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1.
J Urol ; 211(1): 80-89, 2024 01.
Article in English | MEDLINE | ID: mdl-37672753

ABSTRACT

PURPOSE: Primary surgical treatment with retroperitoneal lymph node dissection aims to accurately stage and treat patients with node-positive pure seminoma while avoiding long-term risks of chemotherapy or radiation, traditional standard-of-care treatments. MATERIALS AND METHODS: We reported the pathologic and oncologic outcomes of patients with pure seminoma treated with primary retroperitoneal lymph node dissection in a retrospective, single-institution case series over 10 years. The primary outcome was 2-year recurrence-free survival stratified by adjuvant management strategy (surveillance vs adjuvant chemotherapy). RESULTS: Forty-five patients treated with primary retroperitoneal lymph node dissection for pure testicular seminoma metastatic to the retroperitoneum were identified. Median size of largest lymph node before surgery was 1.8 cm. Viable germ cell tumor, all of which was pure seminoma, was found in 96% (n=43) of patients. The median number of positive nodes and nodes removed was 2 and 54, respectively. Median positive pathologic node size was 2 cm (IQR 1.4-2.5 cm, range 0.1-5 cm). Four of 29 patients managed with postoperative surveillance experienced relapse; 2-year recurrence-free survival was 81%. Median follow-up for those managed with surveillance who did not relapse was 18.5 months. There were no relapses in the retroperitoneum, visceral recurrences, or deaths. Among the 16 patients who received adjuvant treatment, 1 patient experienced relapse in the pelvis at 19 months. CONCLUSIONS: Primary retroperitoneal lymph node dissection for pure seminoma with low-volume metastases to the retroperitoneum is safe and effective, allowing most patients to avoid long-term toxicities from chemotherapy or radiation.


Subject(s)
Neoplasms, Germ Cell and Embryonal , Seminoma , Testicular Neoplasms , Male , Humans , Retrospective Studies , Seminoma/surgery , Seminoma/pathology , Neoplasm Recurrence, Local/pathology , Testicular Neoplasms/surgery , Testicular Neoplasms/pathology , Lymph Node Excision/adverse effects , Neoplasms, Germ Cell and Embryonal/pathology , Retroperitoneal Space/pathology , Adjuvants, Immunologic , Recurrence , Neoplasm Staging
2.
Oncologist ; 26(6): 483-491, 2021 06.
Article in English | MEDLINE | ID: mdl-33586274

ABSTRACT

BACKGROUND: The National Comprehensive Cancer Network recommends either three cycles of bleomycin, etoposide, and cisplatin or four cycles of etoposide and cisplatin (EPx4) as initial chemotherapy for the treatment of good-risk germ cell tumors (GCTs). To assess the response, toxicity, and survival outcomes of EPx4, we analyzed our experience. MATERIAL AND METHODS: Response and survival outcomes, selected toxicities, and adherence to chemotherapy dose and schedule were assessed in patients with good-risk GCT who received EPx4 at Memorial Sloan Kettering Cancer Center between 1982 and 2016. The results were compared with our past results and published data. RESULTS: Between 1982 and 2016, 944 patients with GCT were treated with EPx4, 289 who were previously reported plus 655 treated between January 2000 and August 2016. A favorable response was achieved in 928 of 944 patients (98.3%). Five-year progression-free, disease-specific, and overall survival rates were 93.9%, 98.6%, and 97.9%, respectively. Median follow-up was 7.3 years (range, 2.8 months to 35.5 years). Viable, nonteratomatous malignant GCT was present in 3.5% of 432 postchemotherapy retroperitoneal lymph node dissection specimens from patients with nonseminomatous GCT. Febrile neutropenia and thromboembolic events occurred in 16.0% and 8.9%, respectively, with one treatment-related death. In the more recent 655-patient cohort, full-dose EPx4 was administered to 631 (96.3%), with deviations from planned treatment driven mainly by vascular (n = 13), hematologic (n = 11), renal (n = 7), or infectious (n = 5) events. CONCLUSION: EPx4 is highly effective and well tolerated in patients with good-risk GCTs and remains a standard of care. IMPLICATIONS FOR PRACTICE: Four cycles of etoposide and cisplatin (EPx4) is a standard-of-care regimen for all patients with good-risk germ cell tumors with a favorable response rate and disease-specific survival of 98%. Full-dose administration of etoposide and cisplatin and complete resection of residual disease lead to optimal outcomes. EPx4 should be the recommended regimen in active smokers, patients with reduced or borderline kidney function, and patients aged 50 years or older, which are patient groups at increased risk for bleomycin pulmonary toxicity. Because of a risk of acquired severe pulmonary illness, EPx4 may also be favored for patients who vape or use e-cigarettes and during ongoing transmission of severe acute respiratory syndrome coronavirus 2.


