disease, the Leao model revealed that pcRPLND would be avoided in 10.2% of patients with benign disease with an error rate of 3.8% for viable tumor, while the Vergouwe model would avoid pcRPLND in 27.4% of all patients with benign disease with an error rate of 10.1% for viable tumor and 2.9% for teratoma. Adjusting the models to our data had no significant improvement. Limitations include the retrospective design. CONCLUSIONS The discriminatory accuracy of both models is not sufficient to safely select patients for surveillance strategy instead of pcRPLND. Therefore, further studies including new biomarkers are needed to optimize the accuracy of potential prediction models and to minimize pcRPLND overtreatment.
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Affiliation(s)
- Pia Paffenholz
- Department of Urology, University Hospital Cologne, Cologne, Germany
| | - Tim Nestler
- Department of Urology, University Hospital Cologne, Cologne, Germany
| | - Simon Hoier
- Department of Urology, University Hospital Cologne, Cologne, Germany
| | - David Pfister
- Department of Urology, University Hospital Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - Axel Heidenreich
- Department of Urology, University Hospital Cologne, Cologne, Germany; Department of Urology, Medical University Vienna, Austria.
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European Association of Urology Guidelines on Testis Cancer: Important Take Home Messages. Eur Urol Focus 2019; 5:742-744. [DOI: 10.1016/j.euf.2019.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/01/2019] [Indexed: 11/20/2022]
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Robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy for metastatic mixed testicular germ cell cancer: a case report. J Med Case Rep 2019; 13:272. [PMID: 31451109 PMCID: PMC6710881 DOI: 10.1186/s13256-019-2200-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The robot-assisted laparoscopic management of post-chemotherapy retroperitoneal metastasis and inferior vena cava tumor thrombus secondary to testicular cancer is a challenging task for urologists. CASE PRESENTATION A pathological examination of a 36-year-old Caucasian man who had undergone a right radical orchiectomy showed mixed testicular germ cell cancer (70% embryonal cancer and 30% seminoma); he had undergone four prior courses of cisplatin, etoposide, and bleomycin chemotherapy and was found to have residual retroperitoneal enlarged lymph nodes close to the right renal hilum and a 9.8 cm inferior vena cava tumor thrombus (pT1, N2, M1, S2). Pre-surgical three-dimensional image reconstruction was performed based on contrast computed tomography data. The inferior vena cava tumor thrombus was found in the vena cava at the level of the celiac trunk and the inferior mesenteric artery. Our patient accepted treatment with robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and cava reconstruction on September 12, 2018. During the procedure, a drop-in robotic ultrasound probe was used to define the thrombus. Vena cavoscopy using a flexible ureteroscope found that the tumor thrombus adhered to the cava wall in all directions. The tumor thrombus was dissected free from the inferior vena cava lumen, and vena cava reconstruction was achieved using the da Vinci™ Si HD surgical system. The operative time was 550 minutes. The intraoperative estimated blood loss was 2300 ml. Intraoperative blood transfusions consisted of 10 units of red blood cells (Clavien-Dindo grade II). No Clavien-Dindo grade III or above perioperative complications occurred. The length of hospital stay was 7 days. Pathology revealed no viable cancer cells in any of the residual lymph node tissues or in the vena cava tumor thrombus. CONCLUSION This is the first case of robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and reconstruction for metastatic mixed testicular germ cell cancer published to date. This complicated surgical procedure was facilitated by the innovative usage of three-dimensional image reconstruction for defining the vena cava tumor thrombus, a robotic ultrasound probe for intraoperatively defining the vena cava tumor thrombus, and vena cavoscopy using a flexible ureteroscope.
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Abstract
Retroperitoneal lymph node dissection is an integral part of the management of testicular cancer. Surgical approach and outcomes have improved over the past decades. Several factors influence the complexity of the operation, including numerous patient characteristics and disease-related characteristics. An important consideration lies in the fact that this is largely a vascular operation, and techniques of vascular control should be comfortable for the urologic surgeon performing the procedure. This article discusses the known surgical complications related to this operation and their relative incidence reported throughout the literature.
