ESOU 2019: Challenging the Dogma in Surgical Treatment of Testis Cancer

Prague, Czech Republic ( World-renowned testis cancer surgeon, Dr. Axel Heidenreich, presented this session on challenging the surgical dogma in testis cancer.

  1. “When in doubt, take it out”
Dr. Heidenreich notes that when he was starting his residency training in the early 1990s the dogma was for bilateral orchiectomy as the treatment of choice for synchronous or metachronous bilateral testis cancer. Unfortunately, this leads to an unnecessary orchiectomy in 10-15% of cases with benign disease, lifelong infertility with testosterone supplementation, and psycho-oncological impairment. Since then, the question has been: do we always need to perform bilateral orchiectomy?

Subsequently, Dr. Heidenreich has challenged the dogma and published several papers describing partial orchiectomy (first in 1995), which required no testosterone supplementation during follow-up. An updated manuscript in 2001 of 73 patients with median 91 months (range 3-191) follow-up, reported that 98.6% of patients had no evidence of disease and one died of systemic tumor progression1. No relapsed occurred in 46 patients with associated testicular intraepithelial neoplasia treated with local radiation; 4 patients had local recurrence, salvaged with radical orchiectomy.

According to Dr. Heidenreich, organ-sparing surgery is indicated for:

  • Bilateral metachronous/synchronous testis cancer
  • Tumor diameter < 2 cm (50% parenchyma remaining)
  • Normal serum testosterone and LH
  • Postoperative radiation therapy
Based on these studies, all guidelines on testis cancer have adopted this as a feasible strategy. He proposes the following algorithm for assessing small testis masses2:
UroToday ESOU19 Surgical Treatment of Testis Cancer

  1. “Always act bilateral”
Dr. Heidenreich states that radical bilateral template resection is the treatment of choice in many centers for large residual retroperitoneal masses. He notes that this is often associated with a higher frequency of complications, as well as retrograde/anejaculation. In 2007, the group at Indiana University published their first 100 patients with a modified template retroperitoneal lymph node dissection surgery (RPLND) 3. These patients were highly selected; all had normalized tumor markers and metastases in the primary landing zone. After a median 32 months of follow-up, there were 4 relapses that were all outside the dissection boundaries of a bilateral template RPLND; the 2 and 5-year cancer-specific survival rates were 95%. In 2009, Dr. Heidenreich and his team published their experience with modified template RPLND (n=98)4, noting that these patients should have residual masses <2 cm, or 2-5cm if located in the primary landing zone for testis cancer. In follow-up of these patients, there were no retroperitoneal relapses. Particularly with small masses, Dr. Heidenreich is a proponent for nerve-sparing.

Dr. Heidenreich concluded stating:

  • “When in doubt, take it out” – when in doubt, take a frozen section and save the testis
  • “Always act bilateral” – only act bilateral if residual masses are outside the primary template

Presented by: Axel Heidenreich, Professor of Urology, Chairman, and Director of the Department of Urology, Uro-Oncology, Robot-Assisted, and Specialized Urologic Surgery at the University Hospital in Cologne Germany 

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic

  1. Heidenreich A, Weissbach L, Holtl W, et al. Organ sparing surgery for malignant germ cell tumor of the testis. J Urol 2001 Dec;166(6):2161-2165.
  2. Paffenholz P, Held L, Loosen SH, et al. Testis sparing surgery for benign testicular masses: Diagnostics and Therapeutic Approaches. J Urol 2018 Aug;200(2):353-360.
  3. Beck SD, Foster RS, Bihrle R, et al. Is full bilateral retroperitoneal lymph node dissection always necessary for postchemotherapy residual tumor? Cancer 2007 Sep 15;110(6):1235-1240.
  4. Heidenreich A, Pfister D, Witthuhn R, Thuer D, Albers P. Postchemotherapy retroperitoneal lymph node dissection in advanced testicular cancer: radical or modified template resection. Eur Urol 2009 Jan;55(1):217-224
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