- Email: [email protected]
Commentary on Testis-sparing surgery versus radical orchiectomy in patients with Leydig cell tumors
Urologic Oncology: Seminars and Original Investigations 28 (2010) 344 –346
Urologic Oncology Survey Commentary on Quality of surveillance for stage I testis cancer in the community. Yu HY, Madison RA, Setodji CM, Saigal CS, Department of Urology, University of California-Los Angeles School of Medicine, Los Angeles, CA. J Clin Oncol 2009;27:e282–3; author reply e284 –5 Patients with clinical stage I testicular germ cell tumors have been managed with adjuvant radiotherapy, chemotherapy, or retroperitoneal lymph node dissection (RPLND). The use of surveillance-only strategies at referral centers has yielded survival outcomes comparable to those achieved with adjuvant therapy. We evaluated compliance with follow-up protocols developed at referral centers within the community. We identified patients with stage I testis cancer within a large private insurance claims database and calculated compliance of follow-up test use with guidelines from the National Comprehensive Cancer Network. Surveillance was widely used in the community. Compliance with surveillance and postadjuvant therapy follow-up testing was poor and degraded with increasing time from diagnosis. Nearly 30% of all surveillance patients received no abdominal imaging, chest imaging, or tumor marker tests within the first year of diagnosis. Patients who elected RPLND were most compliant with recommended follow-up testing within the first year. Recurrence rates were consistent with previously reported literature, despite poor compliance. Surveillance is a widely accepted strategy in clinical stage I testicular cancer treatment in the community. However, follow-up care recommendations developed at referral centers are not being adhered to in the community. Although recurrence rates are similar to those of reported literature, the clinical impact of noncompliance on recurrence severity and mortality are not known. Further prospective work needs to be done to evaluate this apparent quality of care problem in the community.
Commentary Active surveillance is a recognized strategy for patients with seminoma or non-seminomatous germ cell tumors. These strategies rely on early detection of metastatic disease with chemotherapy as a backup for the 20% or 30% of patients who have undetectable micrometastatic disease. Reports of the efficacy from an oncologic standpoint have come from academic centers with data managers for careful follow-up and assurance that patients comply with surveillance strategies. The authors have utilized a private insurance claims database to calculate compliance of obtaining tumor markers and imaging studies in patients with testicular cancer followed in the community setting. Compliance with follow up protocols in the community was dismal. Of the 739 adult men with continuous insurance coverage, 279 were managed with surveillance. In year 1, only 48% of patients on surveillance for either seminoma or nonseminomatous germ cell tumor were more than 50% compliant with National Comprehensive Cancer Network guidelines. Furthermore, almost 30% of patients received no abdominal imaging, chest X-ray, or tumor markers within the first year of diagnosis. This report raises significant concerns about the efficacy of surveillance in the community setting. The impact on recurrence and mortality are not known, as many of these patients are not reported in the literature. doi:10.1016/j.urolonc.2010.02.002 Jerome P. Richie, M.D.
Commentary on Testis-sparing surgery versus radical orchiectomy in patients with Leydig cell tumors. Loeser A, Vergho DC, Katzenberger T, Brix D, Kocot A, Spahn M, Gerharz EW, Riedmiller H, Department of Urology, Institute of Pathology, Julius-MaximiliansUniversity Medical School, Würzburg, Germany. Urology 2009;74:370 –2 To compare retrospectively the outcome of testis-sparing surgery (TSS) to radical orchiectomy (RO) in patients with Leydig cell tumor (LCT). Between 1992 and 2008, 16 patients with LCT of the testis were identified. All but 1 tumor could be detected by ultrasonography. ␣-Fetoprotein and -human chorionic gonadotropin levels were normal in all patients. Eight patients underwent RO (mean age at surgery 42 years [27– 61]; median tumor size 12.9 mm [10 –25]) and the remaining 8 underwent TSS (mean age at surgery 34 years [18 – 49]; median 1078-1439/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
J.P. Richie / Urologic Oncology: Seminars and Original Investigations 28 (2010) 344 –346
345
tumor size 8.6 mm [4 –23]). Staging (abdominal computed tomography and chest X-ray or thoracic computed tomography) was negative in all patients. Median follow-up was 77 months (17–186) after RO and 42 months (1– 86 months) after TSS. There was no local recurrence or metastasis in patients after RO. A metachronous LCT was removed from the spermatic cord 29 months after TSS of the ipsilateral testis in 1 patient. Another patient underwent surgical exploration of the testis 31 months after ipsilateral TSS because of a suspicious lesion identified in ultrasonography; a tumor was ruled out by histopathology. In the medium term, TSS is a safe procedure in patients with LCT ⬍ 25 mm.