Subject(s)
COVID-19 , Electronic Nicotine Delivery Systems , Neoplasms, Germ Cell and Embryonal , Testicular Neoplasms , Antineoplastic Combined Chemotherapy Protocols/adverse effects , Bleomycin/adverse effects , Cisplatin/adverse effects , Etoposide/adverse effects , Humans , Male , Neoplasms, Germ Cell and Embryonal/drug therapy , SARS-CoV-2 , Testicular Neoplasms/drug therapy
3.
J Urol ; 204(4): 818-823, 2020 10.
Article in English | MEDLINE | ID: mdl-32364837

ABSTRACT

PURPOSE: We investigated the efficacy and analyzed the complication risk factors of peritoneovenous shunt in treating refractory chylous ascites following retroperitoneal lymph node dissection in patients with urological malignancies. MATERIALS AND METHODS: From April 2001 to March 2019 all patients with refractory chylous ascites after retroperitoneal lymph node dissection treated with peritoneovenous shunt were reviewed. Demographic characteristics, technical success, efficacy, patency period and complications were studied. Univariate and multivariate logistic regression analysis was performed to identify predictors of complications. RESULTS: Twenty patients were included in this study. Testicular cancer was the most common malignancy (85%). The mean number of days from surgery to detection of chylous ascites was 21 days (SD 15, range 4 to 65). Ascites permanently resolved after peritoneovenous shunt in 18 patients (90%), leading to shunt removal in 17 patients (85%) between 46 and 481 days (mean 162, SD 141). The mean serum albumin level increased 24% after shunt placement (mean 3.0±0.6 gm/dl before, 3.9±0.8 gm/dl after, p <0.05). The most common complication was occlusion (30%). Relative risk of complications increased significantly when shunt placement was more than 70 days after surgery and in patients with more than 5 paracenteses before peritoneovenous shunt placement (AR 0.71% vs 0.25%, RR 2.9, p <0.048 and AR 0.6% vs 0.125%, RR 4.8, p <0.04, respectively). CONCLUSIONS: Peritoneovenous shunt permanently treated chylous ascites in 90% of patients after retroperitoneal lymph node dissection. Peritoneovenous shunt was removed in 85% of patients. Shunt placement is an effective and safe treatment option for refractory chylous ascites. These patients might benefit from earlier intervention, after 4 to 6 weeks of conservative management as opposed to 2 to 3 months.


Subject(s)
Chylous Ascites/surgery , Lymph Node Excision , Peritoneovenous Shunt , Postoperative Complications/surgery , Urologic Neoplasms/surgery , Adult , Aged , Aged, 80 and over , Humans , Lymph Node Excision/methods , Lymphatic Metastasis , Male , Middle Aged , Postoperative Complications/epidemiology , Prognosis , Retroperitoneal Space , Retrospective Studies , Risk Factors , Treatment Outcome , Urologic Neoplasms/pathology , Young Adult
4.
J Urol ; 202(2): 272-281, 2019 08.
Article in English | MEDLINE | ID: mdl-31059667

ABSTRACT

PURPOSE: Testis cancer is the most common solid malignancy in young males. The purpose of this guideline is to provide a useful reference on the effective evidence-based treatment of early stage testicular cancer. METHODS: The systematic review utilized to inform this guideline was conducted by a methodology team at the Johns Hopkins University Evidence-based Practice Center. The methodology team searched using PubMed®, Embase®, and the Cochrane Central Register of Controlled Trials (CENTRAL) from January 1980 through August 2018. The evidence review team also reviewed relevant systematic reviews and references provided by the panel to identify articles that may have been missed by the database searches. RESULTS: When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low). Such evidence-based statements are provided as Strong, Moderate, or Conditional Recommendations. In instances of insufficient evidence, additional guidance is provided as Clinical Principles and Expert Opinions. CONCLUSIONS: This guideline attempts to improve a clinician's ability to evaluate and treat patients with testicular cancer, but higher quality evidence in future trials will be essential to improve level of care for these patients.