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Heidenreich A, Paffenholz P, Nestler T, Pfister D. Management of residual masses in testicular germ cell tumors. Expert Rev Anticancer Ther 2019; 19:291-300. [PMID: 30793990 DOI: 10.1080/14737140.2019.1580146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION About 50% of all patients with advanced testicular cancer demonstrate residual retroperitoneal or extraretroperitoneal masses. About two thirds of the masses harbour necrosis/fibrosis only whereas as about 10% and 40% harbour vital cancer or teratoma. Appropriate therapy will result in a high cure rate if performed properly. Areas covered: This review article covers the indication, the surgical technique and the oncological outcome of PC-RPLND and resection of extraretroperitoneal residual masses following chemotherapy in patients with advanced testis cancer. Expert commentary: Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours. Patients with nonseminomas, residual masses < 1cm and good prognosis can undergo active surveillance. In all other cases, PC-RPLND with or without resection of adjacent organs needs to be performed for curative intent. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.
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Affiliation(s)
- Axel Heidenreich
- a Department of Urology, Urologic Oncology, Robot-assisted and Specialized Urologic Surgery , University Hospital Cologne , Köln , Germany
| | - Pia Paffenholz
- a Department of Urology, Urologic Oncology, Robot-assisted and Specialized Urologic Surgery , University Hospital Cologne , Köln , Germany
| | - Tim Nestler
- a Department of Urology, Urologic Oncology, Robot-assisted and Specialized Urologic Surgery , University Hospital Cologne , Köln , Germany
| | - David Pfister
- a Department of Urology, Urologic Oncology, Robot-assisted and Specialized Urologic Surgery , University Hospital Cologne , Köln , Germany
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Hiester A, Nini A, Fingerhut A, Große Siemer R, Winter C, Albers P, Lusch A. Preservation of Ejaculatory Function After Postchemotherapy Retroperitoneal Lymph Node Dissection (PC-RPLND) in Patients With Testicular Cancer: Template vs. Bilateral Resection. Front Surg 2019; 5:80. [PMID: 30705885 PMCID: PMC6345078 DOI: 10.3389/fsurg.2018.00080] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 12/20/2018] [Indexed: 01/04/2023] Open
Abstract
Background: Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays a crucial role in treatment of metastatic non-seminomatous germ cell cancer. Objective: To evaluate the functional outcome regarding the preservation of ejaculatory function comparing a bilateral vs. unilateral template resection in PC-RPLND patients. In addition, oncological safety and perioperative complications of the unilateral template resection was compared to the full bilateral one. Design/Setting/Participants: Between 2003 and 2018, 504 RPLNDs have been performed in 434 patients. The database of consecutive patients was queried to identify 171 patients with PC-RPLND after 1st line chemotherapy for a non-seminoma with or without bilateral template resection. Re-Do's, late relapse, salvage patients, and thoraco-abdominal approaches were excluded. Indication for a template resection was a unilateral residual mass mainly <5 cm as published (1). Outcome, Measurement, and Statistical Analysis: Descriptive statistics were used to report preoperative features, postoperative outcomes and patterns of recurrence, on the overall population and after stratification for the type of resection (bilateral vs. unilateral). Kaplan-Meier analyses were used to describe recurrence- and cancer-specific mortality-free survival rates at different time points. Results and Limitations: Overall, 90 and 81 patients underwent unilateral and bilateral radical resection, respectively. Median size of residual mass was 7 cm for bilateral and 4 cm for unilateral template resection. Clinical stage II and III were present in 31 and 69% of patients, respectively. Median follow-up was 14.5 months (IQR 3.3–37.6). The 1- and 2-year recurrence-free survival rates were 91 and 91%, and 77 and 72% for patients treated with unilateral template and bilateral resection, respectively (p = 0.0078). Median time to recurrence was 9.5 and 9 months in template and bilateral resection group, respectively. Adjunctive procedures were performed in 56 patients (33%) and were significantly more frequent in the bilateral resection group (43 vs. 23%, p = 0.006). The overall high-grade complication rate (Clavien-Dindo ≥ III) was 6, 3, and 9% in unilateral template and bilateral resection group, respectively (p = 0.6). The rate of preservation of antegrade ejaculation was significantly higher in the unilateral group. Conclusions: Antegrade ejaculation in patients undergoing unilateral template resection with a residual mass <5 cm can be preserved at a much higher rate. Moreover, this surgical procedure is oncologically safe in terms of mid-term recurrence and CSM-free survival rates. This data undermines the growing evidence of limited PC-RPLND being justifiable in strictly unilateral residual mass <5 cm. This data has to be confirmed with a longer follow-up regarding in-field and retroperitoneal recurrences.