Commentary This single institution study evaluated 16 patients with Leydig cell tumor seen over a 16-year period. The majority of tumors were detected by ultrasound, and tumor markers were normal in all patients. Half of the patients underwent radical orchiectomy, and patients with generally smaller tumors (median size 8 mm) underwent testis sparing surgery, consisting of exploration via inguinal approach with biopsy and frozen section. There were no recurrences in the radical orchiectomy group. One patient in the partial orchiectomy group was found to have metachronous Leydig cell tumor in the spermatic cord. This small series suggests that patients with relatively small Leydig cell tumors can be considered for testis sparing surgery. doi:10.1016/j.urolonc.2010.02.003 Jerome P. Richie, M.D.
Commentary on Observational study of prevalence of long-term Raynaud-like phenomena and neurological side effects in testicular cancer survivors. Brydøy M, Oldenburg J, Klepp O, Bremnes RM, Wist EA, Wentzel-Larsen T, Hauge ER, Dahl O, Fosså SD, Department of Oncology, Haukeland University Hospital, Bergen, Norway. J Natl Cancer Inst 2009;101:1682–95 Sensory neuropathy (paresthesias), tinnitus, hearing impairment, and Raynaud phenomena are side effects of cisplatin-based chemotherapy used to treat testicular cancer patients. We assessed the long-term occurrence of these side effects among testicular cancer survivors according to the treatment they received. A total of 1,814 men who were treated for unilateral testicular cancer in Norway during 1980 –1994 were invited to participate in a national multicenter follow-up survey conducted during 1998 –2002. The men were allocated to 6 groups according to the treatment they had received. Self-reported symptoms were assessed by a mailed questionnaire that included the Scale for Chemotherapy-Induced Neurotoxicity. A total of 1,409 participants who responded to the questionnaire and/or underwent audiometry were assessable in this study. Respondents to the questionnaire (n ⫽ 1,402) scored the relevant symptoms according to how troubled they were by each (not at all, a little, quite a bit, or very much). Hearing impairment was objectively assessed by audiometry at 4000 Hz in 755 men (7 of whom did not respond to the questionnaire). Group comparisons of symptom assessments were performed with 2 or Kruskal-Wallis tests. Associations between relevant factors and self-reported symptoms or hearing impairment measured by audiometry were assessed using proportional odds ordinal logistic regression models and linear regression models, respectively. All statistical tests were two-sided. The median follow-up for the 1,409 assessable men was 10.7 years (range ⫽ 4 –21 years). All chemotherapy groups had statistically significantly higher odds for increasing severity of all assessed symptoms and inferior audiometric results compared with men who did not receive chemotherapy. Among chemotherapy-treated men, 39% (95% confidence interval [CI] ⫽ 35 to 43) reported Raynaud-like phenomena (defined as white or cold hands or fingers [or feet or toes] on cold exposure), 29% (95% CI ⫽ 25 to 33) reported paresthesias in the hands or feet, 21% (95% CI ⫽ 18 to 25) reported hearing impairment, and 22% (95% CI ⫽ 19 to 26) reported tinnitus as major symptoms troubling them quite a bit or very much. Hearing impairment (odds ratio [OR] ⫽ 5.3, 95% CI ⫽ 3.0 to 9.2) and tinnitus (OR ⫽ 7.1, 95% CI ⫽ 4.1 to 12.4) were particularly common in the dose-intensive chemotherapy group compared with the no chemotherapy group. Men who were treated with radiotherapy had higher odds of self-reported paresthesias in feet compared with those not treated with radiotherapy (OR ⫽ 1.5, 95% CI ⫽ 1.01 to 2.1, P ⫽ 0.04). Long-term survivors of testicular cancer who were treated with cisplatin-based chemotherapy were more often troubled by dosedependent neurological side effects and Raynaud-like phenomena compared with those who were not treated with chemotherapy.
Commentary Testicular cancer is one of the most curable neoplasms, with combination platinum-based chemotherapy being the treatment of choice. Since most patients are cured of their testicular malignancy, morbidity associated with treatment and long-term side effects assume greater import. The authors have evaluated 1,800 men treated over a 14-year period in Norway for the prevalence of long-term Raynaud-like phenomena. Almost 80% of patients responded to a questionnaire that included a scale for chemotherapy-induced neurotoxicity.
