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)

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.

scholarly journals Testicular tumors

2011 ◽  
pp. 28-35
Author(s):  
Giovanni Rosti ◽  
Ornella Carminati ◽  
Claudia Casanova ◽  
Giorgio Papiani
Keyword(s):  
Germ Cell ◽  
Residual Disease ◽  
Clinical Stage ◽  
Germ Cell Tumors ◽  
Stage I ◽  
Prognostic Scores ◽  
Retroperitoneal Lymph Node Dissection ◽  
High Dose ◽  
Advanced Phase ◽  
Response To Chemotherapy

Germ cell tumors of the testes represent a unique paradigm of diseases which can be cured even in extremely advanced phase. Unfortunately, this makes them unique among adult solid tumors. Seminoma and non seminoma are relatively rare with approximatively 25,000 patients in Europe per year, but numbers are increasing world wide. Different strategies are needed depending on stage and prognostic scores. Seminoma is extremely sensitive to radiation therapy and chemotherapy, while all germ cell tumors show a very good response to chemotherapy. Clinical stage I seminoma is currently treated with radiation, single course carboplatin or surveillance policy. Clinical stage I non seminoma can also be approached with different strategies such as retroperitoneal lymph node dissection, observation or one-two courses of standard chemotherapy. Stage II seminoma may be treated with either radiation or chemotherapy, while for all advanced stages chemotherapy is mandatory. Since the mid-eighties PEB (Cisplatin, Etoposide and Bleomycin) is the regimen of choice and no other schedule has proved superior in terms of efficacy. Surgery on the residual disease is crucial to the whole strategy and should be performed or attempted in all cases. Consequently, the correct treatment strategy for these tumors does not depend only on the ability of a single physician, but on a skilled team specialized in this particular tumor. Second line therapies (VeIP, PEI, TIP) can cure 25%–40% of patients, but improved strategies for resistant tumors are desperately needed. High-dose chemotherapy has shown very good results in some studies while being less impressive in others. In any case, it should remain an option for relapsing patients and could be used in some cases of upfront chemotherapy in patients with slow marker decline, but this should only be considered in referring centers.

Post-chemotherapy modified template retroperitoneal lymph node dissection in patients with nonseminomatous germ cell tumours

2021 ◽  
Author(s):  
Murat Zor ◽  
Sercan Yilmaz ◽  
Bahadir Topuz ◽  
Engin Kaya ◽  
Serdar Yalcin ◽  
...  
Keyword(s):  
Lymph Node ◽  
Lymph Nodes ◽  
Germ Cell ◽  
Residual Disease ◽  
Germ Cell Tumors ◽  
Operation Time ◽  
Long Term Results ◽  
Perioperative Outcomes ◽  
Retroperitoneal Lymph Node Dissection

Abstract Introduction/background: Although a full bilateral template RPLND is thought to be the standard of care for the management of postchemotherapy retroperitoneal residual masses for nonseminomatous germ cell tumors (NSGCT), in the past decade modified templates have become increasingly popular. In this study, we aimed to present our oncological and perioperative outcomes of consecutive seventeen NSGCT patients who underwent a modified template unilateral PC-RPLND for retroperitoneal residual disease. Materials and Methods: We retrospectively evaluated the medical records of 17 consecutive NSGCT patients who underwent modified template unilateral PC-RPLND in our university hospital between 2017 and 2020. All patients had normal serum tumour markers with residual disease in the retroperitoneum. Surgical characteristics including the size of the retroperitoneal residual mass, residual tumor pathology, removed lymph nodes, positive percentage of removed lymph nodes, accompanying operations, complications, mean operation time and hospital stay, and long-term results including survival and antegrade ejaculation were evaluated. Results: Eleven patients underwent left and six right-sided surgery. Median residual lymph node diameter was 41mm. Median hospitalisation time was 3.5 days. Median follow-up time was 10.5 months. Necrosis/fibrosis was seen in 6 patients, and teratoma in 11 patients. No viable tumour was seen. No patients died in the follow-up period. None of the patients relapsed during follow-up. Ten/seventeen patients had antegrade ejaculation. Conclusions: Modified template unilateral PC-RPLND leads to very good oncological outcomes with decreased perioperative morbidity as well as better antegrade ejaculation rates. Low volume retroperitoneal disease seems to fit this procedure best.

Accuracy of clinical staging in stage I and IIa/b testicular nonseminomatous germ cell tumors (NSGCT) and implications on survival.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e17058-e17058
Author(s):  
Arnav Srivastava ◽  
Hiren V. Patel ◽  
Sinae Kim ◽  
Isaac Kim ◽  
Eric A. Singer ◽  
...  
Keyword(s):  
Overall Survival ◽  
Imaging Techniques ◽  
Clinical Stage ◽  
Germ Cell Tumors ◽  
Stage I ◽  
Clinical Staging ◽  
Retroperitoneal Lymph Node Dissection ◽  
Kaplan Meier ◽  
Nonseminomatous Germ Cell Tumors