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Affiliation(s)
- Andreas Hiester
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Alessandro Nini
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Anna Fingerhut
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Robert Große Siemer
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Christian Winter
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Peter Albers
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Achim Lusch
- Department of Urology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
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Heidenreich A, Pfister D. Postchemotherapy Retroperitoneal Lymph Node Dissection in Advanced Germ Cell Tumors of the Testis. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42603-7_9-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Heidenreich A, Pfister D. Postchemotherapy Retroperitoneal Lymph Node Dissection in Advanced Germ Cell Tumors of the Testis. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42623-5_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Nicolai N, Biasoni D, Catanzaro MA, Colecchia M, Trama A, Hackl M, Eycken EV, Henau K, Dimitrova N, Sekerija M, Dušek L, Mägi M, Malila N, Leinonen M, Velten M, Troussard X, Bouvier V, Guizard AV, Bouvier AM, Arveux P, Maynadié M, Woronoff AS, Robaszkiewic M, Baldi I, Monnereau A, Tretarre B, Colonna M, Molinié F, Bara S, Schvartz C, Lapôtre-Ledoux B, Grosclaude P, Stabenow R, Luttmann S, Nennecke A, Engel J, Schubert-Fritschle G, Heidrich J, Holleczek B, Jónasson JG, Clough-Gorr K, Comber H, Mazzoleni G, Giacomin A, Sutera Sardo A, Barchielli A, Serraino D, De Angelis R, Mallone S, Tavilla A, Pierannunzio D, Rossi S, Santaquilani M, Knijn A, Pannozzo F, Gennaro V, Benfatto L, Ricci P, Autelitano M, Spagnoli G, Fusco M, Usala M, Vitale F, Michiara M, Tumino R, Mangone L, Falcini F, Ferretti S, Filiberti RA, Marani E, Iannelli A, Sensi F, Piffer S, Gentilini M, Madeddu A, Ziino A, Maspero S, Candela P, Stracci F, Tagliabue G, Rugge M, Trama A, Gatta G, Botta L, Capocaccia R, Pildava S, Smailyte G, Calleja N, Johannesen TB, Rachtan J, Góźdź S, Błaszczyk J, Kępska K, de Lacerda GF, Bento MJ, Miranda A, Diba CS, Almar E, Larrañaga N, de Munain AL, Torrella-Ramos A, Díaz García JM, Marcos-Gragera R, Sanchez MJ, Navarro C, Salmeron D, Moreno-Iribas C, Galceran J, Carulla M, Mousavi M, Bouchardy C, M. Ess S, Bordoni A, Konzelmann I, Rashbass J, Gavin A, Brewster DH, Huws DW, Visser O, Bielska-Lasota M, Primic-Zakelj M, Kunkler I, Benhamou E. Testicular germ-cell tumours and penile squamous cell carcinoma: Appropriate management makes the difference. Eur J Surg Oncol 2019. [DOI: 10.1016/j.ejso.2018.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Diagnosis and management of the growing teratoma syndrome: A single-center experience and review of the literature. Urol Oncol 2018; 36:529.e23-529.e30. [PMID: 30446456 DOI: 10.1016/j.urolonc.2018.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 09/06/2018] [Accepted: 09/22/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the diagnostic, surgical as well as oncological outcome of patients with a growing teratoma syndrome. MATERIAL AND METHODS We performed a retrospective analysis including 680 patients with advanced nonseminomatous germ cell tumors who underwent a postchemotherapy retroperitoneal lymph node dissection. The peri- and postoperative outcome of 22 patients (3%) that fulfilled the criteria of a growing teratoma syndrome were analyzed: nonseminomatous germ cell tumors with increasing tumor size during or after chemotherapy despite normalized or decreasing tumor markers. RESULTS The median tumor diameter at time of surgery was 6 cm (4-12.2). For a complete resection of the residual masses, adjunctive surgery had to be performed in 4 (18%) patients: resection of the abdominal aorta, inferior vena cava or renal vein with graft replacement, nephrectomy and resection of parts of the intestine. Eight postoperative complications occurred in 5 (23%) patients, with 4/8 of these complications affecting only one patient. Fifty percent of all complications were classified as Clavien-Dindo grade III or IV. After a median follow-up of 25 months, relapse occurred in 2 patients (9%); all but one patient is alive resulting in an overall survival of 95.5%. CONCLUSIONS The growing teratoma syndrome is a rare phenomenon among patients with advanced nonseminomatous germ cell tumors and necessitates complete surgical resection of the masses with curative intention. Due to its complexity and potential adjunctive surgery, the treatment should be performed in tertiary referral centers only.
