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Urological Oncology: Testis Cancer
TESTIS CANCER
1311
Urological Oncology: Testis Cancer Re: Survival After Resection for Metastatic Testicular Nonseminomatous Germ Cell Cancer to the Lung or Mediastinum K. A. Kesler, L. E. Kruter, S. M. Perkins, K. M. Rieger, K. J. Sullivan, M. L. Runyan, J. W. Brown and L. H. Einhorn Department of Surgery, Cardiothoracic Division, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana Ann Thorac Surg 2011; 91: 1085–1093.
Background: Since the advent of cisplatin-based chemotherapy, nonseminomatous germ cell tumors (NSGCT) have been considered one of the most curable solid neoplasms and a model for multimodality cancer therapy. We undertook an institutional review of testicular NSGCT patients who underwent operations to remove lung or mediastinal metastases after chemotherapy in the cisplatin era to determine outcomes. Methods: From 1980 to 2006, 431 patients underwent 640 postchemotherapy surgical procedures to remove lung (n ⫽ 159, 36.8%), mediastinal (n ⫽ 136, 31.6%), or both lung and mediastinal (n ⫽ 136, 31.6%) metastases within 2 years of chemotherapy. Multiple variables potentially predictive of survival were analyzed. Results: The overall median survival was 23.4 years, with 295 (68%) patients alive and well after an average follow-up of 5.6 years. There was no survival difference in patients who underwent removal of lung or mediastinal metastases. Pathologic categories of resected residual disease were necrosis (21.5%), teratoma (52.7%), persistent NSGCT (15.0%), and degenerative non-germ cell cancer (10.1%). Multivariable analysis identified older age at time of diagnosis (p ⫽ 0.001), non-germ cell cancer in testes specimen (p ⫽ 0.004), and pathology of residual disease (p ⬍ 0.001) as significantly predictive of survival. Conclusions: Patients who undergo resection of residual lung or mediastinal disease for metastatic testicular NSGCT as a planned approach after cisplatin-based chemotherapy have overall excellent long-term survival. Survival is equivalent comparing hematogenous and lymphatic routes of metastases but depends on the pathology of the resected disease. These results justify an aggressive surgical approach, particularly to remove residual teratoma in the lung or mediastinum after chemotherapy, including multiple surgical procedures if necessary. Editorial Comment: With the advent of chemotherapy in addition to aggressive surgery, nonseminomatous testicular cancer, even when metastatic, has been one of the most successful models for multimodal therapy. Platinum based chemotherapy plus surgical resection for residual disease results in survival rates in the 80% to 90% range. Although the retroperitoneum is the most common site of metastasis, the visceral mediastinum and the lung represent common sites for hematogenous dissemination. The authors review their extensive experience with post-chemotherapy resection of mediastinal and/or pulmonary metastases after platinum based chemotherapy. During a 26-year period 431 patients underwent 640 thoracic surgical procedures. The authors describe their lung and mediastinal operative techniques, postoperative care and followup. There were a total of 6 operative deaths, representing less than 1% of all thoracic procedures. Four of the deaths were related to acute respiratory distress syndrome. With a median followup of at least 5 years, the authors report a 79% survival at 5 years and 73% at 10 years. This extensive experience validates the aggressive surgical approach to remove residual lung or mediastinal disease after chemotherapy for metastatic nonseminomatous germ cell testicular cancer. Jerome P. Richie, M.D.
1311
Urological Oncology: Testis Cancer Re: Survival After Resection for Metastatic Testicular Nonseminomatous Germ Cell Cancer to the Lung or Mediastinum K. A. Kesler, L. E. Kruter, S. M. Perkins, K. M. Rieger, K. J. Sullivan, M. L. Runyan, J. W. Brown and L. H. Einhorn Department of Surgery, Cardiothoracic Division, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana Ann Thorac Surg 2011; 91: 1085–1093.
Background: Since the advent of cisplatin-based chemotherapy, nonseminomatous germ cell tumors (NSGCT) have been considered one of the most curable solid neoplasms and a model for multimodality cancer therapy. We undertook an institutional review of testicular NSGCT patients who underwent operations to remove lung or mediastinal metastases after chemotherapy in the cisplatin era to determine outcomes. Methods: From 1980 to 2006, 431 patients underwent 640 postchemotherapy surgical procedures to remove lung (n ⫽ 159, 36.8%), mediastinal (n ⫽ 136, 31.6%), or both lung and mediastinal (n ⫽ 136, 31.6%) metastases within 2 years of chemotherapy. Multiple variables potentially predictive of survival were analyzed. Results: The overall median survival was 23.4 years, with 295 (68%) patients alive and well after an average follow-up of 5.6 years. There was no survival difference in patients who underwent removal of lung or mediastinal metastases. Pathologic categories of resected residual disease were necrosis (21.5%), teratoma (52.7%), persistent NSGCT (15.0%), and degenerative non-germ cell cancer (10.1%). Multivariable analysis identified older age at time of diagnosis (p ⫽ 0.001), non-germ cell cancer in testes specimen (p ⫽ 0.004), and pathology of residual disease (p ⬍ 0.001) as significantly predictive of survival. Conclusions: Patients who undergo resection of residual lung or mediastinal disease for metastatic testicular NSGCT as a planned approach after cisplatin-based chemotherapy have overall excellent long-term survival. Survival is equivalent comparing hematogenous and lymphatic routes of metastases but depends on the pathology of the resected disease. These results justify an aggressive surgical approach, particularly to remove residual teratoma in the lung or mediastinum after chemotherapy, including multiple surgical procedures if necessary. Editorial Comment: With the advent of chemotherapy in addition to aggressive surgery, nonseminomatous testicular cancer, even when metastatic, has been one of the most successful models for multimodal therapy. Platinum based chemotherapy plus surgical resection for residual disease results in survival rates in the 80% to 90% range. Although the retroperitoneum is the most common site of metastasis, the visceral mediastinum and the lung represent common sites for hematogenous dissemination. The authors review their extensive experience with post-chemotherapy resection of mediastinal and/or pulmonary metastases after platinum based chemotherapy. During a 26-year period 431 patients underwent 640 thoracic surgical procedures. The authors describe their lung and mediastinal operative techniques, postoperative care and followup. There were a total of 6 operative deaths, representing less than 1% of all thoracic procedures. Four of the deaths were related to acute respiratory distress syndrome. With a median followup of at least 5 years, the authors report a 79% survival at 5 years and 73% at 10 years. This extensive experience validates the aggressive surgical approach to remove residual lung or mediastinal disease after chemotherapy for metastatic nonseminomatous germ cell testicular cancer. Jerome P. Richie, M.D.