Is postchemotherapy retroperitoneal surgery necessary in patients with nonseminomatous testicular cancer and minimal residual tumor masses?

PURPOSE At least one third of the patients with metastatic testicular cancer are rendered tumor-free by cisplatin-based chemotherapy. One may question, therefore, the routine use of postchemotherapy retroperitoneal lymph node dissection (RLND), especially if the residual masses are less than 20 mm in diameter. To define the role of such surgery, we analyzed the postchemotherapy histology in testicular cancer patients with minimal residual disease. PATIENTS AND METHODS Seventy-eight patients with advanced nonseminomatous testicular cancer underwent RLND after three to four cycles of cisplatin- or carboplatin-based chemotherapy. In all patients, the largest diameter of the residual retroperitoneal mass was less than 20 mm. RESULTS Complete fibrosis/necrosis was found in 51 patients, mature teratoma in 22, and vital malignant germ cell tumor in five. In two of the latter five patients, alphafetoprotein (AFP) had increased immediately before RLND. In the 76 patients with normal pre-RLND tumor markers, the presence of undifferentiated malignant teratoma (MTU) in the primary tumor and normal prechemotherapy tumor markers were independent parameters predicting complete fibrosis/necrosis, which was demonstrated in all 15 patients with these two pretreatment parameters. CONCLUSIONS Postchemotherapy RLND can be omitted in patients with MTU in the primary tumor who have normal AFP/human chorionic gonadotropin (AFP/HCG) before chemotherapy and whose residual retroperitoneal mass is less than 20 mm in diameter. If the pre-RLND tumor markers are normal, RLND should be performed in all other patients with small residual masses, even in the presence of a normal computed tomography (CT) and particularly if regular follow-up of the patients is not guaranteed.

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Validity of predictions of residual retroperitoneal mass histology in nonseminomatous testicular cancer.

Journal of Clinical Oncology ◽

10.1200/jco.1998.16.1.269 ◽

1998 ◽

Vol 16 (1) ◽

pp. 269-274 ◽

Cited By ~ 76

Author(s):

E W Steyerberg ◽

A Gerl ◽

S D Fossá ◽

D T Sleijfer ◽

R de Wit ◽

...

Keyword(s):

Testicular Cancer ◽

Tumor Markers ◽

Goodness Of Fit ◽

Mature Teratoma ◽

Testicular Germ Cell Tumor ◽

Retroperitoneal Lymph Node Dissection ◽

Testicular Germ Cell ◽

Goodness Of Fit Tests ◽

Predicted Probability ◽

Adequate Reliability

PURPOSE To validate predictions of the histology (necrosis, mature teratoma, or cancer) of residual retroperitoneal masses in patients treated with chemotherapy for metastatic nonseminomatous testicular germ cell tumor. PATIENTS AND METHODS We studied 172 testicular cancer patients who underwent resection while tumor markers were normal. Predictive characteristics for the residual histology were registered, including the presence of teratoma elements in the primary tumor, the prechemotherapy level of tumor markers (alpha-fetaprotein [AFP], human chorionic gonadotropin [HCG], lactate dehydrogenase [LDH]), the size of the residual mass, and the percentage of shrinkage in mass diameter. We calculated the predicted probability of necrosis and the ratio of cancer and mature teratoma with previously published logistic regression formulas. RESULTS The distribution of the residual histology was necrosis in 77 (45%), mature teratoma in 72 (42%), and cancer in 23 (13%). Necrosis could be well distinguished from other tissue, with an area under the receiver operating characteristic (ROC) curve of 82%. No tumor was found in 15 patients with a predicted probability of necrosis over 90%. The predicted probabilities corresponded reliably with the observed probabilities (goodness-of-fit tests, P > .20), although a somewhat higher probability of necrosis was observed in patients treated with chemotherapy containing etoposide. Conversely, cancer could not reliably be predicted or adequately discriminated from mature teratoma. CONCLUSION The predicted probabilities of necrosis have adequate reliability and discriminative power. These predictions may validly support the decision-making process regarding the need and extent of retroperitoneal lymph node dissection.

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Therapeutic supine robotic retroperitoneal lymph node dissection for post-chemotherapy residual masses in testicular cancer: technique and outcome analysis of initial experience

Journal of Robotic Surgery ◽

10.1007/s11701-018-00903-0 ◽

2019 ◽

Vol 13 (6) ◽

pp. 747-756 ◽

Cited By ~ 2

Author(s):

Ashwin Sunil Tamhankar ◽

Saurabh Ramesh Patil ◽

Surya Prakash Ojha ◽

Puneet Ahluwalia ◽

Gagan Gautam

Keyword(s):

Lymph Node ◽

Testicular Cancer ◽

Lymph Node Dissection ◽

Outcome Analysis ◽

Retroperitoneal Lymph Node Dissection ◽

Initial Experience ◽

Node Dissection ◽

Retroperitoneal Lymph Node ◽

Residual Masses

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Pre-Transplantation Level of Minimal Residual Disease Detected by Quantitative Real-Time IgH-PCR Is a Prognostic Parameter in Patients with Multiple Myeloma.