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Murez T, Fléchon A, Savoie PH, Rocher L, Camparo P, Morel-Journel N, Ferretti L, Sèbe P, Méjean A. RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs germinales du testicule French ccAFU guidelines — Update 2018—2020: Testicular germ cell tumors. Prog Urol 2018; 28:S147-S164. [PMID: 30472999 DOI: 10.1016/j.purol.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 11/30/2022]
Abstract
This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy).
Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations.
Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.009.
C’est cette nouvelle version qui doit être utilisée pour citer l’article.
This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published.
The replacement has been published at the doi:10.1016/j.purol.2019.01.009.
That newer version of the text should be used when citing the article.
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Affiliation(s)
- T Murez
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, CHRU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France.
| | - A Fléchon
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'oncologie médicale, centre Léon-Bérard, 28, rue Laennec, 69008 Lyon, France
| | - P-H Savoie
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital d'instruction des armées Sainte-Anne, BP 600, 83800 Toulon cedex 09, France
| | - L Rocher
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de radiologie, CHU Paris Sud, site Kremlin-Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France
| | - P Camparo
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Centre de pathologie, 51, rue de Jeanne-D'Arc, 80000 Amiens, France
| | - N Morel-Journel
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, centre hospitalier Lyon Sud (Pierre Bénite), HCL groupement hospitalier du Sud, 69495 Pierre Bénite cedex, France
| | - L Ferretti
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, MSP de Bordeaux-Bagatelle, 203, route de Toulouse, BP 50048, 33401 Talence cedex, France
| | - P Sèbe
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, groupe hospitalier Diaconesses Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France
| | - A Méjean
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital européen Georges-Pompidou, université Paris Descartes, AP-HP, 75015 Paris, France
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Michalski W, Jonska-Gmyrek J, Poniatowska G, Kucharz J, Stelmasiak P, Nietupski K, Sadowska M, Demkow T, Wiechno P. Testicular teratomas: a growing problem? Med Oncol 2018; 35:153. [PMID: 30367327 DOI: 10.1007/s12032-018-1215-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 10/24/2018] [Indexed: 01/05/2023]
Abstract
Testicular teratomas represent a specific entity within the group of germ-cell tumours. They may comprise elements of all three germ layers. In contrast to prepubertal benign teratomas observed in infants and adolescents, postpubertal teratomas originate from the malignant germ-cell precursor. Given the good prognosis and curability of most patients with germ-cell tumour, medical oncologists and urological surgeons must be well acquainted with the principles of teratomas management. Surgery plays the decisive part in teratomas treatment, as these tumours are resistant to radio- and, to some extent, chemotherapy. In this article we concentrate on the management of post-chemotherapy resection of teratomatous masses, with special attention to the phenomenon of 'growing teratoma syndrome' and somatic-type transformation of teratomas. To understand the nature of teratomas better, we begin with a glimpse of their biological, molecular and immunohistochemical features. Managing germ-cell tumours, teratomas in particular, in high-volume reference centres is of utmost importance to maintain and increase the survivorship rate in these patients.
