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Re: The Clinical Features and Management of Testicular Germ Cell Tumours in Patients Aged 60 Years and Older
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TESTIS CANCER
choice, guidance of interventions, and treatments. The purpose of this review is to discuss the potential role of multiparametric MRI in focal therapy with respect to patient selection and directing (robot-guided) biopsies and intensity-modulated radiation therapy (IMRT). Multiparametric MRI is a versatile and promising technique. It appears to be the best available imaging technique at the moment in localizing, staging (primary as well as recurrent disease, and local as well as distant disease), determining aggressiveness, and volume of PCa. However, larger study populations in multicenter settings have to confirm these promising results. However, before such studies can be performed more research is needed in order to achieve standardized imaging protocols. Editorial Comment: The role of MRI is evolving. As MRI accuracy improves and as focal therapy becomes more integrated in the treatment of patients with prostate cancer, multiparametric MRI will have a larger role in targeted treatment. Multiparametric MRI first and foremost is good at staging local prostate cancer, with a combined sensitivity and specificity of approximately 71% in distinguishing T2 and T3 disease. With the 3.0 Tesla scans these specificities and sensitivities increase. Spectroscopy, dynamic contrast enhancement and diffusion also increase the sensitivity and specificity. There have been limited studies using multiparametric MRI to assess tumor volume. However, MRI appears to have good correlation for tumors greater than 0.5 cm3. The purpose of this article was to review multiparametric MRI and its possible role in guiding specific biopsies and focal therapy. This role includes patient selection for cryosurgery or high intensity focused ultrasound and radio frequency ablation, as well as directing intensity modulated radiation therapy, where the radiation therapist has the ability to increase the dose to the targeted focus of prostate cancer identified on the magnetic resonance scan. Cary Siegel, M.D.
Urological Oncology: Testis Cancer Re: The Clinical Features and Management of Testicular Germ Cell Tumours in Patients Aged 60 Years and Older M. J. Wheater, J. Manners, L. Nolan, P. D. Simmonds, M. C. Hayes and G. M. Mead Department of Medical Oncology, Southampton University Hospitals NHS Trust, Southampton, United Kingdom BJU Int 2011; 108: 1794 –1799.
Objectives: To review the practice of a large referral centre for the management of older patients with testicular germ cell cancer (GCC). There are few published data available on the management of testicular GCC in elderly patients, who often have medical comorbidities and have been excluded from clinical trials. Patients and Methods: We reviewed our prospectively collected database for patients presenting with GCC who were aged ⱖ60 years. Details of presentation, management and outcome were recorded. Results: In total, 60 patients aged ⱖ60 years were identified from 1461 patients treated with GCC from 1979–2005, representing 4% of the total population. Median age was 67 years, 44 had seminoma (73%) and 16 had non-seminoma histology (27%). Stage I seminoma patients were managed with surveillance, adjuvant radiotherapy and adjuvant carboplatin. All stage I non-seminomas underwent surveillance. In total, 15 patients received systemic chemotherapy for metastatic disease with modified bleomycin, etoposide and cisplatin; etoposide and cisplatin; carboplatin-based regimens; or other combinations. Toxicity was manageable, with no toxic deaths. Conclusions: In elderly patients, GCC should be managed with curative intent. Conventional therapies are tolerable for most men with stage I seminoma. In metastatic disease, comorbidity may necessitate treatment modifications. Most patients are cured with manageable toxicity. Editorial Comment: Although testicular cancer occurs at a median age of 30 years, approximately 2% of testis tumors are seen in men 70 and older. Nonseminomatous tumors occur earlier (median age 27 years) compared to seminoma (37 years). Because of comorbidities associated with older age, management of testicular tumor in men older than 60 is more
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
problematic. The authors have reviewed 60 patients older than 60 years. Three quarters of the patients had seminoma, which was generally treated with surveillance or adjuvant radiation therapy. Patients who underwent chemotherapy had manageable toxicity, and there were no deaths related to chemotherapy. The authors conclude that standardized treatment can be used for seminomas and nonseminomas in this older population, albeit with treatment modifications to take into account comorbidities. Jerome P. Richie, M.D.
Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: Squamous Cell Carcinoma of the Penis: Predicting Nodal Metastases by Histologic Grade, Pattern of Invasion and Clinical Examination I. Alkatout, C. M. Naumann, J. Hedderich, A. Hegele, C. Bolenz, K. P. Jünemann and G. Klöppel Department of Pathology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany Urol Oncol 2011; 29: 774 –781.
With a diagnosis of squamous cell carcinoma of the penis, there is still a significant need to define the tumor criteria that allow the disease to be stratified according to the risk of developing lymph node metastases. The histopathology of the primary tumor in 72 consecutive patients with resected squamous cell carcinoma of the penis was reviewed for this study. Tumor tissue was reviewed for (1) histologic grade, (2) invasion pattern, (3) tumor stage, (4) proportion of poorly differentiated tumor cells, (5) invasion depth, (6) proportion of tumor necrosis, (7) angioinvasion, (8) histologic classification, (9) number of lesions, (10) growth pattern, (11) number of mitoses, (12) degree of keratinization, and (13) clinical groin status. It was found that the presence of inguinal lymph node metastases correlated in descending order of frequency with grade G2/G3, clinically positive groin status, reticular invasion, stage pT2/T3, ⬎50% poorly differentiated tumor cells, depth of invasion, and comedolike tumor necrosis. These results revealed that the risk of inguinal lymph node metastasis in penile carcinoma can be predicted on the basis of 3 major factors: histologic grade, pattern of invasion, and clinical groin status. Editorial Comment: Due to the morbidity of the procedure, it is important to identify patients with penile cancer who require inguinal node dissection. This stratification system improves the selection criteria. A concern is whether most pathologists will be able to reproduce the required tumor tissue review. David P. Wood, M.D.
1185
TESTIS CANCER
choice, guidance of interventions, and treatments. The purpose of this review is to discuss the potential role of multiparametric MRI in focal therapy with respect to patient selection and directing (robot-guided) biopsies and intensity-modulated radiation therapy (IMRT). Multiparametric MRI is a versatile and promising technique. It appears to be the best available imaging technique at the moment in localizing, staging (primary as well as recurrent disease, and local as well as distant disease), determining aggressiveness, and volume of PCa. However, larger study populations in multicenter settings have to confirm these promising results. However, before such studies can be performed more research is needed in order to achieve standardized imaging protocols. Editorial Comment: The role of MRI is evolving. As MRI accuracy improves and as focal therapy becomes more integrated in the treatment of patients with prostate cancer, multiparametric MRI will have a larger role in targeted treatment. Multiparametric MRI first and foremost is good at staging local prostate cancer, with a combined sensitivity and specificity of approximately 71% in distinguishing T2 and T3 disease. With the 3.0 Tesla scans these specificities and sensitivities increase. Spectroscopy, dynamic contrast enhancement and diffusion also increase the sensitivity and specificity. There have been limited studies using multiparametric MRI to assess tumor volume. However, MRI appears to have good correlation for tumors greater than 0.5 cm3. The purpose of this article was to review multiparametric MRI and its possible role in guiding specific biopsies and focal therapy. This role includes patient selection for cryosurgery or high intensity focused ultrasound and radio frequency ablation, as well as directing intensity modulated radiation therapy, where the radiation therapist has the ability to increase the dose to the targeted focus of prostate cancer identified on the magnetic resonance scan. Cary Siegel, M.D.
Urological Oncology: Testis Cancer Re: The Clinical Features and Management of Testicular Germ Cell Tumours in Patients Aged 60 Years and Older M. J. Wheater, J. Manners, L. Nolan, P. D. Simmonds, M. C. Hayes and G. M. Mead Department of Medical Oncology, Southampton University Hospitals NHS Trust, Southampton, United Kingdom BJU Int 2011; 108: 1794 –1799.
