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C1 THE CHANGING PRESENTATION OF GERM CELL TESTICULAR TUMORS (GCTTS) BETWEEN 1976 AND 2005
Poster session 1 TESTIS CANCER, TRANSPLANTATION, ANDROLOGY, ED, FERTILITY Friday, 12 October, 11.10-13.00, Poster Room 1
C1
The changing presentation of germ cell testicular tumors (GCTTs) between 1976 and 2005
Argirovic D.1, Argirovic A.2 1 Clinic of Urology, CCS, Outpatient Clinic Argirovic, Dept. of Urology, Belgrade, Serbia, 2CHC Zemun, Dept. of Urology, Belgrade, Serbia Introduction & Objectives: To prospectively investigate the presentation of GCTTs in terms of clinical stage (CS) or histology, as the incidence of this disease (ds) is increasing. Material & Methods: Information was collected from a prospective database initiated in 1966. Patients (pts) diagnosed with GCTTs between 1976 and 2005 were categorized into 3 periods depending on date of diagnosis of the GCTTs and presentation characteristics assessed. For purpose of analysis, pts were assigned to 1 of 3 similar groups in term of duration (10 years [y]) (1976-1985, 1986-1995, 1996-2005). These 3 periods were compared statistically to indentify possible changes in the presentation of GCTTs. Results: Among 1935 pts, the number diagnosed in each period was 111 (6%), 695 (36%) and 1129 (58%), respectively. There was substantial arise in the percentage of pts with GCTTs during the period of 30 y, particularly in 3rd vs. 2nd and 1st decade (P<0.0001). The median (range) age of the whole cohort was 34 (14-80) y. The median age for developing metastatic seminoma (S) was 4 y more then in CS I ds (38 vs. 42 y. respectively), while the median age for the presentation of CS I and metastatic nonseminoma (NS) was identical (31 y). Overall, 46% of pts were diagnosed with S and 54% with NS. The proportion of S increased significantly in time (48% vs. 55%), and this was accompanied by a significant decrease in NS (60% vs. 45%)(P<0.001). The proportion of pts with CS I ds also increased significantly with time (45% vs. 77%), while the proportion of pts with metastatic ds decreased (55% vs. 29%) (P<0.001). In the most recent period 77% had CS I and 23% had metastatic ds. There was a significant rise in proportion of pts with CS I S (27% vs. 47%) and NS (18% vs. 30%), accompanied by a significant decrease in the proportion of pts presenting with metastatic NS (42% vs. 15%)(P<0.001). However, the proportion of patients with metastatic S remained largely unchanged (13% vs. 9%). Conclusions: The present study chows an increase in the proportion of pts with GCTTs in CS I. This is good news for pts with GCTTs, as it not only reduces the need for chemotherapy and/or cytoreductive surgery, but also is associated with better long-term survival. The other finding is that there has been an increase in the proportion of pts presenting with S rather than NS. The reasons for these remains unclear and require further investigation.