Urologic Oncology Survey Commentary on Quality of surveillance for stage I testis cancer in the community. Yu HY, Madison RA, Setodji CM, Saigal CS, Department of Urology, University of California-Los Angeles School of Medicine, Los Angeles, CA. J Clin Oncol 2009;27:e282–3; author reply e284 –5 Patients with clinical stage I testicular germ cell tumors have been managed with adjuvant radiotherapy, chemotherapy, or retroperitoneal lymph node dissection (RPLND). The use of surveillance-only strategies at referral centers has yielded survival outcomes comparable to those achieved with adjuvant therapy. We evaluated compliance with follow-up protocols developed at referral centers within the community. We identified patients with stage I testis cancer within a large private insurance claims database and calculated compliance of follow-up test use with guidelines from the National Comprehensive Cancer Network. Surveillance was widely used in the community. Compliance with surveillance and postadjuvant therapy follow-up testing was poor and degraded with increasing time from diagnosis. Nearly 30% of all surveillance patients received no abdominal imaging, chest imaging, or tumor marker tests within the first year of diagnosis. Patients who elected RPLND were most compliant with recommended follow-up testing within the first year. Recurrence rates were consistent with previously reported literature, despite poor compliance. Surveillance is a widely accepted strategy in clinical stage I testicular cancer treatment in the community. However, follow-up care recommendations developed at referral centers are not being adhered to in the community. Although recurrence rates are similar to those of reported literature, the clinical impact of noncompliance on recurrence severity and mortality are not known. Further prospective work needs to be done to evaluate this apparent quality of care problem in the community.
Commentary Active surveillance is a recognized strategy for patients with seminoma or non-seminomatous germ cell tumors. These strategies rely on early detection of metastatic disease with chemotherapy as a backup for the 20% or 30% of patients who have undetectable micrometastatic disease. Reports of the efficacy from an oncologic standpoint have come from academic centers with data managers for careful follow-up and assurance that patients comply with surveillance strategies. The authors have utilized a private insurance claims database to calculate compliance of obtaining tumor markers and imaging studies in patients with testicular cancer followed in the community setting. Compliance with follow up protocols in the community was dismal. Of the 739 adult men with continuous insurance coverage, 279 were managed with surveillance. In year 1, only 48% of patients on surveillance for either seminoma or nonseminomatous germ cell tumor were more than 50% compliant with National Comprehensive Cancer Network guidelines. Furthermore, almost 30% of patients received no abdominal imaging, chest X-ray, or tumor markers within the first year of diagnosis. This report raises significant concerns about the efficacy of surveillance in the community setting. The impact on recurrence and mortality are not known, as many of these patients are not reported in the literature. doi:10.1016/j.urolonc.2010.02.002 Jerome P. Richie, M.D.
Commentary on Testis-sparing surgery versus radical orchiectomy in patients with Leydig cell tumors. Loeser A, Vergho DC, Katzenberger T, Brix D, Kocot A, Spahn M, Gerharz EW, Riedmiller H, Department of Urology, Institute of Pathology, Julius-MaximiliansUniversity Medical School, Würzburg, Germany. Urology 2009;74:370 –2 To compare retrospectively the outcome of testis-sparing surgery (TSS) to radical orchiectomy (RO) in patients with Leydig cell tumor (LCT). Between 1992 and 2008, 16 patients with LCT of the testis were identified. All but 1 tumor could be detected by ultrasonography. ␣-Fetoprotein and -human chorionic gonadotropin levels were normal in all patients. Eight patients underwent RO (mean age at surgery 42 years [27– 61]; median tumor size 12.9 mm [10 –25]) and the remaining 8 underwent TSS (mean age at surgery 34 years [18 – 49]; median 1078-1439/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
J.P. Richie / Urologic Oncology: Seminars and Original Investigations 28 (2010) 344 –346
345
tumor size 8.6 mm [4 –23]). Staging (abdominal computed tomography and chest X-ray or thoracic computed tomography) was negative in all patients. Median follow-up was 77 months (17–186) after RO and 42 months (1– 86 months) after TSS. There was no local recurrence or metastasis in patients after RO. A metachronous LCT was removed from the spermatic cord 29 months after TSS of the ipsilateral testis in 1 patient. Another patient underwent surgical exploration of the testis 31 months after ipsilateral TSS because of a suspicious lesion identified in ultrasonography; a tumor was ruled out by histopathology. In the medium term, TSS is a safe procedure in patients with LCT ⬍ 25 mm.