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Affiliation(s)
- Wojciech Michalski
- Department of Uro-oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, 5, Roentgen Street, 02-781, Warsaw, Poland
| | - Joanna Jonska-Gmyrek
- Department of Uro-oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, 5, Roentgen Street, 02-781, Warsaw, Poland
| | - Grazyna Poniatowska
- Department of Uro-oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, 5, Roentgen Street, 02-781, Warsaw, Poland
| | - Jakub Kucharz
- Department of Uro-oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, 5, Roentgen Street, 02-781, Warsaw, Poland.
| | - Pawel Stelmasiak
- Department of Uro-oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, 5, Roentgen Street, 02-781, Warsaw, Poland
| | - Karol Nietupski
- Department of Uro-oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, 5, Roentgen Street, 02-781, Warsaw, Poland
| | - Malgorzata Sadowska
- Department of Uro-oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, 5, Roentgen Street, 02-781, Warsaw, Poland
| | - Tomasz Demkow
- Department of Uro-oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, 5, Roentgen Street, 02-781, Warsaw, Poland
| | - Pawel Wiechno
- Department of Uro-oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, 5, Roentgen Street, 02-781, Warsaw, Poland
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Heidenreich A. [Limits of surgery in uro-oncology]. Urologe A 2018; 57:1058-1068. [PMID: 30043291 DOI: 10.1007/s00120-018-0735-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The limits of cancer surgery in uro-oncology are characterized by a carefully weighed risk of surgical feasibility and oncological necessity. The limits of uro-oncological cancer surgery do not represent fixed dogmas but ideally these more or less cognitive boundaries move based on new scientific findings, improved imaging modalities, optimized surgical techniques and perioperative care. The limits of cancer surgery are defined by patient-specific parameters, the biological aggressiveness of the tumor itself, the skills and expertise of the surgeon, and adequate perioperative care of the patient. Dependent on the origin of the cancers of the upper and lower urogenital tract, the specific particularities of each individual cancer in terms of prognosis need to be known, taking into consideration the newest molecular insights and modern multimodality treatment regimes. Only the consideration of the above mentioned basics will allow the best decision to be made with the patient concerning the optimal individual treatment. The current article highlights general parameters of the patient, tumor and surgeon which might define the limits of cancer surgery in uro-oncology. In addition, specific clinical scenarios are discussed with regard to surgery limits in cancer of the kidney, the prostate and the testis.
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Affiliation(s)
- A Heidenreich
- Klinik für Urologie, Uro-Onkologie, roboter-assistierte und spezielle urologische Chirurgie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland. .,Klinik für Urologie, Medizinische Universität Wien, Wien, Österreich.