Subject(s)
Testicular Neoplasms/diagnosis , Testicular Neoplasms/therapy , Algorithms , Humans , Male , Neoplasm Staging , Systematic Reviews as Topic , Testicular Neoplasms/pathology
5.
J Urol ; 197(2): 391-397, 2017 02.
Article in English | MEDLINE | ID: mdl-27720783

ABSTRACT

PURPOSE: Fibrosis accounts for approximately 50% of histological findings at post-chemotherapy retroperitoneal lymph node dissection, and is associated with reported relapse rates of 10% to 15%. We characterized patients with fibrosis at post-chemotherapy retroperitoneal lymph node dissection and identified predictors of adverse outcomes in this group. MATERIALS AND METHODS: We reviewed the medical records of men who underwent post-chemotherapy retroperitoneal lymph node dissection between 1989 and 2013 with histological findings of necrosis/fibrosis. With few exceptions post-chemotherapy retroperitoneal lymph node dissection after 1999 was performed with a bilateral template. Clinical, pathological and treatment related data were reported. Cox regression models were built to identify predictors of disease recurrence. RESULTS: The study cohort included 598 men with a median age of 32 years (IQR 25-38). Most cases (397 of 547, 73%) were classified as IGCCCG good risk, with no significant differences in risk classification before and after 1999 (p=0.55). Median followup was 7.3 years (IQR 3.2-12.3). The 5-year recurrence-free and overall survival rates were 94% and 96%, respectively. Overall 36 patients had disease recurrence, most of which was distant or outside the retroperitoneal lymph node dissection template. Procedures performed after 1999 and the presence of embryonal cell carcinoma on primary histology were associated with improved recurrence-free survival on multivariate analysis (p <0.01). CONCLUSIONS: Disease recurrence in patients with fibrosis at post-chemotherapy retroperitoneal lymph node dissection is an uncommon yet significant event, which is less likely to occur in patients treated after 1999 and in those with embryonal carcinoma on primary histology.


Subject(s)
Fibrosis/pathology , Lymph Node Excision/methods , Necrosis/pathology , Neoplasms, Germ Cell and Embryonal/pathology , Retroperitoneal Space/pathology , Testicular Neoplasms/pathology , Adult , Antineoplastic Agents/therapeutic use , Humans , Lymph Nodes/pathology , Lymph Nodes/surgery , Lymphatic Metastasis , Male , Neoplasm Recurrence, Local/epidemiology , Neoplasm Recurrence, Local/pathology , Neoplasms, Germ Cell and Embryonal/drug therapy , Neoplasms, Germ Cell and Embryonal/surgery , Retrospective Studies , Survival Rate , Testicular Neoplasms/drug therapy , Testicular Neoplasms/surgery , Testis/pathology , Testis/surgery , Treatment Outcome
6.
J Urol ; 205(3): 818, 2021 03.
Article in English | MEDLINE | ID: mdl-33399483
7.
J Urol ; 196(6): 1764-1771, 2016 12.
Article in English | MEDLINE | ID: mdl-27389330