C2
Clinical outcome following post-chemotherapy retroperitoneal lymphadenectomy in patients with intermediate - and poor-risk nonseminomatous testicular tumors
Argirovic D.1, Argirovic A.2 1 Clinic of Urology, CCS, Outpatient Clinic Argirovic, Dept. of Urology, Belgrade, Serbia, 2CHC Zemun, Dept. of Urology, Belgrade, Serbia Introduction & Objectives: To evaluate the outcome of patients (pts) treated with chemotherapy (C) and retroperitoneal lymphadenectomy (RPLA) after an initial diagnosis of IGCCCG intermediate (IR) and poor-risk (PR) metastatic nonseminomatous testicular tumors (NSTT), as the integration of C and surgery in managing advanced NSTT continues to develop. Material & Methods: Between 1980 and 2005, 82 pts initially diagnosed with IGCCCG IR and PR had PC-RPLA with a median follow-up of 95 months. Currently, standard therapy in pts with IR or PR metastatic NSTT at author’s institution constitute of 4 cycles of standard BEP C regimen followed by RPLA and extra-RP (ERP) resection as indicated. In selected cases surgery is used in those with elevated STMs. Results: 65 pts (79%) and 17 (21%) pts were assigned as IR and PR, respectively. The median residual mass was 3.0 cm, ERP RM were present in 20 (14%) pts, 4 pts (20%) underwent redo-operation due to relapse (concordant histology vs primary RP in 70%), 15 (18%) pts had elevated STM before PC-RPLA, 27 (33%) required 2nd- line C and 76 (93%) of all RP RM were completely resected. RedoRPLA due to relapse was performed in 16 pts, 2 after previous attempts elsewhere, combined with nephrectomy in 4 pts and with discordant histology in 5 pts (31%). RP pathology revealed fibrosis in 26%, teratoma in 42% and viable GCT in 32%, with disease-specific survival (DSS) in 76%, 80% and 38%, respectively. The 5-year overall progression free probability (PFP) and DSS were 57% and 69%, respectively. Those requiring 2nd –line C had a higher incidence of viable GCT in the RP (24% vs 49%0 (p<0.0001). In 5 pts (5%) with RM of < 20 mm, 3 (60%) had teratoma and 2 (40%) fibrosis. Pts receiving only 1st line C in comparison to
those with 2nd- line CT had significant difference in NED status regarding the RP pathology: fibrosis (94% vs 20%)(p<0.0001), teratoma (88% vs 55%)(p<0.0001) and viable GCT (54% vs 23%)(p=0.005). The pts with PR NSTT were at slightly higher risk of progression (55% vs 47%) and worse outcome (69% vs 53%). There was no difference in outcome between the pts with ERP vs those with ds limited to the RP (32% vs 40%). Pts receiving only 1st- line C vs those requiring 2nd-line C had higher PFP (66% vs 41%)(p<0.01), and better DSS ( 76% vs 48%)(p<0.01). On multivariable analysis incomplete resection (p<0.001), size of PC RM (p=0.01) and the finding of teratoma (p=0.005) or viable GCT (p<0.001) at PC-RPLA independently predicted ds progression. Conclusions: Pts with advanced NSTT had long-term freedom from progression when C is combined with resection of RM. Our data suggest that the tumor response to C, coupled with complete resection of all RM, predicts long-term freedom from ds progression.
C3
Thoracic metastasectomy for nonseminomatous testicular tumors (NSTT): Long-term survival and prognostic factors
Argirovic D.1, Argirovic A.2, Stanic V.3 Clinic of Urology, CCS, Outpatient Clinic Argirovic, Dept. of Urology, Belgrade, Serbia, 2CHC Zemun, Dept. of Urology, Belgrade, Serbia, 3Military Medical Academy, Dept. of Thoracic Surgery, Belgrade, Serbia
1
Introduction & Objectives: To examine histologic finding and clinical outcomes of pts who underwent chest dissection for residual lung masses. Material & Methods: From 1983-2004, 56 pts underwent asynchronous PC thoracotomy > 2 months (m) after retroperitoneal lymphadenectomy (RPLA) for residual disease (ds). All patients received primary cisplatin-based C, whereas 15 (26.8%) pts some other form of salvage C.30 pts underwent RPLA and 7 pts some other form of extrapulmonal resection. 25 pts had unilateral and 31 bilateral lung metastasis. Number of resected lung metastasis ranged from 1-75, measuring from 1-8 cm in diameter. Results: During lung resection, 23 (41.1%) had necrosis (N), 18 (32.1%) had teratoma (T), 13 (23.2%) had vital carcinoma (VC), 1 (1.8%) had N/VC and 1 (1.8%) had N/T. There was 93.6% concordance in bilateral lung metastasis. For the 41 pts receiving 1st line C alone before surgery the incidence of VC was 24.4%, compared with 46.7% for the 15 pts receiving 2nd line C (P=0.0001). The prognosis was more favorable in pts with N (91.3%) and T (82.3%) vs. VC (43.7%) (p<0.0002). Histology at RPLA demonstrated the presence of N, T and VC in 20%, 43.3% and 36.7%, respectively. 