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640 TESTIS SPEARING SURGERY (TSS) IN THE TREATMENT OF BILATERAL TESTICULAR GERM CELL TUMORS (BTGCT)
Vol. 183, No. 4, Supplement, Monday, May 31, 2010
germ cell tumours (TGCT). Although performed routinely and in a standardized approach in experienced centres, it is currently unclear if these results can be transferred into the general urological community. It was the purpose of our study to correlate the outcome of PCRPLND in terms of treatment associated complications among various centres and surgeons of the German Testicular Cancer Study Group (GTCSG). METHODS: 307 patients with advanced nonseminomatous germ cell tumors with normalized or plateauing tumor markers following 3-4 cycles PEB chemotherapy underwent PCRPLND. Depending on size and location of the retroperitoneal masses, a radical bilateral PCRPLND and a modified template resection were performed in 146 and 181 patients, respectively. Intra- and postoperative as well as early and late complications were evaluated according to a 5-scale semiquantitative scoring system. Type and frequency of complications were correlated with the number of surgeries per hospital and surgeon, size and location of the mass. RESULTS: Mean OR-time was 215 (90-615) minutes; mean blood loss was 580 (150 -3400) ml, 58 (18.9%) patients required 2-6 transfusions of red blood cell packages. 61 (19.8%) patients underwent additional resection of adjacent organs such as nephrectomy (n⫽21, 6.8%), partial of complete resection of the inferior vena cava (n⫽27, 8.8%), partial liver resection (n⫽14, 4.5%) and bowel surgery (n⫽6, 1.9%). There was a significant correlation between the frequency of complications and size of lesion, number of previous chemotherapies, volume of the hospital and volume of the surgeon (p ⬍ 0.002). The frequency of adjunctive surgery increased significantly if 2 or more cytotoxic regimes had been applied. CONCLUSIONS: PC-RPLND is a standard but complex surgical procedure in the management of patients with advanced testis cancer. The data of the GTCSG demonstrate that PC-RPLND becomes even more complex with increasing size of the residual mass and number of previous chemotherapeutic regimes. Since the frequency of complications also depends on the surgeon’s volume, PC-RPLND should be concentrated at centres only. Source of Funding: None
639 TESTIS-SPARING SURGERY FOR PRESUMED TESTICULAR MALIGNANCY IN PATIENTS WITH PRIOR GERM CELL TUMORS OR A SOLITARY TESTICLE- A LARGE NORTH AMERICAN EXPERIENCE Nathan Lawrentschuk, Alvaro Zuniga, Michael Jewett*, Toronto, Canada INTRODUCTION AND OBJECTIVES: Testis-sparing surgery (TSS) for imperative indications such as a metachranous germ cell tumor or in a solitary testicle is becoming a more accepted option to minimize functional, physical and psychological morbidity as data accumulates that oncologic outcome is rarely compromised. As most data originates from Europe, our objective was to review our institutional experience in North America. METHODS: We identified men in our institutional database having testis-sparing surgery for presumed testicular malignancy that had prior germ cell tumors (GCT) or a solitary testicle between 1994 and 2009. Demographic, clinical, pathological and outcome data were identified. Patients who were found to have malignant neoplasms and therefore risk of metastases were followed with physical examination, serum markers and imaging. RESULTS: 27 men fulfilled the criteria (median age 34 years) with the median ultrasound lesion size was 10mm (range 5-28mm) with location split evenly between upper mid an d lower poles of the testes. 24 men had metachronous lesions with 3 lesions in solitary testes. 17 men (63%) had malignant lesions (9 seminoma, 3 teratoma, 1 embryonal, 3 leydig cell and 1 CIS) whilst 10 (37%) had benign pathology. The median follow-up was 4 years (0.5-10.4 years) in men with malignant lesions. CIS was seen in 38% patients with GCT. Testosterone substitution was observed in 31% patients treated with POs. Follow-up found local recurrence in 2 patients despite clear margins with both
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undergoing radical orchiectomy and one having chemotherapy. One further patient had distant recurrence in an embryonal carcinoma with a retroperitoneal node (2 cm) and negative serum markers at 4 months of follow-up necessitating RPLND with embryonal cancer in a solitary node. One patient with seminoma and the CIS only patient both elected to have radiation and both have normal testosterone levels. The other 5 patients with CIS were underwent surveillance. CONCLUSIONS: TSS is an option in men with imperative indications to reduce morbidity but is potentially associated with recurrence, the need for adjuvant treatment and androgen substitution. Clearly a definite benefit of TSS is that a significant proportion of our patients (48%) with suspicious testicular lesions did not have GCT and were managed definitely with an organ-sparing approach. Source of Funding: None