ABSTRACT

PURPOSE: Metastatic testis cancer in the retroperitoneum presents a technical challenge to urologists in the primary and post-chemotherapy settings. Where possible, bilateral nerve sparing retroperitoneal lymph node dissection should be performed in an effort to preserve ejaculatory function. However, this is often difficult to achieve, given the complex neurovascular anatomy. We performed what is to our knowledge the first comprehensive examination of the anatomical relationships between the sympathetic nerves of the aortic plexus and the lumbar vessels to facilitate navigation and nerve sparing during bilateral retroperitoneal lymph node dissection. MATERIALS AND METHODS: The relative anatomy of the infrarenal vasculature (lumbar vessels, right gonadal vein and inferior mesenteric artery) was investigated in 21 embalmed human cadavers. The complex relationships between these vessels and the sympathetic nerves of the aortic plexus were examined by dissection of an additional 8 fresh human cadavers. RESULTS: Analysis of the infrarenal vasculature from 21 cadavers demonstrated that the position of the right gonadal vein and the inferior mesenteric artery may be useful to locate the right superior lumbar vein and the first pair of infrarenal lumbar arteries as well as the common lumbar trunk (vein) and the second pair of infrarenal lumbar arteries, respectively. Furthermore, the lumbar splanchnic nerves supplying the aortic plexus were most often positioned anteromedial to the respective lumbar vein. CONCLUSIONS: The current study describes the complex neurovascular relationships that are crucial to performing successful nerve sparing retroperitoneal lymph node dissection. Surgical techniques are also discussed. Collectively, these results may help surgeons decrease the rate of postoperative retrograde ejaculation and/or anejaculation.


Subject(s)
Lymph Node Excision/methods , Testicular Neoplasms/secondary , Testicular Neoplasms/surgery , Cadaver , Humans , Lymphatic Metastasis , Male , Retroperitoneal Space
8.
J Vasc Interv Radiol ; 27(5): 665-73, 2016 May.
Article in English | MEDLINE | ID: mdl-26965362

ABSTRACT

PURPOSE: To evaluate the safety and efficacy of percutaneous peritoneovenous shunt (PPVS) placement in treating intractable chylous ascites (CA) in patients with cancer. MATERIALS AND METHODS: Data from 28 patients with refractory CA treated with PPVS from April 2001 to June 2015 were reviewed. Demographic characteristics, technical success, efficacy, laboratory values, and complications were recorded. Univariate and multivariate logistic regression analysis was performed. RESULTS: Technical success was 100%, and ascites resolved or symptoms were relieved in 92.3% (26 of 28) of patients. In 13 (46%) patients with urologic malignancies, whose ascites had resulted from retroperitoneal lymph node dissection, the ascites resolved, resulting in shunt removal within 128 days ± 84. The shunt provided palliation of symptoms in 13 of the remaining 15 patients (87%) for a mean duration of 198 days ± 214. Serum albumin levels increased significantly (21.4%) after PPVS placement from a mean of 2.98 g/dL ± 0.64 before the procedure to 3.62 g/dL ± 0.83 (P < .001). The complication rate was 37%, including shunt malfunction/occlusion (22%), venous thrombosis (7%), and subclinical disseminated intravascular coagulopathy (DIC) (7%). Smaller venous limb size (11.5 F) and the presence of peritoneal tumor were associated with a higher rate of shunt malfunction (P < .05). No patient developed overt DIC. CONCLUSIONS: PPVS can safely and effectively treat CA in patients with cancer, resulting in significant improvement in serum albumin in addition to palliation of symptoms.


Subject(s)
Chylous Ascites/therapy , Neoplasms/complications , Peritoneovenous Shunt/methods , Adult , Aged , Aged, 80 and over , Biomarkers/blood , Chylous Ascites/blood , Chylous Ascites/diagnosis , Chylous Ascites/etiology , Disseminated Intravascular Coagulation/etiology , Female , Humans , Logistic Models , Male , Middle Aged , Multivariate Analysis , Palliative Care , Peritoneovenous Shunt/adverse effects , Retrospective Studies , Risk Factors , Serum Albumin/metabolism , Serum Albumin, Human , Time Factors , Treatment Outcome , Venous Thrombosis/etiology , Young Adult
9.
Am J Hum Genet ; 91(2): 379-83, 2012 Aug 10.
Article in English | MEDLINE | ID: mdl-22863192

ABSTRACT

Although heritable factors are an important determinant of risk of early-onset cancer, the majority of these malignancies appear to occur sporadically without identifiable risk factors. Germline de novo copy-number variations (CNVs) have been observed in sporadic neurocognitive and cardiovascular disorders. We explored this mechanism in 382 genomes of 116 early-onset cancer case-parent trios and unaffected siblings. Unique de novo germline CNVs were not observed in 107 breast or colon cancer trios or controls but were indeed found in 7% of 43 testicular germ cell tumor trios; this percentage exceeds background CNV rates and suggests a rare de novo genetic paradigm for susceptibility to some human malignancies.


