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Factors that influence the results of salvage surgery in patients with chemorefractory germ cell carcinomas with elevated tumor markers
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R.G. Rowland / Urologic Oncology: Seminars and Original Investigations 22 (2004) 157–164
Commentary This report on 87 patients with retroperitoneal adenopathy at presentation who were treated with primary chemotherapy and had post-chemotherapy RPLND examines possible predictive factors to assess the risk of having teratoma or carcinoma in small postchemotherapy residual retroperitoneal adenopathy. The authors concluded that there were no predictive factors and that all patients with residual retroperitoneal adenopathy require surgical intervention. These results vary from earlier experience at Indiana University, where only 1 of 16 patients had residual teratoma or carcinoma in small masses after chemotherapy. The difference may be explained by the facts that in the current study, 54 of 87 patients had teratoma in the primary tumor and the Indiana series excluded these patients and required ⬎90% decrease in the CT volume of adenopathy, not just tumors ⱕ20 mm. doi:10.1016/j.urolonc.2004.02.011 Randall G. Rowland, M.D., Ph.D.
Factors that influence the results of salvage surgery in patients with chemorefractory germ cell carcinomas with elevated tumor markers. Habuchi T, Kamoto T, Hara I, Kawai K, Nakao M, Nonomura N, Kobayashi T, Ogawa O, Kamidono S, Akaza H, Okuyama A, Kato T, Miki T, Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan. Cancer 2003;98:1635– 42 Background: A standard concept for the integration of surgery into the chemotherapy-based treatment of patients with advanced germ cell carcinoma has been that surgery should be avoided in patients with serum tumor markers (alpha-fetoprotein [AFP] and human chorionic gonadotropin [HCG]) that remain elevated. However, some patients may benefit from resection under such chemorefractory conditions. The objective of this retrospective study was to clarify the outcome and clinical prognostic variables of salvage surgery in patients with disseminated (AJCC Stage II or III) testicular germ cell carcinoma or extragonadal germ cell carcinoma who had elevated serum markers. Methods: The authors reviewed the clinical records of 24 patients who underwent salvage surgery with elevated serum AFP and/or HCG levels after at least 3 courses of cisplatin-based, systemic chemotherapy between January, 1985 and December, 2000. The survival rates were compared between the subgroups with regard to preoperative and postoperative clinical parameters using the Kaplan-Meier method and a Cox proportional hazards model. Results: Ten of 24 patients (41.7%) were rendered free of disease and alive without disease after the surgery with or without adjuvant therapy at a median follow-up of 74 months (range, 24-207 months). Among the preoperative parameters, high HCG levels were associated with significantly poorer survival (hazard ratio [HR], 8.321; 95% confidence interval [95% CI], 1.0753-64.553; P ⫽ 0.043 and P ⫽ 0.016, respectively; log-rank test). In addition, patients who had visceral lesions at resection had a significantly poorer prognosis compared with patients who had retroperitoneal and/or mediastinal lymph node lesions (P ⫽ 0.038; log-rank test). Among postoperative parameters, incomplete resection and persistently high HCG levels were associated significantly with poor survival, with a risk of death from disease of 12.516-fold (95% CI, 1.786-87.781) and 9.311-fold (95% CI, 1.796-48.256), respectively. Conclusions: Salvage surgery in patients with high serum tumors markers resulted in long-term disease free status in approximately 40% of patients in a small subset with advanced germ cell carcinoma. Patients with elevated AFP levels alone (i.e., normal HCG levels) or with lymph node lesions alone seem to be good candidates for such surgery. Complete resection of target lesions and normalization of HCG levels after surgery are mandatory to achieve long-term disease free status.
Commentary The authors present a series of 24 patients who had salvage RPLND for chemorefractive testis tumors evidenced by persistent masses with elevation of AFP and/or -HCG after 3 or more courses of platinum-based chemotherapy. Retrospective analysis showed that the patients with high levels of -HCG did not do as well as those patients with low levels of -HCG or elevation of AFP alone. Even in the case of high levels of -HCG, 40% had long-term disease-free survival. This again shows that salvage RPLND in selected patients who do not achieve a complete marker response to chemotherapy serves as well as or better than second-line chemotherapy. doi:10.1016/j.urolonc.2004.02.009 Randall G. Rowland, M.D., Ph.D.
Does retroperitoneal lymph node dissection have a curative role for patients with sex cord-stromal testicular tumors? Mosharafa AA, Foster RS, Bihrle R, Koch MO, Ulbright TM, Einhorn LH, Donohue JP, Department of Urology, Indiana University School of Medicine, Indianapolis, IN. Cancer 2003;98:753–7 Background: Sex cord-stromal tumors account for ⬍ 5% of all adult testicular tumors, and 10% are malignant. Due to the limited reported experience, there is no agreement on the best management, especially in patients who have tumors with malignant pathologic features or who present with metastatic disease. The authors attempt to evaluate the role of retroperitoneal lymph node dissection (RPLND) in the management of patients with these malignant sex cord-stromal tumors.