640 TESTIS SPEARING SURGERY (TSS) IN THE TREATMENT OF BILATERAL TESTICULAR GERM CELL TUMORS (BTGCT) Nebojsa Bojanic*, Sava Micic, Aleksandar Vuksanovic, Aleksandar Janjic, Ivan Vukovic, Cane Tulic, Otas Durutovic, Djordje Nale, Belgrade, Yugoslavia INTRODUCTION AND OBJECTIVES: Retrospective analysis of indications, results and follow-up of patients subjected to TSS in treatment of BTGCT. METHODS: The total of 26 patients with BTGCT (19 metachronous and 7 synchronous BTGCTs) were treated in the period 19962009. After standard preparation with TSH level determination and echo verification of the testicular tumor change, TSS was performed during warm and cold ischemia. None of the patients underwent local radiation therapy subsequent to TSS. RESULTS: Thirteen TSS were performed in 12 patients; 8/19 patients with metachronous and 4/7 patients with synchronous BTGCT. One of the patients developed testicular atrophy with progression of the disease (retroperitoneal lymphadenopathy) 4 months subsequent to TSS and he underwent radical orchiectomy and adjuvant CHT according to PEB protocol; one patient had local relapse of the disease 65 months after TSS and he underwent radical orchiectomy and follow-up; one patient underwent repeated TSS due to tumor relapse 13 months after the initial TSS. All treated patients had no evidence of the disease over the 18-month follow-up period (range 4-79). TIN was evidenced in 9 out of 12 patients subjected to TSS, while adjuvant therapy was applied in 7 out of 12 patients after TSS. None of the patients underwent adjuvant irradiation therapy of the testicle after TSS and CHT. CONCLUSIONS: TSS is a highly effective surgical method in treatment of BTGCT, unilateral testicular tumors and it may and should be applied whenever possible. TSS is highly effective from the oncological point of view and it enables for life-long hormone substitution to be avoided. Avoiding of local irradiation therapy of the testicles enables preservation of fertility and reduces the risk of local relapse and progression of the disease, however follow-up examinations should be carried out in shorter time intervals. Source of Funding: None
641 INCREASED INCIDENCE OF LEYDIG CELL TUMORS OF THE TESTIS IN THE ERA OF IMPROVED ULTRASOUND Nicolai Leonhartsberger*, Florian Zangerl, Brigitte Stoehr, Andreas Fritzer, Hannes Steiner, Innsbruck, Austria INTRODUCTION AND OBJECTIVES: Leydig cell tumors (LCTs) are uncommon, accounting for 1-3% of all testicular neoplasms, its differentiation between malignant and benign forms is often difficult. Our objective was to report the case-series of 29 Leydig cell tumors in 25 patients diagnosed at our center. METHODS: From 1999 to 2008 out of 197 testicular tumors a total of 25 patients with Leydig cell tumors were treated in our depart-
germ cell tumours (TGCT). Although performed routinely and in a standardized approach in experienced centres, it is currently unclear if these results can be transferred into the general urological community. It was the purpose of our study to correlate the outcome of PCRPLND in terms of treatment associated complications among various centres and surgeons of the German Testicular Cancer Study Group (GTCSG). METHODS: 307 patients with advanced nonseminomatous germ cell tumors with normalized or plateauing tumor markers following 3-4 cycles PEB chemotherapy underwent PCRPLND. Depending on size and location of the retroperitoneal masses, a radical bilateral PCRPLND and a modified template resection were performed in 146 and 181 patients, respectively. Intra- and postoperative as well as early and late complications were evaluated according to a 5-scale semiquantitative scoring system. Type and frequency of complications were correlated with the number of surgeries per hospital and surgeon, size and location of the mass. RESULTS: Mean OR-time was 215 (90-615) minutes; mean blood loss was 580 (150 -3400) ml, 58 (18.9%) patients required 2-6 transfusions of red blood cell packages. 61 (19.8%) patients underwent additional resection of adjacent organs such as nephrectomy (n⫽21, 6.8%), partial of complete resection of the inferior vena cava (n⫽27, 8.8%), partial liver resection (n⫽14, 4.5%) and bowel surgery (n⫽6, 1.9%). There was a significant correlation between the frequency of complications and size of lesion, number of previous chemotherapies, volume of the hospital and volume of the surgeon (p ⬍ 0.002). The frequency of adjunctive surgery increased significantly if 2 or more cytotoxic regimes had been applied. CONCLUSIONS: PC-RPLND is a standard but complex surgical procedure in the management of patients with advanced testis cancer. The data of the GTCSG demonstrate that PC-RPLND becomes even more complex with increasing size of the residual mass and number of previous chemotherapeutic regimes. Since the frequency of complications also depends on the surgeon’s volume, PC-RPLND should be concentrated at centres only. Source of Funding: None