Commentary This single institution study evaluated 16 patients with Leydig cell tumor seen over a 16-year period. The majority of tumors were detected by ultrasound, and tumor markers were normal in all patients. Half of the patients underwent radical orchiectomy, and patients with generally smaller tumors (median size 8 mm) underwent testis sparing surgery, consisting of exploration via inguinal approach with biopsy and frozen section. There were no recurrences in the radical orchiectomy group. One patient in the partial orchiectomy group was found to have metachronous Leydig cell tumor in the spermatic cord. This small series suggests that patients with relatively small Leydig cell tumors can be considered for testis sparing surgery. doi:10.1016/j.urolonc.2010.02.003 Jerome P. Richie, M.D.
Commentary on Observational study of prevalence of long-term Raynaud-like phenomena and neurological side effects in testicular cancer survivors. Brydøy M, Oldenburg J, Klepp O, Bremnes RM, Wist EA, Wentzel-Larsen T, Hauge ER, Dahl O, Fosså SD, Department of Oncology, Haukeland University Hospital, Bergen, Norway. J Natl Cancer Inst 2009;101:1682–95 Sensory neuropathy (paresthesias), tinnitus, hearing impairment, and Raynaud phenomena are side effects of cisplatin-based chemotherapy used to treat testicular cancer patients. We assessed the long-term occurrence of these side effects among testicular cancer survivors according to the treatment they received. A total of 1,814 men who were treated for unilateral testicular cancer in Norway during 1980 –1994 were invited to participate in a national multicenter follow-up survey conducted during 1998 –2002. The men were allocated to 6 groups according to the treatment they had received. Self-reported symptoms were assessed by a mailed questionnaire that included the Scale for Chemotherapy-Induced Neurotoxicity. A total of 1,409 participants who responded to the questionnaire and/or underwent audiometry were assessable in this study. Respondents to the questionnaire (n ⫽ 1,402) scored the relevant symptoms according to how troubled they were by each (not at all, a little, quite a bit, or very much). Hearing impairment was objectively assessed by audiometry at 4000 Hz in 755 men (7 of whom did not respond to the questionnaire). Group comparisons of symptom assessments were performed with 2 or Kruskal-Wallis tests. Associations between relevant factors and self-reported symptoms or hearing impairment measured by audiometry were assessed using proportional odds ordinal logistic regression models and linear regression models, respectively. All statistical tests were two-sided. The median follow-up for the 1,409 assessable men was 10.7 years (range ⫽ 4 –21 years). All chemotherapy groups had statistically significantly higher odds for increasing severity of all assessed symptoms and inferior audiometric results compared with men who did not receive chemotherapy. Among chemotherapy-treated men, 39% (95% confidence interval [CI] ⫽ 35 to 43) reported Raynaud-like phenomena (defined as white or cold hands or fingers [or feet or toes] on cold exposure), 29% (95% CI ⫽ 25 to 33) reported paresthesias in the hands or feet, 21% (95% CI ⫽ 18 to 25) reported hearing impairment, and 22% (95% CI ⫽ 19 to 26) reported tinnitus as major symptoms troubling them quite a bit or very much. Hearing impairment (odds ratio [OR] ⫽ 5.3, 95% CI ⫽ 3.0 to 9.2) and tinnitus (OR ⫽ 7.1, 95% CI ⫽ 4.1 to 12.4) were particularly common in the dose-intensive chemotherapy group compared with the no chemotherapy group. Men who were treated with radiotherapy had higher odds of self-reported paresthesias in feet compared with those not treated with radiotherapy (OR ⫽ 1.5, 95% CI ⫽ 1.01 to 2.1, P ⫽ 0.04). Long-term survivors of testicular cancer who were treated with cisplatin-based chemotherapy were more often troubled by dosedependent neurological side effects and Raynaud-like phenomena compared with those who were not treated with chemotherapy.
Commentary Testicular cancer is one of the most curable neoplasms, with combination platinum-based chemotherapy being the treatment of choice. Since most patients are cured of their testicular malignancy, morbidity associated with treatment and long-term side effects assume greater import. The authors have evaluated 1,800 men treated over a 14-year period in Norway for the prevalence of long-term Raynaud-like phenomena. Almost 80% of patients responded to a questionnaire that included a scale for chemotherapy-induced neurotoxicity.