Testicular cancer with small metastatic burden: optimal approach in 2024.

PURPOSE OF REVIEW: Recent advancements in the management of clinical stage II (CS II) testicular cancer have transformed it into a predominantly curable condition. This success in treatment advancements has markedly extended patient survival. However, these treatments carry risks and morbidities, which is important to consider given the disease's impact on young men and the emerging understanding of long-term treatment consequences. RECENT FINDINGS: Emerging data support primary retroperitoneal lymph node dissection (RPLND) for select CS II seminoma patients, with similar short-term outcomes to chemotherapy but less treatment intensity. Recent studies have also challenged the reflexive use of adjuvant chemotherapy for pathologic node-positive disease, as growing evidence shows low relapse rates regardless of nodal stage. Furthermore, novel biomarkers like circulating serum microRNA-371a-3p levels can help predict the presence of viable germ cell tumor at time of RPLND. SUMMARY: Advances in risk stratification and therapy enable personalized de-escalation approaches for oligometastatic testicular cancer, optimizing survivorship. Upfront RPLND, reassessing adjuvant systemic therapy for RPLND pN+ disease, and novel biomarkers will shape precision treatment to achieve high cure rates with excellent quality of life. Ongoing trials of reduced-intensity regimens, accurate prognostic models, improved surgical strategy, and emerging biomarkers represent the next frontier in tailored curative therapy.

Metastasis-directed therapy in testicular cancer.

PURPOSE OF REVIEW: This review highlights the importance of addressing testicular cancer metastasizing beyond the retroperitoneum, focusing on multidisciplinary approaches and advances in treatment. RECENT FINDINGS: Recent literature emphasizes on the evolving landscape of metastasis-directed therapy, including surgical interventions, chemotherapy regimens, and radiation therapy. The effectiveness of these treatments varies depending on the site of metastasis, with various approaches improving survival rates and quality of life for patients. We divide our review in an organ-specific manner and focus on chemotherapeutic, surgical, and radiation therapy approaches pertaining to each site of metastasis. SUMMARY: Our review suggests the pressing need for continued research to refine and personalize treatment strategies. These efforts are important for enhancing clinical practice, ultimately leading to better outcomes for patients with metastatic testicular cancer.

Optimizing outcomes in men with prostate cancer: the cardiovascular event lowering (CaELo) pathways.

INTRODUCTION: Risk of cardiovascular disease is higher among men with prostate cancer than men without, and prostate cancer treatments (especially those that are hormonally based) are associated with increased cardiovascular risk. MATERIALS AND METHODS: An 11-member panel of urologic, medical, and radiation oncologists (along with a men's health specialist and an endocrinologist/preventive cardiologist) met to discuss current practices and challenges in the management of cardiovascular risk in prostate cancer patients who are taking androgen deprivation therapies (ADT) including LHRH analogues, alone and in combination with androgen-targeted therapies (ATTs). RESULTS: The panel developed an assessment algorithm to categorize patients by risk and deploy a risk-adapted management strategy, in collaboration with other healthcare providers (the patient's healthcare "village"), with the goal of preventing as well as reducing cardiovascular events. The panel also developed a patient questionnaire for cardiovascular risk as well as a checklist to ensure that all aspects of cardiovascular disease risk reduction are completed and monitored. CONCLUSIONS: Prostate cancer patients receiving ADT with or without ATT need to be more zealously assessed for prevention and aggressively managed to reduce cardiovascular events. This can and should include participation from the entire multidisciplinary healthcare team.

MicroRNAs in Testicular Germ Cell Tumors: The Teratoma Challenge.

Testicular germ cell tumors (TGCTs) are relatively common in young men, making accurate diagnosis and prognosis assessment essential. MicroRNAs (miRNAs), including microRNA-371a-3p (miR-371a-3p), have shown promise as biomarkers for TGCTs. This review discusses the recent advancements in the use of miRNA biomarkers in TGCTs, with a focus on the challenges surrounding the noninvasive detection of teratomas. Circulating miR-371a-3p, which is expressed in undifferentiated TGCTs but not in teratomas, is a promising biomarker for TGCTs. Its detection in serum, plasma, and, potentially, cystic fluid could be useful for TGCT diagnosis, surveillance, and monitoring of therapeutic response. Other miRNAs, such as miR-375-3p and miR-375-5p, have been investigated to differentiate between TGCT subtypes (teratoma, necrosis/fibrosis, and viable tumors), which can aid in treatment decisions. However, a reliable marker for teratoma has yet to be identified. The clinical applications of miRNA biomarkers could spare patients from unnecessary surgeries and allow for more personalized therapeutic approaches. Particularly in patients with residual masses larger than 1 cm following chemotherapy, it is critical to differentiate between viable tumors, teratomas, and necrosis/fibrosis. Teratomas, which mimic somatic tissues, present a challenge in differentiation and require a comprehensive diagnostic approach. The combination of miR-371 and miR-375 shows potential in enhancing diagnostic precision, aiding in distinguishing between teratomas, viable tumors, and necrosis. The implementation of miRNA biomarkers in TGCT care could improve patient outcomes, reduce overtreatment, and facilitate personalized therapeutic strategies. However, a reliable marker for teratoma is still lacking. Future research should focus on the clinical validation and standardization of these biomarkers to fully realize their potential.

Optimal imaging techniques across the spectrum of testicular cancer.

Over the years, several imaging techniques have been used in the diagnosis and management of testicular cancer. We compartmentalize disease stages into preorchiectomy, stage 1, initial stage 2 and 3 and postchemotherapy stage 2 and 3. We then elaborate on various imaging modalities that are relevant to each of these stages. We also describe evolving imaging tools that have shown promise. We attempt to provide a comprehensive review of these techniques over the spectrum of testicular cancer.