13 (43.3%) pts had discordant histology in the lung and RP, 2 (6.7%) with VC in the lung and 11 (36.7%) with VC only in the RP (p<0.004). N was found at thoracotomy in 60% pts with N only in RPLN. When RP histology was N, and the primary NSTT was T negative, the probability of N at thoracotomy increased to 80%. 4 of 9 (44.4%) pts with VC at RPLA died of ds, compared with 4 of 15 (26.7%) with T and none with N (p<0.05). The presence of associate RPLA (80,8% vs. 70% )(P=0.201) did not influence overall survival (OS). Recurrences occurred in 20 (35.7%) pts within median free interval of 21.7 m, with CR following applied therapy in 6 (30%) pts. Repeat RPLA was done in 5 (16.7%) pts (2T, 3VC)(1 discordant histology, VC) and redo thoracic surgery in 5 (8.9%) pts (3T,2VC)(1 discordant histology,T). Alive and free of ds are 42 (75%) pts at mean follow-up (MFU) of 180.83±56.98 m. 14 (25%) pts died of ds within MFU of 47.79±49.34m. The 5- and 10-year overall survival rates were 82.2% and 80.4%, respectively. The 5 y OS rate in pts with N/T vs. VC were 92.5% vs. 56.3%, and at 10 y rate were 87.5% vs. 50% (P<0.0019). Multivariate analysis identified salvage C (P<0.004) and VC either in RP (P<0.015) or extra RP site (P<0.02) as predictive for overall survival. Conclusions: The pts with finding of N in one lung field can be spared of contralateral dissection in cases of bilateral metastatic ds. In pts with finding of N at RPLA and without T compound in the primary NSTT, resection of residual lung metastasis may be unnecessary. The proper integration of C and surgery provide an excellent outcome in pts with disseminated NSTT.
Eur Urol Suppl 2012;11(4):83
C1
The changing presentation of germ cell testicular tumors (GCTTs) between 1976 and 2005
Argirovic D.1, Argirovic A.2 1 Clinic of Urology, CCS, Outpatient Clinic Argirovic, Dept. of Urology, Belgrade, Serbia, 2CHC Zemun, Dept. of Urology, Belgrade, Serbia Introduction & Objectives: To prospectively investigate the presentation of GCTTs in terms of clinical stage (CS) or histology, as the incidence of this disease (ds) is increasing. Material & Methods: Information was collected from a prospective database initiated in 1966. Patients (pts) diagnosed with GCTTs between 1976 and 2005 were categorized into 3 periods depending on date of diagnosis of the GCTTs and presentation characteristics assessed. For purpose of analysis, pts were assigned to 1 of 3 similar groups in term of duration (10 years [y]) (1976-1985, 1986-1995, 1996-2005). These 3 periods were compared statistically to indentify possible changes in the presentation of GCTTs. Results: Among 1935 pts, the number diagnosed in each period was 111 (6%), 695 (36%) and 1129 (58%), respectively. There was substantial arise in the percentage of pts with GCTTs during the period of 30 y, particularly in 3rd vs. 2nd and 1st decade (P<0.0001). The median (range) age of the whole cohort was 34 (14-80) y. The median age for developing metastatic seminoma (S) was 4 y more then in CS I ds (38 vs. 42 y. respectively), while the median age for the presentation of CS I and metastatic nonseminoma (NS) was identical (31 y). Overall, 46% of pts were diagnosed with S and 54% with NS. The proportion of S increased significantly in time (48% vs. 55%), and this was accompanied by a significant decrease in NS (60% vs. 45%)(P<0.001). The proportion of pts with CS I ds also increased significantly with time (45% vs. 77%), while the proportion of pts with metastatic ds decreased (55% vs. 29%) (P<0.001). In the most recent period 77% had CS I and 23% had metastatic ds. There was a significant rise in proportion of pts with CS I S (27% vs. 47%) and NS (18% vs. 30%), accompanied by a significant decrease in the proportion of pts presenting with metastatic NS (42% vs. 15%)(P<0.001). However, the proportion of patients with metastatic S remained largely unchanged (13% vs. 9%). Conclusions: The present study chows an increase in the proportion of pts with GCTTs in CS I. This is good news for pts with GCTTs, as it not only reduces the need for chemotherapy and/or cytoreductive surgery, but also is associated with better long-term survival. The other finding is that there has been an increase in the proportion of pts presenting with S rather than NS. The reasons for these remains unclear and require further investigation.