e17058 Background: Clinical stage (CS) dictates treatment in men with testicular cancer and its inaccuracy may affect clinical outcome. We evaluate the accuracy of clinical staging in men with CS I and CS IIA/B NSGCT and explore the implications of inaccurate staging on overall survival. Methods: Using the National Cancer Database (NCDB), we abstracted all patients with clinical Stage I-IIB NSGCT who received a primary retroperitoneal lymph node dissection (RPLND) from 2004 to 2014. Primary RPLND was defined as RPLND performed for CS I-IIB patients without prior chemotherapy. CS was cross-tabulated with pathologic nodal staging data. Survival for patients who were accurately staged (CS I patients with pN0 disease, CS IIA patients with pN1 disease) and for CS I patients found to have pN+ disease was determined using the Kaplan Meier method. Results: 1,639 CS I-IIB patients underwent primary RPLND. Among CS I patients, 23% had upstaging of disease (pN1-3), of which 13.9%, 8%, and 1.1% were pN1, pN2, and pN3, respectively (Table). Pathologic N1-3 disease was higher in CS IB vs. CS IA patients (35.1% vs 14.2%, respectively). Of CS IIA patients, 23.1% had pN0 disease, while 44.8%, 13.4%, and 1.3% had pN1, pN2, and pN3 disease, respectively. At a median follow-up of 56.3 months, mortality rates for CS I patients who had pN1, pN2, and pN3 disease were 2.8%, 4%, and 9.1%, respectively, and < 1% for men with pN0 disease. 10-year overall survival for CS1 patients was significantly less favorable if upstaged to pN2 or pN3 disease after RPLND vs. pN0 or pN1. Conclusions: Nearly a quarter of patients with CS I NSGCT are under-staged and are found to have pN1-3 after RPLND. Nodal disease burden is associated with survival. Novel imaging techniques and biomarkers are needed to improve the sensitivity of detecting NSGCT. [Table: see text]

Randomized Phase III Trial Comparing Retroperitoneal Lymph Node Dissection With One Course of Bleomycin and Etoposide Plus Cisplatin Chemotherapy in the Adjuvant Treatment of Clinical Stage I Nonseminomatous Testicular Germ Cell Tumors: AUO Trial AH 01/94 by the German Testicular Cancer Study Group

2008 ◽  
Vol 26 (18) ◽  
pp. 2966-2972 ◽  
Author(s):  
Peter Albers ◽  
Roswitha Siener ◽  
Susanne Krege ◽  
Hans-Uwe Schmelz ◽  
Klaus-Peter Dieckmann ◽  
...  
Keyword(s):  
Lymph Node ◽  
Germ Cell ◽  
Lymph Node Dissection ◽  
Adjuvant Treatment ◽  
Clinical Stage ◽  
Germ Cell Tumors ◽  
Stage I ◽  
Retroperitoneal Lymph Node Dissection ◽  
Node Dissection ◽  
Retroperitoneal Lymph Node

PurposeRetroperitoneal lymph node dissection (RPLND) and adjuvant chemotherapy are two adjuvant treatment options for patients with clinical stage I nonseminomatous germ cell tumors of the testis (NSGCT). Aim of this trial was to prove the advantage of one cycle of bleomycin, etoposide, and cisplatin (BEP) chemotherapy compared with RPLND in terms of recurrence.Patients and MethodsBetween 1996 and 2005, 382 patients were randomly assigned to receive either RPLND (n = 191) or one course of BEP (n = 191) after orchidectomy. The primary study end point was the rate of recurrence. The trial was powered to detect a 7% reduction (from 10% to 3%) of recurrence with chemotherapy compared with surgery.ResultsAfter a median follow-up of 4.7 years, two and 15 recurrences were observed in the intention-to-treat population with chemotherapy and surgery, respectively (P = .0011). The difference in the 2-year recurrence-free survival rate between chemotherapy (99.46%; 95% CI, 96.20% to 99.92%) and surgery (91.87%; 95% CI, 86.87% to 95.02%) was 7.59% (95% CI, 3.13% to 12.05%). The hazard ratio to experience a tumor recurrence with surgery as opposed to chemotherapy was 7.937 (95% CI, 1.808 to 34.48).ConclusionTo our knowledge, this is the largest randomized trial investigating adjuvant treatment strategies in clinical stage I NSGCT, which showed the superiority of one course BEP over RPLND performed according to community standards to prevent recurrence. Although not standard treatment, one course of BEP is active in an unselected group of patients with clinical stage I disease and merits further investigation.

scholarly journals Quality of Surveillance for Stage I Testis Cancer in the Community

2009 ◽  
Vol 27 (26) ◽  
pp. 4327-4332 ◽  
Author(s):  
Hua-yin Yu ◽  
Rodger A. Madison ◽  
Claude M. Setodji ◽  
Christopher S. Saigal
Keyword(s):  
Private Insurance ◽  
Clinical Stage ◽  
Germ Cell Tumors ◽  
Stage I ◽  
Retroperitoneal Lymph Node Dissection ◽  
Testis Cancer ◽  
First Year ◽  
Recurrence Rates

Purpose Patients with clinical stage I testicular germ cell tumors have been managed with adjuvant radiotherapy, chemotherapy, or retroperitoneal lymph node dissection (RPLND). The use of surveillance-only strategies at referral centers has yielded survival outcomes comparable to those achieved with adjuvant therapy. We evaluated compliance with follow-up protocols developed at referral centers within the community. Methods We identified patients with stage I testis cancer within a large private insurance claims database and calculated compliance of follow-up test use with guidelines from the National Comprehensive Cancer Network. Results Surveillance was widely used in the community. Compliance with surveillance and postadjuvant therapy follow-up testing was poor and degraded with increasing time from diagnosis. Nearly 30% of all surveillance patients received no abdominal imaging, chest imaging, or tumor marker tests within the first year of diagnosis. Patients who elected RPLND were most compliant with recommended follow-up testing within the first year. Recurrence rates were consistent with previously reported literature, despite poor compliance. Conclusion Surveillance is a widely accepted strategy in clinical stage I testicular cancer treatment in the community. However, follow-up care recommendations developed at referral centers are not being adhered to in the community. Although recurrence rates are similar to those of reported literature, the clinical impact of noncompliance on recurrence severity and mortality are not known. Further prospective work needs to be done to evaluate this apparent quality of care problem in the community.

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