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971 A COMPREHENSIVE REVIEW OF THE CLINICAL PRESENTATION, PATHOLOGIC FINDINGS, AND OUTCOMES IN REGRESSED TESTICULAR GERM CELL TUMORS
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THE JOURNAL OF UROLOGY姞
extragonadal primaries, and a history of prior groin surgeries. Surgery is curative in most patients and pelvic pathology was teratoma in over half. Source of Funding: None
971 A COMPREHENSIVE REVIEW OF THE CLINICAL PRESENTATION, PATHOLOGIC FINDINGS, AND OUTCOMES IN REGRESSED TESTICULAR GERM CELL TUMORS Geoffrey Gotto*, Christopher Przybycin, Amit Gupta, Andrew Feifer, Melanie Bernstein, Daniel Sjoberg, Victor Reuter, Hikmat Al-Ahmadie, Joel Sheinfeld, New York, NY INTRODUCTION AND OBJECTIVES: Regressed testicular tumors (RTTs) account for a significant proportion of what were once considered to be extragonadal germ cell tumors (GCTs). The clinical presentation and outcomes of patients with “burned-out” primary tumors are poorly understood as are their pathologic characteristics. We describe our experience with this unique subset of testicular GCTs. METHODS: We reviewed our prospectively-maintained testicular cancer database for radical orchiectomies performed from 1977– 2009. Specimens without viable tumor were reviewed by dedicated genitourinary pathologists blinded as to whether or not the patient had received prior chemotherapy. Kaplan-Meier curves were generated to describe recurrence-free and overall survival. RESULTS: We identified 80 patients with testicular or extragonadal GCTs but with no viable tumor in the radical orchiectomy specimen. A total of 28 patients had not received prior chemotherapy. Pathologic findings at the time of retroperitoneal lymph node dissection or biopsy of a metastatic site included non-seminomatous GCT (NSGCT) in 11 (39%), seminoma in 6 (21%), unspecified GCT in 3 (11%), and sarcoma in 1 (4%). Benign disease was identified in the remaining 7 patients (25%). The 11 patients with NSGCT included 4 with embryonal carcinoma (14%), 2 with choriocarcinoma (7%), 2 with teratoma (7%), 2 with mixed NSGCT (7%), and 1 with yolk sac (4%). At presentation, the clinical stage was I in 3 patients (14%), II in 10 patients (45%), and III in 9 patients (41%). Based on the IGCCCG classification system, 10 were good risk (56%), 3 were intermediate risk (17%), and 5 were poor risk (28%). Intratubular germ cell neoplasia was identified in 8 patients (29%). Additional findings included hyalinization in 24 (86%), nodular scar in 22 (79%), Sertoli cell-only pattern in 21 (75%), interstitial fibrosis in 22 (79%), inflammation in 13 (46%), tubular calcification in 11 (39%), coarse calcification in 10 (36%), psammomatous calcification in 7 (25%), and necrosis in 1 (4%). Fiveyear recurrence-free, cancer-specific, and overall survival rates were 83% (95% CI: 61%, 93%), 96% (95% CI: 75%, 99%), and 96% (95% CI: 75%, 99%), respectively. CONCLUSIONS: To our knowledge, this is the largest published review of patients with RTT. We describe in detail the pathologic findings in this unique subset of testicular GCTs as well as their clinical presentation and outcomes. Source of Funding: None
972 INCREASED POSITIVE LYMPH NODE DENSITY AT TIME OF RETROPERITONEAL LYMPH NODE DISSECTION DECREASES OVERALL SURVIVAL AND CANCER-SPECIFIC SURVIVAL Dan Lewinshtein*, Sandra Koo, Christopher Porter, Seattle, WA INTRODUCTION AND OBJECTIVES: The benefit of a thorough retroperitoneal lymph node dissection (RPLND) for testicular cancer is well established and essentially eliminates retroperitoneal disease recurrence. Efforts to stratify patients with node-positive bladder cancer into different prognostic groups based on lymph node density is also well established. We hypothesized that testicular cancer patients exhibit the same phenomenon. We explored the association