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Heidenreich A, Paffenholz P, Nestler T, Pfister D. Primary and Postchemotherapy Retroperitoneal Lymphadenectomy for Testicular Cancer. Oncol Res Treat 2018; 41:370-378. [PMID: 29772568 DOI: 10.1159/000489508] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 04/23/2018] [Indexed: 11/19/2022]
Abstract
Clinical stage I (CS I) testicular non-seminomatous germ cell tumours (NSGCT) are highly curable. Following orchidectomy, a risk-adapted approach using active surveillance, nerve-sparing retroperitoneal lymph node dissection (RPLND) and primary chemotherapy is recommended by the current guidelines. CS I is defined as showing negative values for tumour markers (or values declining to their half-life following orchidectomy) and negative imaging studies of the chest, abdomen and retroperitoneum. Active surveillance can be performed in low- and high-risk NSGCT with an anticipated relapse rate of about 15% and 50%, respectively. The majority of patients will relapse with good and intermediate prognosis tumours, which have to be treated with 3 to 4 cycles of chemotherapy. About 25-30% of these patients will have to undergo postchemotherapy (PC) RPLND for residual masses. Primary chemotherapy with 1-2 cycles of cisplatin, etoposide, bleomycin (PEB) is a therapeutic option for high-risk CS I NSGCT associated with a recurrence rate of only 2-3% and a minimal acute and long-term toxicity rate. Nerve-sparing RPLND, if performed properly, will cure about 85% of all high-risk patients with CS I NSGCT without the need for chemotherapy. PC-RPLND plays an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours (TGCT). According to current guidelines and recommendations, PC-RPLND in advanced seminomas with residual tumours is only indicated if a positron emission tomography scan performed 6-8 weeks after chemotherapy is positive. In non-seminomatous TGCT, PC-RPLND is indicated for all residual radiographical lesions with negative or plateauing markers. Loss of antegrade ejaculation represents the most common long-term complication, which can be prevented by a nerve-sparing or modified template resection. The relapse rate after PC-RPLND is around 12%; however, it increases significantly to about 45% in cases with redo RPLND and late relapses. Patients with increasing markers should undergo salvage chemotherapy. Only select patients with elevated markers who are thought to be chemo-refractory might undergo desperation PC-RPLND if all radiographically visible lesions are completely resectable. PC-RPLND requires a complex surgical approach and should only be performed in experienced, tertiary referral centres.
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Heidenreich A, Paffenholz P, Haidl F, Pfister D. [When is surgical resection of metastases in testicular germ cell tumors indicated and is there a scientific basis?]. Urologe A 2018; 56:627-636. [PMID: 28432399 DOI: 10.1007/s00120-017-0385-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Surgical resection of metastases represents an integral part of curative management in patients with testicular germ cell tumors (GCT). Primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) for low volume metastases in clinical stages I-IIB has to be differentiated from the more complex and more extensive postchemotherapeutic procedures. In Europe, primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) for clinical stage I nonseminomatous GCT (NSGCT) plays a subordinate. In clinical stage IIA/B, nsRPLND is indicated for patients with marker-negative metastases in whom cure rates of about 65% can be achieved with surgery alone. For clinical stage IIA/B seminomas, nsRPLND represents an individual, still experimental procedure with high cure rates. Postchemotherapy residual tumor resection (pRTR) for advanced seminomas is only indicated in the context of a FDG-PET/CT-positive residual mass >3 cm in diameter. For NSGCT, pRTR is indicated in patients with residual masses >1 cm and negative or plateauing tumor markers to resect persisting teratoma or vital cancer. Complete resection of all masses including resection of adjacent vascular, visceral or skeletal metastases is mandatory to achieving the highest cure rate possible. Due to the complexity and the lower rate of significant morbidity and mortality, these procedures should be done at tertiary referral centers.