Subject(s)
DNA Copy Number Variations/genetics , Genetic Predisposition to Disease/genetics , Genomics/methods , Germ-Line Mutation/genetics , Testicular Neoplasms/genetics , Adult , Humans , Male , Parents , Research Design
10.
J Urol ; 204(1): 101-102, 2020 07.
Article in English | MEDLINE | ID: mdl-32330401
11.
J Urol ; 193(2): 513-8, 2015 Feb.
Article in English | MEDLINE | ID: mdl-25150639

ABSTRACT

PURPOSE: Patients with good risk nonseminomatous germ cell tumors received induction chemotherapy with 4 cycles of etoposide and cisplatin (EPx4) or 3 cycles of bleomycin, etoposide and cisplatin (BEPx3). We report the histological results at post-chemotherapy retroperitoneal lymph node dissection after induction chemotherapy in patients treated with etoposide and cisplatin or bleomycin, etoposide and cisplatin for good risk nonseminomatous germ cell tumors. MATERIALS AND METHODS: Post-chemotherapy retroperitoneal lymph node dissection was performed in 579 patients after induction chemotherapy. Of these patients 505 were treated with EPx4 and 74 were treated with BEPx3 or BEPx4. Clinical and pathological features are reported. RESULTS: No difference in the frequency of viable residual cancer was observed with bleomycin, etoposide and cisplatin vs etoposide and cisplatin (5% vs 6%, respectively, p=not significant). Teratoma was more prevalent in the bleomycin, etoposide and cisplatin group vs etoposide and cisplatin group (57% vs 34%, respectively, p <0.001). On multivariate analysis patients who received induction bleomycin, etoposide and cisplatin had a twofold greater risk of harboring teratoma at post-chemotherapy retroperitoneal lymph node dissection (OR 2.0; 95% CI 1.0, 4.0; p=0.04). When excluding patients from analysis who received BEPx4, those who received BEPx3 still had a 3.7-fold increased risk of teratoma in the retroperitoneum (OR 3.7; 95% CI 1.5, 8.9; p=0.004). Relapse-free and disease specific survival was not different between the 2 regimens. CONCLUSIONS: Viable cancer was equally uncommon after treatment with both regimens. Overall, relapse-free and disease specific survival did not differ between the groups. The discrepancy between regimens in the frequency of teratoma is not explained but may be due to an unrecognized selection bias rather than an effect of the regimen.


Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Lymph Node Excision , Neoplasms, Germ Cell and Embryonal/drug therapy , Neoplasms, Germ Cell and Embryonal/surgery , Teratoma/drug therapy , Teratoma/surgery , Testicular Neoplasms/drug therapy , Testicular Neoplasms/surgery , Adult , Bleomycin/administration & dosage , Cisplatin/administration & dosage , Combined Modality Therapy , Etoposide/administration & dosage , Humans , Induction Chemotherapy , Male , Retrospective Studies , Risk Assessment , Teratoma/epidemiology , Testicular Neoplasms/epidemiology
14.
J Natl Compr Canc Netw ; 13(6): 811-22, 2015 Jun.
Article in English | MEDLINE | ID: mdl-26085395

ABSTRACT

Testicular cancer is the most common cancer in men aged 15 to 40 years in the United States, Canada, and many European countries. Given the excellent prognosis of most men with testicular cancer, updates in care after treatment have become very important. This article provides a review of the available evidence, integrated with expert medical judgment, in the area of testicular cancer follow-up.