C2
Clinical outcome following post-chemotherapy retroperitoneal lymphadenectomy in patients with intermediate - and poor-risk nonseminomatous testicular tumors
Argirovic D.1, Argirovic A.2 1 Clinic of Urology, CCS, Outpatient Clinic Argirovic, Dept. of Urology, Belgrade, Serbia, 2CHC Zemun, Dept. of Urology, Belgrade, Serbia Introduction & Objectives: To evaluate the outcome of patients (pts) treated with chemotherapy (C) and retroperitoneal lymphadenectomy (RPLA) after an initial diagnosis of IGCCCG intermediate (IR) and poor-risk (PR) metastatic nonseminomatous testicular tumors (NSTT), as the integration of C and surgery in managing advanced NSTT continues to develop. Material & Methods: Between 1980 and 2005, 82 pts initially diagnosed with IGCCCG IR and PR had PC-RPLA with a median follow-up of 95 months. Currently, standard therapy in pts with IR or PR metastatic NSTT at author’s institution constitute of 4 cycles of standard BEP C regimen followed by RPLA and extra-RP (ERP) resection as indicated. In selected cases surgery is used in those with elevated STMs. Results: 65 pts (79%) and 17 (21%) pts were assigned as IR and PR, respectively. The median residual mass was 3.0 cm, ERP RM were present in 20 (14%) pts, 4 pts (20%) underwent redo-operation due to relapse (concordant histology vs primary RP in 70%), 15 (18%) pts had elevated STM before PC-RPLA, 27 (33%) required 2nd- line C and 76 (93%) of all RP RM were completely resected. RedoRPLA due to relapse was performed in 16 pts, 2 after previous attempts elsewhere, combined with nephrectomy in 4 pts and with discordant histology in 5 pts (31%). RP pathology revealed fibrosis in 26%, teratoma in 42% and viable GCT in 32%, with disease-specific survival (DSS) in 76%, 80% and 38%, respectively. The 5-year overall progression free probability (PFP) and DSS were 57% and 69%, respectively. Those requiring 2nd –line C had a higher incidence of viable GCT in the RP (24% vs 49%0 (p<0.0001). In 5 pts (5%) with RM of < 20 mm, 3 (60%) had teratoma and 2 (40%) fibrosis. Pts receiving only 1st line C in comparison to
those with 2nd- line CT had significant difference in NED status regarding the RP pathology: fibrosis (94% vs 20%)(p<0.0001), teratoma (88% vs 55%)(p<0.0001) and viable GCT (54% vs 23%)(p=0.005). The pts with PR NSTT were at slightly higher risk of progression (55% vs 47%) and worse outcome (69% vs 53%). There was no difference in outcome between the pts with ERP vs those with ds limited to the RP (32% vs 40%). Pts receiving only 1st- line C vs those requiring 2nd-line C had higher PFP (66% vs 41%)(p<0.01), and better DSS ( 76% vs 48%)(p<0.01). On multivariable analysis incomplete resection (p<0.001), size of PC RM (p=0.01) and the finding of teratoma (p=0.005) or viable GCT (p<0.001) at PC-RPLA independently predicted ds progression. Conclusions: Pts with advanced NSTT had long-term freedom from progression when C is combined with resection of RM. Our data suggest that the tumor response to C, coupled with complete resection of all RM, predicts long-term freedom from ds progression.