Vol. 185, No. 4S, Supplement, Monday, May 16, 2011
between extent of RPLND and lymph node density with overall survival and cancer-specific survival in nonseminomatous germ cell tumors (NSGCT). METHODS: We retrospectively searched the Surveillance Epidemiology and End Results database for all patients who had undergone RPLND for NSGCT between 1973 and 2006. We performed logistic regression to assess the ability of number of positive nodes, total number of nodes removed at RPLND, and lymph node density to predict overall- and cancer-specific survival. We adjusted for stage and age. In addition, we used Kaplan-Meier life table analysis to evaluate actuarial survival probability as a function of these variables at the time of RPLND. RESULTS: The cohort consisted of 562 patients and 92.5% were stage II. Median age and median number of nodes removed were 28 years (17–71) and 17 (⫹/⫺ 13.5 SD), respectively. The median number of positive nodes was 2 (SD 5.0). The median lymph node density was 17.9% (SD 29%). On univariate analysis, positive lymph node density was a significant predictor of overall mortality (HR 9.82; p⬍0.001). On multivariate analysis, only age (HR 1.062; p⫽0.008) and stage (reference, p⫽0.003) were significant predictors of overall mortality; however, there was a trend for positive lymph node density to be a predictor of overall mortality (HR 3.125; p⫽0.090). On Kaplan-Meier actuarial analysis, mean time to cancer-specific mortality was significantly shorter for those patients with 9 or fewer nodes removed at time of RPLND (17.8 years vs. 18.8 years; p⬍0.001). Moreover, patients with a positive lymph node density greater than 30% had a significantly shorter mean time to testicular cancer mortality (18.1 years vs. 18.9 years; p⫽0.001). CONCLUSIONS: In patients with NSGCT and positive retroperitoneal lymph nodes, an increased number of lymph nodes removed was associated with improved overall and cancer-specific survival. Moreover, improved overall survival and testicular cancer-specific survival was found in patients with a positive lymph node density less than 30%. Taken together, these data support performing a complete RPLND. Source of Funding: None
973 LAPAROSCOPIC RETROPERITONEAL LYMPH-NODE DISSECTION (L-RPLND): EVOLUTION TOWARDS A SINGLE-STATEGY MANAGEMENT IN CLINICAL STAGE I (CS I) NON-SEMINOMATOUS GERM-CELL TUMORS OF THE TESTIS (NSGCTT) Nicola Nicolai*, Davide Biasoni, Mario Catanzaro, Silvia Stagni, Tullio Torelli, Andrea Necchi, Luigi Piva, Angelo Milani, Giorgio Pizzocaro, Roberto Salvioni, Milano, Italy INTRODUCTION AND OBJECTIVES: L-RPLND remains a controversial procedure for CS I NSGCTT patients (pts). Long-term efficacy has not been unraveled yet, as most of the pts with nodal metastases at RPLND undergo adjuvant chemotherapy (CT). METHODS: We analyzed the data of 155 L-RPLND between July 1999 and October 2010. Two/thirds of patients had neither vascular invasion nor embryonal carcinoma component ⬎ 90% in primary tumor. Median number of removed nodes was 14 (IQR 10 –19). Nodal metastases (pN⫹) were found in 18 (12%) pts, and 7 of them underwent adjuvant CT. Since October 2008, only patients with nodal metastasis having tumor density greater than 20% were candidate to adjuvant CT (2/8). All patients underwent a follow-up program. RESULTS: After a median follow-up of 36 months, 9 patients (6%) relapsed, all of them occurring within 6 months. None the 7 patients who underwent adjuvant CT relapsed. Five (4%) relapses occurred among 137 patients with no nodal metastases while 4 (36%) occurred among 11 patients with nodal metastases not receiving adjuvant CT. Among the 8 pN⫹ pts recorded since Oct 2008, 2 underwent adjuvant chemotherapy and 6 were observed, 1/6 (17%) relapsing at 3 months.
