First, differentiating somatic transformation from a late relapse is difficult. Late relapse is a relapse that occurs 2 years past primary therapy in the NSGCT patient population. But, this late relapse is not always viable GCT, and may include somatic malignant transformation – and often, these are difficult to distinguish clinically. The incidence of late relapses is about 1.3% in men with GCT – but the latency period is very variable, and can occur years to decades after primary treatment. The overall late relapse is slightly higher in men with seminoma (3.2%) than in NSGCT (1.4%). And, a significant portion of these later relapses will have somatic de-differentiation.
Late relapses often occur well after routine surveillance is completed. As such, most patients present with symptoms, including abdominal pain, back pain, and/or lethargy. However, while it is often presumed that symptomatic recurrences are associated with worse outcomes due to their larger size at presentation, this has actually not been demonstrated.
He does note that a significant portion of these later relapses will have somatic de-differentiation, and therefore obtaining tissue is recommended and should be acquired if it can be. Marker assays may also be helpful – traditional tumor markers are currently used, though other novel markers such as mi-R371 may be introduced later.
The bulk of his talk focused on when to do surgery in these patients. And to answer that, each case should be approached individually (ideally in a multidisciplinary setting of TCa specialists) – and the following 3 questions should always be asked:
- What is the distribution of metastases? Retroperitoneal, chest, extremities, etc.
- What is the cell type? Obtain tissue if possible, as it may guide the need for surgery or the type of systemic therapy
- Is surgery technically feasible – does it allow complete and safe removal? These are not easy cases and may be associated with morbidity that delays systemic therapy… so it may not be worth operating if the tumor cannot be completely removed.
- Some abdominal disease resection will require multi-visceral and neuro-vascular resection – so make sure you have the right support teams involved ahead of time
- When complete resection is achieved, long-term cure is possible – 26-69% of men remained disease free after this type of intervention. 5-year CSS ~65% in some series.
- Choose your patient carefully
- Accept that not every patient is suitable for surgery and that not everyone is curable with surgery
- “Don’t try this surgery at home if you don’t have friends….” In other specialties at your hospital (as surgical support) and friends in the urologic oncology community to run cases by!
Presented by: Noel W Clarke, Professor of Urologic Oncology, Director of the Genitourinary Research Group, Manchester University, Consultant Urologist at Salford Royal Hospital and The Christie, Manchester
Written by: Thenappan Chandrasekar, MD (Clinical Instructor, Thomas Jefferson University) (twitter: @tchandra_uromd, @TjuUrology) at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019.