EMUC 2020: Organ Preservation in Challenging Cases - Testicular Cancer

(UroToday.com) In an oral presentation in the session examining Organ Preservation in Challenging Cases at the 12th European Multidisciplinary Congress on Urological Cancers (EMUC), Dr. Andreas Hiester and Dr. Peter Albers led a discussion regarding organ sparing surgery in testicular cancer.

To begin, Dr. Hiester emphasized that the European Association of Urology (EAU) guidelines on testicular cancer state, “although organ-sparing surgery is not indicated in the presence of non-tumoural contralateral testis, it can be attempted in special cases with all the necessary precautions.” This begs the next question: what are the special cases? Dr. Hiester laid out a number of circumstances which may meet these criteria: metachronous secondary testicular tumors in solitary testis; synchronous bilateral testicular tumors; tumor in a solitary testis occupying less than 30% of the parenchyma; suspicion of a potentially benign tumor; and benign tumors based on frozen sections. However, other indications may be considered as well he postulated: a small, non-palpable testicular seminoma detected on ultrasound or in young patients in whom low testosterone levels may be anticipated following surgery.

He highlighted the case of a 24-year-old patient with a small 12x8mm left-sided testicular tumor with normal markers. Intraoperative enucleation with frozen section was interpreted as no malignancy and final histology demonstrated a Leydig-cell tumor.

Dr. Albers then interjected to point out a number of characteristics present in this case which may point towards an organ sparing approach:

  1. a small, low volume tumor: volumes less than 2.8 cubic centimeters is associated with an increased likelihood of benign histology;
  2. low testosterone levels, as radical orchiectomy may aggravate hypogonadism; and
  3. frozen section analysis which may be close to 100% accurate in the diagnosis of non-malignant histology.
Dr. Hiester then presented a second case of a 65-year-old man with a left-sided, small testicular mass measuring 20mm. He had normal tumor markers. Dr. Albers pointed out that, while this patient could in theory be eligible for organ sparing surgery on the basis of normal markers and a low volume lesion, he is older, without indication to preserve fertility, and with apparent adequate testosterone production from the contralateral normal testis. Notably, in this age group, alternative diagnoses (including lymphoma) must be considered. Thus, taking a “safety first” perspective, he advocated orchiectomy in this setting. In the end, this was performed demonstrating pT1 seminoma.

Dr. Hiester then raised the question as to whether there is a role for testis sparing surgery in malignant tumors with a normal contralateral testis. Dr. Albers suggested that this should be considered only in very selected patients including small postpubertal teratomas and, with appropriate informed consent, potentially in small seminomas without germ cell neoplasia in situ (GCNIS) and postoperative radiotherapy. He argued strongly that there is no indication for this approach in elderly patients and those with seminoma and GCNIS.

Circling back to the second case, Dr. Hiester said that ongoing surveillance subsequently demonstrated a small retroperitoneal recurrence, consistent with reclassification from CS I A to CS II A disease. Based on NCCN and EAU guidelines, he discussed treatment options including radiotherapy and chemotherapy. Dr. Hiester described fine needle puncture guided biopsy which histologically demonstrated no malignancy. The patient was then offered:

  1. a wait and see approach with repeat imaging in 6-8 weeks
  2. chemotherapy
  3. radiotherapy
  4. primary retroperitoneal lymph node dissection (RPLND), in the context of the PRIMETEST trial.
The patient underwent unilateral template robotic RPLND, with final histology consistent with a 2.5cm metastatic seminoma amongst 13 lymph nodes removed. He suggested that the use of m371a-p may assist with diagnostic decisions in this context.

Presented by: Andreas Hiester, MD, and Peter Albers, MD, Department of Urology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany

Written by: Christopher J.D. Wallis, Urologic Oncology Fellow, Vanderbilt University Medical Center Contact: @WallisCJD on Twitter at the 12th European Multidisciplinary Congress on Urological Cancers (EMUC) (#EMUC20 ), November 13th - 14th, 2020
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