THE JOURNAL OF UROLOGY姞
extragonadal primaries, and a history of prior groin surgeries. Surgery is curative in most patients and pelvic pathology was teratoma in over half. Source of Funding: None
971 A COMPREHENSIVE REVIEW OF THE CLINICAL PRESENTATION, PATHOLOGIC FINDINGS, AND OUTCOMES IN REGRESSED TESTICULAR GERM CELL TUMORS Geoffrey Gotto*, Christopher Przybycin, Amit Gupta, Andrew Feifer, Melanie Bernstein, Daniel Sjoberg, Victor Reuter, Hikmat Al-Ahmadie, Joel Sheinfeld, New York, NY INTRODUCTION AND OBJECTIVES: Regressed testicular tumors (RTTs) account for a significant proportion of what were once considered to be extragonadal germ cell tumors (GCTs). The clinical presentation and outcomes of patients with “burned-out” primary tumors are poorly understood as are their pathologic characteristics. We describe our experience with this unique subset of testicular GCTs. METHODS: We reviewed our prospectively-maintained testicular cancer database for radical orchiectomies performed from 1977– 2009. Specimens without viable tumor were reviewed by dedicated genitourinary pathologists blinded as to whether or not the patient had received prior chemotherapy. Kaplan-Meier curves were generated to describe recurrence-free and overall survival. RESULTS: We identified 80 patients with testicular or extragonadal GCTs but with no viable tumor in the radical orchiectomy specimen. A total of 28 patients had not received prior chemotherapy. Pathologic findings at the time of retroperitoneal lymph node dissection or biopsy of a metastatic site included non-seminomatous GCT (NSGCT) in 11 (39%), seminoma in 6 (21%), unspecified GCT in 3 (11%), and sarcoma in 1 (4%). Benign disease was identified in the remaining 7 patients (25%). The 11 patients with NSGCT included 4 with embryonal carcinoma (14%), 2 with choriocarcinoma (7%), 2 with teratoma (7%), 2 with mixed NSGCT (7%), and 1 with yolk sac (4%). At presentation, the clinical stage was I in 3 patients (14%), II in 10 patients (45%), and III in 9 patients (41%). Based on the IGCCCG classification system, 10 were good risk (56%), 3 were intermediate risk (17%), and 5 were poor risk (28%). Intratubular germ cell neoplasia was identified in 8 patients (29%). Additional findings included hyalinization in 24 (86%), nodular scar in 22 (79%), Sertoli cell-only pattern in 21 (75%), interstitial fibrosis in 22 (79%), inflammation in 13 (46%), tubular calcification in 11 (39%), coarse calcification in 10 (36%), psammomatous calcification in 7 (25%), and necrosis in 1 (4%). Fiveyear recurrence-free, cancer-specific, and overall survival rates were 83% (95% CI: 61%, 93%), 96% (95% CI: 75%, 99%), and 96% (95% CI: 75%, 99%), respectively. CONCLUSIONS: To our knowledge, this is the largest published review of patients with RTT. We describe in detail the pathologic findings in this unique subset of testicular GCTs as well as their clinical presentation and outcomes. Source of Funding: None
972 INCREASED POSITIVE LYMPH NODE DENSITY AT TIME OF RETROPERITONEAL LYMPH NODE DISSECTION DECREASES OVERALL SURVIVAL AND CANCER-SPECIFIC SURVIVAL Dan Lewinshtein*, Sandra Koo, Christopher Porter, Seattle, WA INTRODUCTION AND OBJECTIVES: The benefit of a thorough retroperitoneal lymph node dissection (RPLND) for testicular cancer is well established and essentially eliminates retroperitoneal disease recurrence. Efforts to stratify patients with node-positive bladder cancer into different prognostic groups based on lymph node density is also well established. We hypothesized that testicular cancer patients exhibit the same phenomenon. We explored the association
Vol. 185, No. 4S, Supplement, Monday, May 16, 2011