Subject(s)
Testicular Neoplasms/therapy , Combined Modality Therapy , Consensus , Disease Management , Follow-Up Studies , Humans , Interdisciplinary Communication , Male , Treatment Outcome
15.
J Natl Compr Canc Netw ; 13(2): 151-9, 2015 Feb.
Article in English | MEDLINE | ID: mdl-25691606

ABSTRACT

The NCCN Guidelines for Kidney Cancer provide multidisciplinary recommendations for the clinical management of patients with clear cell and non-clear cell renal carcinoma. These NCCN Guidelines Insights highlight the recent updates/changes in these guidelines, and updates include axitinib as first-line treatment option for patients with clear cell renal carcinoma, new data to support pazopanib as subsequent therapy for patients with clear cell carcinoma after first-line treatment with another tyrosine kinase inhibitor, and guidelines for follow-up of patients with renal cell carcinoma.


Subject(s)
Carcinoma, Renal Cell/drug therapy , Kidney Neoplasms/drug therapy , Axitinib , Carcinoma, Renal Cell/diagnosis , Humans , Imidazoles/therapeutic use , Indazoles/therapeutic use , Kidney Neoplasms/diagnosis , Protein Kinase Inhibitors/therapeutic use , Pyrimidines/therapeutic use , Sulfonamides/therapeutic use
16.
J Natl Compr Canc Netw ; 13(6): 772-99, 2015 Jun.
Article in English | MEDLINE | ID: mdl-26085393

ABSTRACT

Germ cell tumors (GCTs) account for 95% of testicular cancers. Testicular GCTs constitute the most common solid tumor in men between the ages of 20 and 34 years, and the incidence of testicular GCTs has been increasing in the past 2 decades. Testicular GCTs are classified into 2 broad groups--pure seminoma and nonseminoma--which are treated differently. Pure seminomas, unlike nonseminomas, are more likely to be localized to the testis at presentation. Nonseminoma is the more clinically aggressive tumor associated with elevated serum concentrations of alphafetoprotein (AFP). The diagnosis of a seminoma is restricted to pure seminoma histology and a normal serum concentration of AFP. When both seminoma and elements of a nonseminoma are present, management follows that for a nonseminoma. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Testicular Cancer outline the diagnosis, workup, risk assessment, treatment, and follow-up schedules for patients with both pure seminoma and nonseminoma.


Subject(s)
Seminoma/therapy , Testicular Neoplasms/therapy , Combined Modality Therapy , Disease Management , Humans , Male , Neoplasm Staging , Practice Guidelines as Topic , Seminoma/diagnosis , Testicular Neoplasms/diagnosis
17.
J Urol ; 192(2): 415-9, 2014 Aug.
Article in English | MEDLINE | ID: mdl-24518791

ABSTRACT

PURPOSE: We evaluated pathological variables of testicular sex cord-stromal tumors, management options and clinical outcomes. MATERIALS AND METHODS: We retrospectively reviewed the records of 48 patients with testicular sex cord-stromal tumors treated at Memorial Sloan-Kettering Cancer Center between 1997 and 2012. Clinical outcomes were compared based on treatment and previously described pathological factors associated with metastatic potential. RESULTS: Of the 48 patients 37 underwent surveillance without retroperitoneal lymph node dissection, including 34 with no high risk feature and 3 with 1. Median followup was 14.5 months (IQR 6.9-32.5). No patient experienced recurrence. Retroperitoneal lymph node dissection was performed in 11 patients, including 6 with clinical stage I disease and 2 or more high risk features who underwent early dissection, 2 with clinical stage IIa disease at diagnosis who underwent early dissection and 3 with clinical stage I disease and 2 or more high risk features who were observed elsewhere but referred to our institution due to retroperitoneal disease. Six patients with clinical stage I disease underwent early dissection, 4 had no evidence of disease at a median followup of 6.6 years and 2 experienced recurrence and died of disease. Neither of the 2 patients with IIa disease at diagnosis experienced relapse. All 3 patients with delayed dissection experienced relapse and 1 died of disease. CONCLUSIONS: Patients with testicular sex cord-stromal tumors and 1 or no high risk feature can be safely observed without retroperitoneal lymph node dissection but longer followup is needed. Given the lack of effective alternative treatments, early retroperitoneal lymph node dissection may be beneficial in those with 2 or more high risk features, or clinical stage IIa disease.