R.G. Rowland / Urologic Oncology: Seminars and Original Investigations 22 (2004) 157–164
Commentary This report on 87 patients with retroperitoneal adenopathy at presentation who were treated with primary chemotherapy and had post-chemotherapy RPLND examines possible predictive factors to assess the risk of having teratoma or carcinoma in small postchemotherapy residual retroperitoneal adenopathy. The authors concluded that there were no predictive factors and that all patients with residual retroperitoneal adenopathy require surgical intervention. These results vary from earlier experience at Indiana University, where only 1 of 16 patients had residual teratoma or carcinoma in small masses after chemotherapy. The difference may be explained by the facts that in the current study, 54 of 87 patients had teratoma in the primary tumor and the Indiana series excluded these patients and required ⬎90% decrease in the CT volume of adenopathy, not just tumors ⱕ20 mm. doi:10.1016/j.urolonc.2004.02.011 Randall G. Rowland, M.D., Ph.D.
Factors that influence the results of salvage surgery in patients with chemorefractory germ cell carcinomas with elevated tumor markers. Habuchi T, Kamoto T, Hara I, Kawai K, Nakao M, Nonomura N, Kobayashi T, Ogawa O, Kamidono S, Akaza H, Okuyama A, Kato T, Miki T, Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan. Cancer 2003;98:1635– 42 Background: A standard concept for the integration of surgery into the chemotherapy-based treatment of patients with advanced germ cell carcinoma has been that surgery should be avoided in patients with serum tumor markers (alpha-fetoprotein [AFP] and human chorionic gonadotropin [HCG]) that remain elevated. However, some patients may benefit from resection under such chemorefractory conditions. The objective of this retrospective study was to clarify the outcome and clinical prognostic variables of salvage surgery in patients with disseminated (AJCC Stage II or III) testicular germ cell carcinoma or extragonadal germ cell carcinoma who had elevated serum markers. Methods: The authors reviewed the clinical records of 24 patients who underwent salvage surgery with elevated serum AFP and/or HCG levels after at least 3 courses of cisplatin-based, systemic chemotherapy between January, 1985 and December, 2000. The survival rates were compared between the subgroups with regard to preoperative and postoperative clinical parameters using the Kaplan-Meier method and a Cox proportional hazards model. Results: Ten of 24 patients (41.7%) were rendered free of disease and alive without disease after the surgery with or without adjuvant therapy at a median follow-up of 74 months (range, 24-207 months). Among the preoperative parameters, high HCG levels were associated with significantly poorer survival (hazard ratio [HR], 8.321; 95% confidence interval [95% CI], 1.0753-64.553; P ⫽ 0.043 and P ⫽ 0.016, respectively; log-rank test). In addition, patients who had visceral lesions at resection had a significantly poorer prognosis compared with patients who had retroperitoneal and/or mediastinal lymph node lesions (P ⫽ 0.038; log-rank test). Among postoperative parameters, incomplete resection and persistently high HCG levels were associated significantly with poor survival, with a risk of death from disease of 12.516-fold (95% CI, 1.786-87.781) and 9.311-fold (95% CI, 1.796-48.256), respectively. Conclusions: Salvage surgery in patients with high serum tumors markers resulted in long-term disease free status in approximately 40% of patients in a small subset with advanced germ cell carcinoma. Patients with elevated AFP levels alone (i.e., normal HCG levels) or with lymph node lesions alone seem to be good candidates for such surgery. Complete resection of target lesions and normalization of HCG levels after surgery are mandatory to achieve long-term disease free status.
Commentary The authors present a series of 24 patients who had salvage RPLND for chemorefractive testis tumors evidenced by persistent masses with elevation of AFP and/or -HCG after 3 or more courses of platinum-based chemotherapy. Retrospective analysis showed that the patients with high levels of -HCG did not do as well as those patients with low levels of -HCG or elevation of AFP alone. Even in the case of high levels of -HCG, 40% had long-term disease-free survival. This again shows that salvage RPLND in selected patients who do not achieve a complete marker response to chemotherapy serves as well as or better than second-line chemotherapy. doi:10.1016/j.urolonc.2004.02.009 Randall G. Rowland, M.D., Ph.D.
Does retroperitoneal lymph node dissection have a curative role for patients with sex cord-stromal testicular tumors? Mosharafa AA, Foster RS, Bihrle R, Koch MO, Ulbright TM, Einhorn LH, Donohue JP, Department of Urology, Indiana University School of Medicine, Indianapolis, IN. Cancer 2003;98:753–7 Background: Sex cord-stromal tumors account for ⬍ 5% of all adult testicular tumors, and 10% are malignant. Due to the limited reported experience, there is no agreement on the best management, especially in patients who have tumors with malignant pathologic features or who present with metastatic disease. The authors attempt to evaluate the role of retroperitoneal lymph node dissection (RPLND) in the management of patients with these malignant sex cord-stromal tumors.