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Affiliation(s)
- A Heidenreich
- Klinik für Urologie, Uro - Onkologie, Roboter-assistierte und Spezielle Urologische Chirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - P Paffenholz
- Klinik für Urologie, Uro - Onkologie, Roboter-assistierte und Spezielle Urologische Chirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - F Haidl
- Klinik für Urologie, Uro - Onkologie, Roboter-assistierte und Spezielle Urologische Chirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - D Pfister
- Klinik für Urologie, Uro - Onkologie, Roboter-assistierte und Spezielle Urologische Chirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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Surgical management and outcomes of patients with bone metastases in germ cell tumors: A case series. Urol Oncol 2018; 36:82.e1-82.e5. [DOI: 10.1016/j.urolonc.2017.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 08/16/2017] [Accepted: 10/22/2017] [Indexed: 11/21/2022]
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Paffenholz P, Heidegger IM, Kuhr K, Loosen SH, Pfister D, Heidenreich A. Non-Guideline-concordant Treatment of Testicular Cancer Is Associated With Reduced Relapse-free Survival. Clin Genitourin Cancer 2017; 16:S1558-7673(17)30273-2. [PMID: 28964691 DOI: 10.1016/j.clgc.2017.08.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/29/2017] [Accepted: 08/31/2017] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The management of testicular cancer (TC) requires a complex multimodal therapeutic approach. Despite the availability of regularly updated guidelines, non-guideline-concordant treatment of TC still occurs. The purpose of the present study was to evaluate the compliance patterns in diagnosis and therapy and their potential effects on patient outcomes with respect to the guidelines of the European Association of Urology. PATIENTS AND METHODS We performed a retrospective analysis of 131 patients diagnosed with TC who had been referred to our department from September 2015 to October 2016. Patient characteristics were compared with European Association of Urology guideline recommendations. RESULTS Of the 131 primary treated patients, 23 (18%) had received a non-guideline-concordant treatment. The most common error was undertreatment (n = 12; 52%), mainly due to missing chemotherapy cycles. Overtreatment occurred in 30% of patients (n = 7); however, inappropriate treatment (n = 2; 9%) and misdiagnosis (n = 2; 9%) were rarely observed. In salvage therapy, non-guideline concordant treatment was observed less frequently compared to patients receiving primary therapy (12% vs. 18%). Of the 131 patients, 35 developed a relapse, 23 of whom were treated correctly and 6 of whom were undertreated. Undertreatment of patients resulted in significantly reduced relapse-free survival compared with guideline-concordant management in primary treated patients (P = .005). CONCLUSION Despite the standardization of treatment by interdisciplinary guidelines, its integration into daily practice remains limited. Undertreatment of TC patients is associated with significantly reduced relapse-free survival and should thus be avoided.
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Affiliation(s)
- Pia Paffenholz
- Department of Urology, Uro-Oncology, Robot Assisted and Reconstructive Urologic Surgery, University Hospital Cologne, Cologne, Germany
| | | | - Kathrin Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology, University Hospital Cologne, Cologne, Germany
| | - Sven Heiko Loosen
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - David Pfister
- Department of Urology, Uro-Oncology, Robot Assisted and Reconstructive Urologic Surgery, University Hospital Cologne, Cologne, Germany
| | - Axel Heidenreich
- Department of Urology, Uro-Oncology, Robot Assisted and Reconstructive Urologic Surgery, University Hospital Cologne, Cologne, Germany.
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Abstract
PURPOSE OF REVIEW In the present review, we summarize the recent developments in the management of germ cell tumors (GCTs). RECENT FINDINGS Treatment-related acute and late-onset toxicity remains a key challenge in the management of GCTs. Recent data show that patients with large retroperitoneal lymph node metastases are at increased risk of venous thromboembolism and may benefit from prophylactic anticoagulation. Predictive models have been developed to identify patients with residual retroperitoneal lymph node masses who are more likely to benefit from surgical resection. However, their clinical use remains hampered by relatively low accuracy. There are currently multiple conventional-dose chemotherapy (CDCT) options for salvage therapy in patients with refractory or recurrent disease. In addition, more efficacious high-dose chemotherapy (HDCT) regimens continue to be developed. The role of salvage CDCT versus HDCT is currently being prospectively investigated.Finally, intratumoral heterogeneity is a common finding in cancer and an obvious observation in GCTs. Despite intratumoral heterogeneity, recent studies on nonseminomatous GCT have identified distinct histological subgroups and a potentially lethal clinical phenotype. Importantly, comprehensive molecular profiling so far has not elucidated the biologic basis or the clinical underpinnings of intratumoral heterogeneity in GCTs. SUMMARY Remaining challenges to be addressed include minimizing therapeutic toxicity and improving outcomes in patients with refractory/recurrent GCTs or malignant transformation of teratomas.
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