Subject(s)
Sex Cord-Gonadal Stromal Tumors/secondary , Sex Cord-Gonadal Stromal Tumors/surgery , Testicular Neoplasms/pathology , Testicular Neoplasms/surgery , Adult , Humans , Lymph Node Excision , Male , Middle Aged , Orchiectomy , Retrospective Studies , Treatment Outcome
19.
J Clin Oncol ; : JCO2302542, 2024 Jul 19.
Article in English | MEDLINE | ID: mdl-39028926

ABSTRACT

PURPOSE: Paclitaxel, ifosfamide, and cisplatin (TIP) is an established salvage regimen for germ cell tumors (GCT) on the basis of a phase II trial, but efficacy on a large patient cohort including patients with unfavorable risk features and long-term outcomes has not been reported. Herein, we report updated treatment efficacy and long-term follow-up with TIP. PATIENTS AND METHODS: Patients with GCT who received TIP after cisplatin-based chemotherapy were eligible. Favorable response (complete response or partial response with negative tumor markers), overall survival (OS) and progression-free survival (PFS) rates, relapse, and toxicity were determined. Disease was reclassified according to the International Prognostic Factor Study Group (IPFSG) score. RESULTS: Of the 104 patients, 87 had favorable risk factors and 17 had at least one unfavorable factor by Memorial Sloan Kettering Cancer Center (MSKCC) criteria. Ten patients were treated for a second gonadal primary GCT. With a median follow-up of 8.9 years, the 5-year PFS and OS rates were 66% (95% CI, 55 to 74) and 69% (95% CI, 59 to 77), respectively. Among 87 patients with favorable-risk disease, 69 (79%) achieved a favorable response with 5-year PFS and OS rates of 67% (95% CI, 56 to 76) and 72% (95% CI, 61 to 80), respectively. Among 17 patients with MSKCC unfavorable-risk disease, 13 (76%) achieved a favorable response with 5-year PFS and OS rates of 59% (95% CI, 33 to 78) and 56% (95% CI, 28 to 76), respectively. After IPFSG reclassification, 5-year PFS and OS rates for patients with ≤intermediate-risk disease were 75% (95% CI, 50 to 89) and 73% (95% CI, 55 to 85), respectively. CONCLUSION: TIP is an effective second-line regimen for patients with GCT. Similar outcomes were observed in patients with favorable- and unfavorable-risk disease. The randomized TIGER trial (ClinicalTrials.gov identifier: NCT02375204) comparing TIP with high-dose chemotherapy will determine the optimal second-line treatment approach.

20.
Urology ; 2024 Aug 09.
Article in English | MEDLINE | ID: mdl-39128634

ABSTRACT

OBJECTIVE: To review the presentation and long-term oncologic outcomes of patients with regressed ("burnt out") primary testicular germ cell tumors (GCT). Certain testicular GCT can present with complete regression of the primary tumor. It is not well established if this is associated with more aggressive disease or worse oncologic outcomes. METHODS: We queried our prospectively maintained testicular cancer clinical database at a tertiary cancer center and identified patients without prior chemotherapy who had regressed primary GCT at radical orchiectomy from 1990-2023. All specimens were reviewed by a genitourinary pathologist at diagnosis. Long-term clinical outcomes were reported by Kaplan-Meier method. RESULTS: Fifty-six patients met inclusion criteria; at diagnosis, 17 had no evidence of extra-testicular disease and 39 had advanced (clinical stage [CS] II+) GCT. All CSx (no viable disease or germ cell neoplasia in situ at orchiectomy, and no evidence of advanced disease) and CS0 patients were managed with surveillance and had 5-year recurrence-free survival (RFS) of 88% (95% CI: 39%, 98%). All patients with CS II+ disease underwent primary treatment with surgery (n=5) or first-line chemotherapy (n=34). Two- and 5-year RFS for patients with CSII+ disease was 94% (95% CI: 78%, 98%) and 90% (95% CI: 72%, 97%), respectively. CONCLUSION: Patients with regressed primary testicular GCT often present with advanced disease, possibly due to lack of early clinical signs from the primary tumor. Our analysis shows excellent long-term oncologic outcomes similar to those reported in the literature for patients with viable primary testicular GCT.

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