C3
Thoracic metastasectomy for nonseminomatous testicular tumors (NSTT): Long-term survival and prognostic factors
Argirovic D.1, Argirovic A.2, Stanic V.3 Clinic of Urology, CCS, Outpatient Clinic Argirovic, Dept. of Urology, Belgrade, Serbia, 2CHC Zemun, Dept. of Urology, Belgrade, Serbia, 3Military Medical Academy, Dept. of Thoracic Surgery, Belgrade, Serbia
1
Introduction & Objectives: To examine histologic finding and clinical outcomes of pts who underwent chest dissection for residual lung masses. Material & Methods: From 1983-2004, 56 pts underwent asynchronous PC thoracotomy > 2 months (m) after retroperitoneal lymphadenectomy (RPLA) for residual disease (ds). All patients received primary cisplatin-based C, whereas 15 (26.8%) pts some other form of salvage C.30 pts underwent RPLA and 7 pts some other form of extrapulmonal resection. 25 pts had unilateral and 31 bilateral lung metastasis. Number of resected lung metastasis ranged from 1-75, measuring from 1-8 cm in diameter. Results: During lung resection, 23 (41.1%) had necrosis (N), 18 (32.1%) had teratoma (T), 13 (23.2%) had vital carcinoma (VC), 1 (1.8%) had N/VC and 1 (1.8%) had N/T. There was 93.6% concordance in bilateral lung metastasis. For the 41 pts receiving 1st line C alone before surgery the incidence of VC was 24.4%, compared with 46.7% for the 15 pts receiving 2nd line C (P=0.0001). The prognosis was more favorable in pts with N (91.3%) and T (82.3%) vs. VC (43.7%) (p<0.0002). Histology at RPLA demonstrated the presence of N, T and VC in 20%, 43.3% and 36.7%, respectively. 13 (43.3%) pts had discordant histology in the lung and RP, 2 (6.7%) with VC in the lung and 11 (36.7%) with VC only in the RP (p<0.004). N was found at thoracotomy in 60% pts with N only in RPLN. When RP histology was N, and the primary NSTT was T negative, the probability of N at thoracotomy increased to 80%. 4 of 9 (44.4%) pts with VC at RPLA died of ds, compared with 4 of 15 (26.7%) with T and none with N (p<0.05). The presence of associate RPLA (80,8% vs. 70% )(P=0.201) did not influence overall survival (OS). Recurrences occurred in 20 (35.7%) pts within median free interval of 21.7 m, with CR following applied therapy in 6 (30%) pts. Repeat RPLA was done in 5 (16.7%) pts (2T, 3VC)(1 discordant histology, VC) and redo thoracic surgery in 5 (8.9%) pts (3T,2VC)(1 discordant histology,T). Alive and free of ds are 42 (75%) pts at mean follow-up (MFU) of 180.83±56.98 m. 14 (25%) pts died of ds within MFU of 47.79±49.34m. The 5- and 10-year overall survival rates were 82.2% and 80.4%, respectively. The 5 y OS rate in pts with N/T vs. VC were 92.5% vs. 56.3%, and at 10 y rate were 87.5% vs. 50% (P<0.0019). Multivariate analysis identified salvage C (P<0.004) and VC either in RP (P<0.015) or extra RP site (P<0.02) as predictive for overall survival. Conclusions: The pts with finding of N in one lung field can be spared of contralateral dissection in cases of bilateral metastatic ds. In pts with finding of N at RPLA and without T compound in the primary NSTT, resection of residual lung metastasis may be unnecessary. The proper integration of C and surgery provide an excellent outcome in pts with disseminated NSTT.
Eur Urol Suppl 2012;11(4):83