Alvaro Zuniga

Partial Orchiectomy for Presumed Malignancy in Patients With a Solitary Testis Due to a Prior Germ Cell Tumor: A Large North American Experience

PURPOSE Partial orchiectomy is becoming more accepted for indications such as a metachronous germ cell tumor due to reported oncological control, and minimal functional, physical and psychological morbidity. Most data originate from Europe. Thus, we reviewed our North American experience with such men who underwent partial orchiectomy for a presumed contralateral testicular malignancy. MATERIALS AND METHODS We identified demographic, clinical, pathological and outcome data on men in our institutional database who underwent partial orchiectomy for presumed testicular malignancy from 1994 to 2009 and had a prior germ cell tumor. Patients were followed with examination, markers and imaging. RESULTS We identified 27 men, of whom 17 (63%) had malignancy, including seminoma in 9, teratoma in 3, embryonal lesion in 1, Leydig cell tumor in 3 and carcinoma in situ in 1, and 10 (37%) had benign lesions. Frozen section was accurate, no positive margins were reported and all tumors were stage 1. Carcinoma in situ was found in 9 patients (53%). No perioperative complications were recorded. Management after partial orchiectomy was observation in 12 of 17 cases. Two patients underwent completion orchiectomy for local recurrence of carcinoma in situ only, including chemotherapy in 1. A patient with seminoma elected radiation and 1 required retroperitoneal lymph node dissection for teratoma. The remaining 5 patients with carcinoma in situ were surveilled. Of the men 31% required testosterone substitution. All patients were disease free at a median 5.7-year followup with no local recurrences. CONCLUSIONS Partial orchiectomy is an option to decrease morbidity in men with a metachronous germ cell tumor. Clearly a definite benefit of partial orchiectomy is that a significant proportion of patients with suspicious testicular lesions did not have malignancy and were definitively treated with an organ sparing approach. However, partial orchiectomy is potentially associated with the need for adjuvant treatment and androgen substitution, which should be discussed with all patients.

Surveillance in stage I nonseminomatous germ cell tumours of the testis

Germ cell tumours (GCTs) are the most common malignancy in men aged 15–34 years; it is estimated that 8090 men will be diagnosed with and 380 men will die from GCTs in 2008 in the USA [1]. In the UK, there were 2109 new cases of GCT diagnosed in 2005 and 78 deaths from testicular cancer in 2006 [2,3]. There is a geographical variation in the incidence of GCT. Within the European Union there is about a five-fold variation in incidence between countries with the highest and lowest rates. For example, Denmark, Germany and Austria report age-standardized rates of ≈ 10 per 100 000, while Lithuania, Estonia, Spain and Latvia have agestandardized rates of ≈ 2 per 100 000 [4]. More than half of GCTs present with clinical stage (CS) I disease, defined as those with the tumour markers α -fetoprotein, hCG and lactate dehydrogenase that are or become normal after orchidectomy with no evidence of metastatic disease on imaging studies. A third of nonseminoma GCTs (NSGCT) and 70–80% of seminomas present as CS I [5,6]. With appropriate therapy, the cure rate of patients with CS I NSGCT should be close to 100% [7–10].

Organ-sparing approaches for testicular masses

Organ-sparing approaches are currently practiced in urology for many malignancies. Partial orchiectomy of germ cell tumors (GCT) provides potential benefits over radical surgery by reducing the need for androgen substitution, lessening psychological stress, and preserving fertility, with a durable cure rate. Furthermore, many testicular lesions detected clinically or by ultrasonography will be benign, in which case radical orchiectomy represents overtreatment. Partial orchiectomy for benign lesions allows preservation of endocrine and exocrine function, and reduced risk of local recurrence. However, selection criteria are not clear and one must always be suspicious that a GCT might exist. Carcinoma in situ that remains in the salvaged testicle is a challenge to treat. Radiation therapy is an option, although there is a high chance that patients will subsequently require hormonal replacement. Partial orchiectomy should be undertaken only in selected patients—men with bilateral testicular cancer or GCT in a solitary testis—if the size and location of the mass are amenable to surgery. Informed patient consent discussing radical orchiectomy as the gold standard is mandatory, and discussion of the risks associated with CIS and its treatment, as well as the need for androgen supplementation are paramount. Alternative strategies of organ preservation, such as radiotherapy, HIFU and chemotherapy, might be appropriate treatment options in the future. However, the safety and efficacy of these procedures needs to be demonstrated in comparison with partial orchiectomy in larger and prospective studies with longer follow-up.