between extent of RPLND and lymph node density with overall survival and cancer-specific survival in nonseminomatous germ cell tumors (NSGCT). METHODS: We retrospectively searched the Surveillance Epidemiology and End Results database for all patients who had undergone RPLND for NSGCT between 1973 and 2006. We performed logistic regression to assess the ability of number of positive nodes, total number of nodes removed at RPLND, and lymph node density to predict overall- and cancer-specific survival. We adjusted for stage and age. In addition, we used Kaplan-Meier life table analysis to evaluate actuarial survival probability as a function of these variables at the time of RPLND. RESULTS: The cohort consisted of 562 patients and 92.5% were stage II. Median age and median number of nodes removed were 28 years (17–71) and 17 (⫹/⫺ 13.5 SD), respectively. The median number of positive nodes was 2 (SD 5.0). The median lymph node density was 17.9% (SD 29%). On univariate analysis, positive lymph node density was a significant predictor of overall mortality (HR 9.82; p⬍0.001). On multivariate analysis, only age (HR 1.062; p⫽0.008) and stage (reference, p⫽0.003) were significant predictors of overall mortality; however, there was a trend for positive lymph node density to be a predictor of overall mortality (HR 3.125; p⫽0.090). On Kaplan-Meier actuarial analysis, mean time to cancer-specific mortality was significantly shorter for those patients with 9 or fewer nodes removed at time of RPLND (17.8 years vs. 18.8 years; p⬍0.001). Moreover, patients with a positive lymph node density greater than 30% had a significantly shorter mean time to testicular cancer mortality (18.1 years vs. 18.9 years; p⫽0.001). CONCLUSIONS: In patients with NSGCT and positive retroperitoneal lymph nodes, an increased number of lymph nodes removed was associated with improved overall and cancer-specific survival. Moreover, improved overall survival and testicular cancer-specific survival was found in patients with a positive lymph node density less than 30%. Taken together, these data support performing a complete RPLND. Source of Funding: None
973 LAPAROSCOPIC RETROPERITONEAL LYMPH-NODE DISSECTION (L-RPLND): EVOLUTION TOWARDS A SINGLE-STATEGY MANAGEMENT IN CLINICAL STAGE I (CS I) NON-SEMINOMATOUS GERM-CELL TUMORS OF THE TESTIS (NSGCTT) Nicola Nicolai*, Davide Biasoni, Mario Catanzaro, Silvia Stagni, Tullio Torelli, Andrea Necchi, Luigi Piva, Angelo Milani, Giorgio Pizzocaro, Roberto Salvioni, Milano, Italy INTRODUCTION AND OBJECTIVES: L-RPLND remains a controversial procedure for CS I NSGCTT patients (pts). Long-term efficacy has not been unraveled yet, as most of the pts with nodal metastases at RPLND undergo adjuvant chemotherapy (CT). METHODS: We analyzed the data of 155 L-RPLND between July 1999 and October 2010. Two/thirds of patients had neither vascular invasion nor embryonal carcinoma component ⬎ 90% in primary tumor. Median number of removed nodes was 14 (IQR 10 –19). Nodal metastases (pN⫹) were found in 18 (12%) pts, and 7 of them underwent adjuvant CT. Since October 2008, only patients with nodal metastasis having tumor density greater than 20% were candidate to adjuvant CT (2/8). All patients underwent a follow-up program. RESULTS: After a median follow-up of 36 months, 9 patients (6%) relapsed, all of them occurring within 6 months. None the 7 patients who underwent adjuvant CT relapsed. Five (4%) relapses occurred among 137 patients with no nodal metastases while 4 (36%) occurred among 11 patients with nodal metastases not receiving adjuvant CT. Among the 8 pN⫹ pts recorded since Oct 2008, 2 underwent adjuvant chemotherapy and 6 were observed, 1/6 (17%) relapsing at 3 months.