639 TESTIS-SPARING SURGERY FOR PRESUMED TESTICULAR MALIGNANCY IN PATIENTS WITH PRIOR GERM CELL TUMORS OR A SOLITARY TESTICLE- A LARGE NORTH AMERICAN EXPERIENCE Nathan Lawrentschuk, Alvaro Zuniga, Michael Jewett*, Toronto, Canada INTRODUCTION AND OBJECTIVES: Testis-sparing surgery (TSS) for imperative indications such as a metachranous germ cell tumor or in a solitary testicle is becoming a more accepted option to minimize functional, physical and psychological morbidity as data accumulates that oncologic outcome is rarely compromised. As most data originates from Europe, our objective was to review our institutional experience in North America. METHODS: We identified men in our institutional database having testis-sparing surgery for presumed testicular malignancy that had prior germ cell tumors (GCT) or a solitary testicle between 1994 and 2009. Demographic, clinical, pathological and outcome data were identified. Patients who were found to have malignant neoplasms and therefore risk of metastases were followed with physical examination, serum markers and imaging. RESULTS: 27 men fulfilled the criteria (median age 34 years) with the median ultrasound lesion size was 10mm (range 5-28mm) with location split evenly between upper mid an d lower poles of the testes. 24 men had metachronous lesions with 3 lesions in solitary testes. 17 men (63%) had malignant lesions (9 seminoma, 3 teratoma, 1 embryonal, 3 leydig cell and 1 CIS) whilst 10 (37%) had benign pathology. The median follow-up was 4 years (0.5-10.4 years) in men with malignant lesions. CIS was seen in 38% patients with GCT. Testosterone substitution was observed in 31% patients treated with POs. Follow-up found local recurrence in 2 patients despite clear margins with both
THE JOURNAL OF UROLOGY姞
e251
undergoing radical orchiectomy and one having chemotherapy. One further patient had distant recurrence in an embryonal carcinoma with a retroperitoneal node (2 cm) and negative serum markers at 4 months of follow-up necessitating RPLND with embryonal cancer in a solitary node. One patient with seminoma and the CIS only patient both elected to have radiation and both have normal testosterone levels. The other 5 patients with CIS were underwent surveillance. CONCLUSIONS: TSS is an option in men with imperative indications to reduce morbidity but is potentially associated with recurrence, the need for adjuvant treatment and androgen substitution. Clearly a definite benefit of TSS is that a significant proportion of our patients (48%) with suspicious testicular lesions did not have GCT and were managed definitely with an organ-sparing approach. Source of Funding: None
640 TESTIS SPEARING SURGERY (TSS) IN THE TREATMENT OF BILATERAL TESTICULAR GERM CELL TUMORS (BTGCT) Nebojsa Bojanic*, Sava Micic, Aleksandar Vuksanovic, Aleksandar Janjic, Ivan Vukovic, Cane Tulic, Otas Durutovic, Djordje Nale, Belgrade, Yugoslavia INTRODUCTION AND OBJECTIVES: Retrospective analysis of indications, results and follow-up of patients subjected to TSS in treatment of BTGCT. METHODS: The total of 26 patients with BTGCT (19 metachronous and 7 synchronous BTGCTs) were treated in the period 19962009. After standard preparation with TSH level determination and echo verification of the testicular tumor change, TSS was performed during warm and cold ischemia. None of the patients underwent local radiation therapy subsequent to TSS. RESULTS: Thirteen TSS were performed in 12 patients; 8/19 patients with metachronous and 4/7 patients with synchronous BTGCT. One of the patients developed testicular atrophy with progression of the disease (retroperitoneal lymphadenopathy) 4 months subsequent to TSS and he underwent radical orchiectomy and adjuvant CHT according to PEB protocol; one patient had local relapse of the disease 65 months after TSS and he underwent radical orchiectomy and follow-up; one patient underwent repeated TSS due to tumor relapse 13 months after the initial TSS. All treated patients had no evidence of the disease over the 18-month follow-up period (range 4-79). TIN was evidenced in 9 out of 12 patients subjected to TSS, while adjuvant therapy was applied in 7 out of 12 patients after TSS. None of the patients underwent adjuvant irradiation therapy of the testicle after TSS and CHT. CONCLUSIONS: TSS is a highly effective surgical method in treatment of BTGCT, unilateral testicular tumors and it may and should be applied whenever possible. TSS is highly effective from the oncological point of view and it enables for life-long hormone substitution to be avoided. Avoiding of local irradiation therapy of the testicles enables preservation of fertility and reduces the risk of local relapse and progression of the disease, however follow-up examinations should be carried out in shorter time intervals. Source of Funding: None
641 INCREASED INCIDENCE OF LEYDIG CELL TUMORS OF THE TESTIS IN THE ERA OF IMPROVED ULTRASOUND Nicolai Leonhartsberger*, Florian Zangerl, Brigitte Stoehr, Andreas Fritzer, Hannes Steiner, Innsbruck, Austria INTRODUCTION AND OBJECTIVES: Leydig cell tumors (LCTs) are uncommon, accounting for 1-3% of all testicular neoplasms, its differentiation between malignant and benign forms is often difficult. Our objective was to report the case-series of 29 Leydig cell tumors in 25 patients diagnosed at our center. METHODS: From 1999 to 2008 out of 197 testicular tumors a total of 25 patients with Leydig cell tumors were treated in our depart-