Blood ◽

10.1182/blood.v104.11.4871.4871 ◽

2004 ◽

Vol 104 (11) ◽

pp. 4871-4871

Author(s):

Roland Fenk ◽

Mark Korthals ◽

Guido Kobbe ◽

Ulrich Steidl ◽

Thorsten Graef ◽

...

Keyword(s):

Multiple Myeloma ◽

Bone Marrow ◽

Prognostic Factors ◽

Tumor Cells ◽

Residual Disease ◽

Residual Tumor ◽

Prognostic Group ◽

Tumor Level ◽

Minimal Residual

Abstract Background: High-dose chemotherapy with autologous stem cell transplantation has improved outcome and survival of patients with multiple myeloma. However, the majority of patients suffer from relapse. Using real-time quantitative (RQ) PCR we have shown before (Haematologica 89,2004) that the amount of residual tumor cells in the bone marrow of patients before transplantation is of prognostic relevance. In this study we evaluated in a larger group of patients with multiple myeloma whether a pre-transplantation level of clonotypic cells in the bone marrow is predictive for time-to-progression (TTP) and overall survival (OS). Further, we compared results with known prognostic factors. Patients and Methods: Bone marrow samples of 19 patients with stage II/III multiple myeloma were obtained after induction therapy but before transplantation. Immunoglobulin heavy chain (IgH) RQ-PCR using patient-specific Taqman probes was performed to quantify pre-transplantation tumor levels. The proportion of clonotypic cells was assessed as IgH/2 beta-actin ratio in percent. Medical records of patients were reviewed for prognostic factors and outcome. Results: The median level of residual tumor cells in bone marrow of all patients at the time before transplantation was 0.3 %. At 23 month median follow-up after transplantation the median TTP and OS in our study were 14 and 36 month, respectively. The threshold level of 0.03% clonotypic cells identified two prognostic groups (p<0.0001, log rank). Twelve patients in the bad prognostic group had an early relapse with a median TTP of 9 month (range: 3 – 17 month). All patients in the good prognostic group (n=7) had ongoing remissions after a median follow-up of 24 month (range: 13–44 month). Univariat analysis was performed including other prognostic factors at the time before transplantation such as cytogenetic abnormalities, beta2-microglobulin, hemoglobulin, platelet count, LDH, CRP, serum albumine and age. Besides the pre-transplant level of minimal residual disease, CRP level was predictive for TTP. In multivariat analysis using a step-wise cox regression model grouping by pre-transplantation tumor level was the only prognostic factor for TTP (p = 0.05). Moreover, low pre-transplantation tumor levels also showed a trend for a better OS, but in multivariat analysis only normal cytogenetics were predictive for a superior outcome (p = 0.03). Conclusion: Quantitative molecular assessment of pre-transplantation tumor level in the bone marrow is an independent prognostic parameter for the progression-free survival of patients with multiple myeloma and thus helps to guide therapeutic interventions

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Management of clinical stage (CS) I and II patients with non-seminomatous germ cell tumors of the testis (NSGCTT) avoiding upfront retroperitoneal lymph node dissection (RPLND)

Journal of Clinical Oncology ◽

10.1200/jco.2007.25.18_suppl.5090 ◽

2007 ◽

Vol 25 (18_suppl) ◽

pp. 5090-5090

Author(s):

A. Flechon ◽

F. El Karak ◽

C. Salas ◽

M. Rivoire ◽

J. Droz

Keyword(s):

