San Antonio, Texas USA (UroToday.com) The management of testicular germ cell tumors (GCTs) is one of the more tightly protocoled treatment algorithms in Urology. Unfortunately, data from the NCCN suggests that 30% of GCT patients don’t get guideline-directed care, and their survival is potentially worse as a result.
Of course, clinicians and patients are both interested in limiting treatment toxicities while still obtaining good oncologic outcomes; but care must be taken to know when limiting care is appropriate. Dr. Masterson from Indiana University outlines several areas of caution when limiting protocol-driven treatment from a surgical perspective.
The first important point is that not all GCTs are chemosensitive. Indeed, teratomas that undergo malignant transformation or PNET transformation have a dismal 13% complete response (CR) rate to chemotherapy. One should therefore strongly consider a virgin RPLND for CSI (clinical stage 1) disease. In these patients, he would also recommend post-chemo (PC-RPLND) for all CRs and residual masses. Similarly, sex cord stromal tumors do not have any effective chemotherapeutic options available. Furthermore, the defined risk factors for metastatic progression of stromal tumors are unreliable in the clinical setting. Therefore, one should strongly consider primary RPLND for CSI disease and not flirt with a bad outcome by attempting surveillance on these known high-risk cancers. One should also remember that extra-gonadal/retroperitoneal GCTs deserve an ipsilateral orchiectomy, and this should not be overlooked even in the setting of tumor marker normalization or normal testicular imaging.
There is clear consensus that PC residual masses >1cm should be resected. Unfortunately, a surprising number of patients still present to tertiary care centers that have been incorrectly surveilled for masses >1cm. Dr. Masterson made a plea to Urologist to remain closely involved in patients’ management after sending them to Medical Oncology for chemotherapy. The surgeon’s perspective regarding PC masses is important, as it may mean the difference between appropriate vs. inappropriate care.
There has also been a big push over the last decade to utilize limited retroperitoneal dissection templates, and this is encouraged when done safely. Nonetheless, some pitfalls should be kept in mind. The ultimate goal of an RPLND is to avoid an in-field relapse. Therefore, avoid inappropriate omissions: divide lumbars, widely resect the ipsilateral gonadal vein, etc. Remember the importance of good retro-aortic/caval dissection – don’t allow quality to diminish due to template limitation.
It is generally considered safe to perform a limited-template dissection in patients with CSI, CSIIA, and select IIB patients, and those with unifocal disease limited to the primary landing zone. In the PC setting, the following can be considered for limited template: Any primary pre-chemo/post-chemo tumor that is <5cm, unifocal, within the primary landing zone, has STM normalization, and is Good/Intermediate IGCCCG risk disease. One should carefully monitor size, however, as rapidly growing masses warrant more expanded templates.
Dr. Masterson concludes that certain variations in treatment are appropriate but should be approached with caution. Always consider disease entities that may be chemo-resistant, as those should receive upfront aggressive surgical management. Understand the appropriate use of limited-template RPLND in the primary and PC settings. Limited templates do not mean limited quality; hence surgeons should insure complete dissection to avoid in-field recurrence.
The long-term side effects of chemotherapy are significant, and recent studies have brought these even more to light. The pendulum may therefore be swinging back toward surgery for the management of testis cancer, and it is important to maintain quality in the management of this disease.
Presented By: Timothy A. Masterson, MD; Indiana University School of Medicine
Written By: Shreyas Joshi, MD, Fox Chase Cancer Center
17th Annual Meeting of the Society of Urologic Oncology - November 30 -December 2, 2016 – San Antonio, Texas USA