Comparative Analysis of Performance of Large Language Models in Urogynecology.

IMPORTANCE: Despite growing popularity in medicine, data on large language models in urogynecology are lacking. OBJECTIVE: The aim of this study was to compare the performance of ChatGPT-3.5, GPT-4, and Bard on the American Urogynecologic Society self-assessment examination. STUDY DESIGN: The examination features 185 questions with a passing score of 80. We tested 3 models-ChatGPT-3.5, GPT-4, and Bard on every question. Dedicated accounts enabled controlled comparisons. Questions with prompts were inputted into each model's interface, and responses were evaluated for correctness, logical reasoning behind answer choice, and sourcing. Data on subcategory, question type, correctness rate, question difficulty, and reference quality were noted. The Fisher exact or χ2 test was used for statistical analysis. RESULTS: Out of 185 questions, GPT-4 answered 61.6% questions correctly compared with 54.6% for GPT-3.5 and 42.7% for Bard. GPT-4 answered all questions, whereas GPT-3.5 and Bard declined to answer 4 and 25 questions, respectively. All models demonstrated logical reasoning in their correct responses. Performance of all large language models was inversely proportional to the difficulty level of the questions. Bard referenced sources 97.5% of the time, more often than GPT-4 (83.3%) and GPT-3.5 (39%). GPT-3.5 cited books and websites, whereas GPT-4 and Bard additionally cited journal articles and society guidelines. Median journal impact factor and number of citations were 3.6 with 20 citations for GPT-4 and 2.6 with 25 citations for Bard. CONCLUSIONS: Although GPT-4 outperformed GPT-3.5 and Bard, none of the models achieved a passing score. Clinicians should use language models cautiously in patient care scenarios until more evidence emerges.

Comparative Effectiveness of Partial Gland Cryoablation Versus Robotic Radical Prostatectomy for Cancer Control.

BACKGROUND AND OBJECTIVE: There is an absence of high-level evidence comparing oncologic endpoints for partial gland ablation, and most series use prostate-specific antigen (PSA) rather than biopsy endpoints. Our aim was to compare oncologic outcomes between partial gland cryoablation (PGC) and radical prostatectomy (RP) for prostate cancer. METHODS: This was a retrospective, single-center analysis of subjects treated with PGC (n = 98) or RP (n = 536) between January 2017 and December 2022 as primary treatment for intermediate-risk (Gleason grade group [GG] 2-3) prostate cancer. Oncologic endpoints included surveillance biopsies per protocol after PGC in comparison to serial PSA testing after RP. The primary outcome was treatment failure, defined as a need for any salvage treatment or development of metastatic disease. Treatment failure and survival analyses were conducted using Cox proportional-hazard regression and Kaplan Meier survival curves. KEY FINDINGS AND LIMITATIONS: After applying the inclusion/exclusion criteria, the PGC (n = 75) and RP (n = 298) groups were compared. PGC patients were significantly older (71 vs 64 yr; p < 0.001), but there were no differences in PSA, biopsy GG, or treatment year between the groups. The PGC group had higher rates of treatment failures at 24 mo (33% vs 11%; p < 0.001) and 48 mo (43% vs 14%; p < 0.001). One PGC patient (2.1%) and one RP patient (0.7%) developed metastases by 48-mo follow-up (p = 0.4). On adjusted analysis, PGC was associated with a higher risk of treatment failure (hazard ratio 4.6, 95% confidence interval 2.7-7.9; p < 0.001). Limitations include observational biases associated with the retrospective study design. CONCLUSIONS: This is the first comparative effectiveness study of cancer control outcomes for PGC versus RP. The results demonstrate an almost fivefold higher risk of treatment failure with PGC during short-term follow-up. PATIENT SUMMARY: We compared cancer control outcomes for patients with intermediate-risk prostate cancer treated with partial gland cryoablation versus radical prostatectomy. We found that partial gland cryoablation had an almost fivefold higher risk of treatment failure. Men with prostate cancer should be counseled regarding this difference in treatment failure.

Advancing GCT Management: A Review of miR-371a-3p and Other miRNAs in Comparison to Traditional Serum Tumor Markers.

MicroRNAs, short non-protein coding RNAs, are overexpressed in GCTs. Circulating levels of germ cell tumor (GCT)-associated miRNAs, such as miR-371a-3p, can be utilized as efficient and cost-effective alternatives in diagnosing and managing patients presenting with GCTs. This quality of miRNAs has demonstrated favorable performance characteristics as a reliable blood-based biomarker with high diagnostic accuracy compared to current serum tumor markers (STMs), including α-fetoprotein (AFP), beta human chorionic gonadotropin (ß-hCG), and lactate dehydrogenase (LDH). The conventional STMs exhibit limited specificity and sensitivity. Potential clinical implications of miRNAs include impact on de-escalating or intensifying treatment, detecting recurrence at earlier stages, and lessening the necessity of cross-sectional imaging or invasive tissue biopsy for non-teratomatous GCTs. Here, we also highlight the outstanding issues that must be addressed prior to clinical implementation. Standards for measuring circulating miRNAs and determining ideal cutoff values are essential for integration into current clinical guidelines.

Sustainability in Urology: Ideas for a Greener Future.

Sustainability in urology can be achieved via conscientious practices that minimize the negative impact of our services while achieving ethical and responsible patient care. We highlight novel and actionable ideas that could pave the path towards healthier, greener urological practice.