Medical Management ◽

Residual Disease ◽

Clinical Stage ◽

Germ Cell Tumors ◽

Retroperitoneal Lymph Node Dissection ◽

Retroperitoneal Lymph Node ◽

Residual Masses ◽

Time To Relapse ◽

Car Accident

5090 Background: CS I, Is, IIa and IIb may be treated by either upfront RPLND or upfront medical management followed by RPLND in selected cases. We retrospectively analyzed the later approach. Methods: From 1993 to 2003, 225 NSGCTT patients CS I and Is, IIa, IIb were treated at our center. In total, 148 patients with CS I were managed by surveillance followed by CT and surgical exeresis of residual disease in case of relapse and 77 with CS Is, IIa and IIb underwent upfront chemotherapy and RPLND in case of residual masses. Median follow-up was 52 months for all patients (0.16–165 months). Results: In CS I: 47/148 (32%) patients relapsed: 22/42 (52%) patients with microvascular involvement versus 25/106 without (24%). The median time to relapse was 5 months (0.16–79 months). All relapsing patients received CT except one for whom we have no information. Twenty-two patients (46%) had RPLND. Two patients died, one probably of haemorrhage one month after RPLND and one in a car accident. In CS II: 4 (5%) patients had CS Is, 40 (52%) CS IIa and 33 (43%) CS IIb. Respectively 71 (92%), 5 (6.5%) and 1 (1,5%) patients had good, intermediate or poor prognosis according to the IGCCCG. All patients received cisplatin-based chemotherapy. Forty-one (53%) patients had RPLND after CT and one refused surgery for residual disease. Histological review showed a teratoma in 22 cases (54%), necrosis in 16 (39%) and residual active disease in 3 (7%). Six patients (8%) relapsed: 1 of them had a growing teratoma. One patient died of disease and all others are alive with no evidence of disease. In total, after medical management of CS I and II, avoiding primary RPLND, only 124 (55%) and 63 (28%) patients had eventually CT and RPLND respectively. Ninety-nine percent patients were cured. Conclusions: Upfront medical treatment of CS I and CS II NSGCTT is a good option which allows to avoid unnecessary CT and RPLND indications. [Table: see text] No significant financial relationships to disclose.

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706 EXTERNAL VALIDATION OF THE HEIDENREICH CRITERIA FOR THE SELECTION OF PATIENTS FOR UNILATERAL OR BILATERAL POST CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION FOR RESIDUAL MASSES OF TESTICULAR CANCER

The Journal of Urology ◽

10.1016/j.juro.2013.02.264 ◽

2013 ◽

Vol 189 (4S) ◽

Author(s):

Cedric Vallier ◽

Pierre-Henri Savoie ◽

Jean Robert Delpero ◽

Franck Bladou ◽

Gwenaelle Gravis ◽

...

Keyword(s):

Lymph Node ◽

Testicular Cancer ◽

Lymph Node Dissection ◽

External Validation ◽

Retroperitoneal Lymph Node Dissection ◽

Node Dissection ◽

Retroperitoneal Lymph Node ◽

Residual Masses ◽

Selection Of Patients ◽

Selection Of

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Second-Look Surgery for Intracranial Germ Cell Tumors

Neurosurgery ◽

10.1227/neu.0000000000000697 ◽

2015 ◽

Vol 76 (6) ◽

pp. 658-662 ◽

Cited By ~ 11

Author(s):

Hideki Ogiwara ◽

Chikako Kiyotani ◽

Keita Terashima ◽

Nobuhito Morota

Keyword(s):

Germ Cell ◽

Tumor Markers ◽

Mature Teratoma ◽

Germ Cell Tumors ◽

Residual Tumor ◽

Complete Response ◽

Mixed Germ Cell Tumor ◽

Second Look ◽

Intracranial Germ Cell Tumors ◽

Atypical Cells

Abstract BACKGROUND: The role of second-look surgery in intracranial germ cell tumors (GCTs) needs to be reviewed. OBJECTIVE: To present our experience of second-look surgery in patients with intracranial GCTs who showed less than complete response despite normalizing or decreasing tumor markers after chemotherapy. METHODS: Retrospective review of 7 patients who underwent second-look surgery for an intracranial GCT was performed. RESULTS: Of 23 consecutive patients with newly diagnosed intracranial GCTs treated between August 2003 and August 2013, 7 patients (30%) underwent second-look surgery. The mean age was 9.4 years. The initial diagnoses were mixed germ cell tumor in 5 and immature teratoma in 2. Second-look surgery was performed after 1 to 3 courses of chemotherapy. Magnetic resonance imaging at the surgery demonstrated increasing residual tumor in 4 and stable residual tumor in 3. Tumor markers were normalized in 5 and nearly normalized in 2. Gross total resection was achieved in all patients. Histopathology at second-look surgery revealed mature teratoma in 5, fibrosis with atypical cells in 1, and fibrosis in 1. All patients subsequently underwent additional chemoradiation therapy according to the initial diagnosis. All patients are alive with no evidence of recurrence, with a mean follow-up of 48 months. CONCLUSION: Second-look surgery plays an important role in the treatment of intracranial GCTs. Surgery may be encouraged at a relatively early phase after chemotherapy when the residual tumor increases or does not change size despite normalized or nearly normalized tumor markers in order to achieve complete resection and improve outcome.

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