Objectives: To review the practice of a large referral centre for the management of older patients with testicular germ cell cancer (GCC). There are few published data available on the management of testicular GCC in elderly patients, who often have medical comorbidities and have been excluded from clinical trials. Patients and Methods: We reviewed our prospectively collected database for patients presenting with GCC who were aged ⱖ60 years. Details of presentation, management and outcome were recorded. Results: In total, 60 patients aged ⱖ60 years were identified from 1461 patients treated with GCC from 1979–2005, representing 4% of the total population. Median age was 67 years, 44 had seminoma (73%) and 16 had non-seminoma histology (27%). Stage I seminoma patients were managed with surveillance, adjuvant radiotherapy and adjuvant carboplatin. All stage I non-seminomas underwent surveillance. In total, 15 patients received systemic chemotherapy for metastatic disease with modified bleomycin, etoposide and cisplatin; etoposide and cisplatin; carboplatin-based regimens; or other combinations. Toxicity was manageable, with no toxic deaths. Conclusions: In elderly patients, GCC should be managed with curative intent. Conventional therapies are tolerable for most men with stage I seminoma. In metastatic disease, comorbidity may necessitate treatment modifications. Most patients are cured with manageable toxicity. Editorial Comment: Although testicular cancer occurs at a median age of 30 years, approximately 2% of testis tumors are seen in men 70 and older. Nonseminomatous tumors occur earlier (median age 27 years) compared to seminoma (37 years). Because of comorbidities associated with older age, management of testicular tumor in men older than 60 is more
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
problematic. The authors have reviewed 60 patients older than 60 years. Three quarters of the patients had seminoma, which was generally treated with surveillance or adjuvant radiation therapy. Patients who underwent chemotherapy had manageable toxicity, and there were no deaths related to chemotherapy. The authors conclude that standardized treatment can be used for seminomas and nonseminomas in this older population, albeit with treatment modifications to take into account comorbidities. Jerome P. Richie, M.D.
Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: Squamous Cell Carcinoma of the Penis: Predicting Nodal Metastases by Histologic Grade, Pattern of Invasion and Clinical Examination I. Alkatout, C. M. Naumann, J. Hedderich, A. Hegele, C. Bolenz, K. P. Jünemann and G. Klöppel Department of Pathology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany Urol Oncol 2011; 29: 774 –781.
With a diagnosis of squamous cell carcinoma of the penis, there is still a significant need to define the tumor criteria that allow the disease to be stratified according to the risk of developing lymph node metastases. The histopathology of the primary tumor in 72 consecutive patients with resected squamous cell carcinoma of the penis was reviewed for this study. Tumor tissue was reviewed for (1) histologic grade, (2) invasion pattern, (3) tumor stage, (4) proportion of poorly differentiated tumor cells, (5) invasion depth, (6) proportion of tumor necrosis, (7) angioinvasion, (8) histologic classification, (9) number of lesions, (10) growth pattern, (11) number of mitoses, (12) degree of keratinization, and (13) clinical groin status. It was found that the presence of inguinal lymph node metastases correlated in descending order of frequency with grade G2/G3, clinically positive groin status, reticular invasion, stage pT2/T3, ⬎50% poorly differentiated tumor cells, depth of invasion, and comedolike tumor necrosis. These results revealed that the risk of inguinal lymph node metastasis in penile carcinoma can be predicted on the basis of 3 major factors: histologic grade, pattern of invasion, and clinical groin status. Editorial Comment: Due to the morbidity of the procedure, it is important to identify patients with penile cancer who require inguinal node dissection. This stratification system improves the selection criteria. A concern is whether most pathologists will be able to reproduce the required tumor tissue review. David P. Wood, M.D.
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