Who Will Fail Local Therapy for Renal Cell Carcinoma

I n addition to providing reassurance, renal cell carcinoma (RCC) followup is designed to detect recurrence. It is expensive and only useful if relapse can be treated with benefit. We resect local recurrence and solitary metastasis in the belief that this practice improves outcome. The new targeted systemic therapies may have an adjuvant role or their efficacy may improve with recurrent disease detected early at a smaller volume. Therefore, it is appropriate that this issue of The Journal includes 2 reports that address the problem of identifying patients who will fail surgical treatment of their primary tumor. These studies represent a massive amount of data analysis. Yossepowitch et al (page 2158) report on a pooled analysis of partial nephrectomy for RCC, finding that the detection of positive surgical margins, usually a marker of incomplete excision in cancer surgery, failed to predict local recurrence or progression. This observation does not appear to help identify those who will have disease progression. In fact it might lead to the conclusion that the surgery was not necessary or that careful attention to complete tumor excision is unwarranted. Others have reported similar findings. Positive surgical margins in a radical prostatectomy or cystectomy specimen predict recurrence, so why not with RCC? There are several possibilities. Some margin negative cases might in fact have had a minute positive margin that was not detected. Conversely, the positive margins may have been artifactual, as surgeons know that the normal renal cortex strips away easily. In a retrospective review it may be difficult to determine if a recurrence is in the margin or if it is a new primary tumor because both scenarios can occur. However, all the possible explanations are compatible with the hypothesis that many small RCCs are relatively indolent or less significant than comorbidities. Local control and cause specific survival are remarkably high with surgery. Despite this finding, with the increasing incidence of early stage RCCs and their treatment, there has not been a decrease in overall mortality. Experience with initial active surveillance reveals little or no growth in most small renal masses (SRMs) presumed to be RCC, although there does appear to be a small but real risk of metastases for which salvage treatment is rarely curative. Although not specifically stated, most of the small tumors were probably low grade and the proportion of clear cell RCC as opposed to arguably less malignant nonclear cell types was lower than that with radical nephrectomy. Maybe local recurrence was present but indolent and not detected during the study period. Median followup was 3.4 years with only 10% of patients followed to 10 years. Given the natural history data this interval may be too short to determine the real rates of recurrence and progression. Parenthetically, this may also explain the reported high local control rate with ablative treatment, at least in the short term. Event rates may simply be too low to conclude that margins are

PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION FOR CLINICAL LOW STAGE NONSEMINOMATOUS GERM CELL TESTICULAR TUMORS

498 PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION FOR CLINICAL LOW STAGE NONSEMINOMATOUS GERM CELL TESTICULAR TUMORS David Kakiashvili*, Lynn Anson-Cartwright, Malcolm Moore, Jeremy F G Sturgeon, Alvaro Zuniga, Padraig R Warde, Peter Chung, Justin Liu, Clement Ma, Michael A S Jewett. Toronto, ON, Canada. INTRODUCTION AND OBJECTIVE: Non-risk adapted surveillance is the recommended standard of care for clinical stage I non-seminomatous germ cell testis tumors (NSGCTT) at the Princess Margaret Hospital Testis Tumor Clinic. Primary bilateral retroperitoneal lymph node dissection with sympathetic nerve sparing when feasible (NS-RPLND) is offered as an alternative at patient request and when surveillance is contraindicated. Small volume stage II patients with low marker levels are offered surgery as they usually do not need subsequent chemotherapy. We have evaluated our experience with primary RPLND. METHODS: The charts of the 120 consecutive patients from the Princess Margaret Hospital Testis Tumor Clinic with clinical low stage NSGCTT who underwent primary NS-RPLND between November 1984, when NS was introduced, and October 2007 were reviewed. Adjuvant chemotherapy was offered if resected disease was extensive or pathological characteristics were adverse. Perioperative tumor characteristics, histology, need for additional treatment and functional outcomes, including loss of antegrade ejaculation were assessed. Survival outcomes were generated using the Kaplan-Meier method. RESULTS: The median age at diagnosis was 28.6 years. The median time of follow-up was 4.9 years (0.02 20.89 ). 51 patients (42.5%) were clinical stage I and 69(57.5%) were stage II (61-IIA and 8 IIB). Of those with initial stage I, 20 underwent immediate RPLND and 31 at progression to clinical stage II ( 25 IIA and 6-II B).Outcomes were similar for these groups. Laparotomy revealed grossly enlarged lymph