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Urological Oncology: Testis Cancer
558
TESTIS CANCER
prevalent in the EL group. There were no significant differences in 5-year survival (hazard ratio [HR] 1.09, 95% CI 0.78 –1.50; p⫽0.62), 5-year disease-free survival (HR 1.23, 95% CI 0.75–2.03, p⫽0.41), and local (OR 0.83, 95% CI 0.61–1.13; p⫽0.23) or distant recurrence (OR 0.93, 95% CI 0.72–1.21; p⫽0.60). Interpretation: Extended lymphadenectomy does not seem to confer a significant overall cancer-specific advantage, but does seem to be associated with increased urinary and sexual dysfunction. Funding: The National Institute for Health Research Biomedical Research Centre, London, UK. Editorial Comment: These authors are to be congratulated for their objective data set. In these data extended lymphadenectomy did not appear to produce a cancer specific advantage, but did produce a higher rate of sexual dysfunction. These data suggest that refinements in surgical lymph node approach might be important in this patient cohort, in that cancer survivorship is not impacted by modified lymphadenectomy while sexual function might benefit. Allen Seftel, M.D.
Urological Oncology: Testis Cancer Risk-Adapted Treatment in Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer: The SWENOTECA Management Program T. Tandstad, O. Dahl, G. Cohn-Cedermark, E. Cavallin-Stahl, U. Stierner, A. Solberg, C. Langberg, R. M. Bremnes, A. Laurell, H. Wijkstrom and O. Klepp Department of Oncology, St. Olav’s University Hospital, Trondheim, Norway J Clin Oncol 2009; 27: 2122–2128.
Purpose: To offer minimized risk-adapted adjuvant treatment on a nationwide basis for patients with clinical stage 1 (CS1) nonseminomatous germ-cell testicular cancer (NSGCT). The aim was to reduce the risk of relapse and thereby reducing the need of later salvage chemotherapy while maintaining a high cure rate. Patients and Methods: From 1998 to 2005, 745 Norwegian and Swedish patients were included into a prospective, community-based multicenter Swedish and Norwegian Testicular Cancer Project (SWENOTECA) management program. Treatment strategy depended on the presence or absence of vascular tumor invasion (VASC). VASC-positive patients were recommended brief adjuvant chemotherapy (ACT) with bleomycin, etoposide, and cisplatin (BEP), whereas VASC-negative patients could choose between ACT and surveillance. Results: At a median follow-up of 4.7 years, there have been 51 relapses. On surveillance, 41.7% of VASC⫹ patients relapsed, compared with 13.2% of VASC- patients. After one course of BEP, 3.2% of VASC⫹ and 1.3% of VASC- patients relapsed. The toxicity of adjuvant BEP was low. Eight patients have died, none died from progressive disease. Conclusion: One course of adjuvant BEP reduces the risk of relapse by approximately 90% in both VASC⫹ and VASC- CS1 NSGCT, and may be a new option as initial treatment for all CS1 NSGCT. One course of adjuvant BEP for VASC⫹ CS1 reduces the total burden of chemotherapy compared with surveillance or two courses of BEP. SWENOTECA currently recommends one course of BEP as standard treatment of VASC⫹ CS1 NSGCT, whereas both surveillance and one course of BEP are options for VASC- CS1 NSGCT. Editorial Comment: The authors applied a risk adaptive treatment program using presence or absence of vascular invasion to decide on chemotherapy versus surveillance. For patients with vascular invasion 1 course of adjuvant bleomycin, etoposide and cisplatin was recommended versus 1 course of chemotherapy or surveillance for patients without vascular invasion. This prospective, community based, multicenter trial included 745 patients. Relapse occurred in 51 patients, including 41.7% of those who were vascular positive and did not elect to receive chemotherapy, and 13% of those who were vascular negative. Among patients who received 1 cycle of bleomycin, etoposide and cisplatin relapse occurred in 3% of those who
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
were vascular positive and 1.3% of those who were vascular negative. There was no differentiation in these groups regarding percentage of embryonal carcinoma. Cases that relapsed were managed by salvage chemotherapy with 1 or 2 additional courses of bleomycin, etoposide and cisplatin. A third cycle was administered in cases of complete relapse, and more intensified treatment with ifosfamide in cases of incomplete relapse. Although not randomized, this study consists of a large population that includes many patients diagnosed with stage I disease and multiple participating hospitals. It is clear that patients with vascular invasion should not be offered surveillance. Jerome P. Richie, M.D.
Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Long-Term Results of Brachytherapy for Carcinoma of the Penis Confined to the Glans (N- or NX) R. de Crevoisier, K. Slimane, N. Sanfilippo, A. Bossi, M. Albano, I. Dumas, P. Wibault, K. Fizazi, A. Gerbaulet and C. Haie-Meder Department of Radiation Oncology, Institut Gustave-Roussy, Villejuif, France Int J Radiat Oncol Biol Phys 2009; 74: 1150 –1156.
Purpose: To analyze the results of exclusive interstitial low-dose-rate brachytherapy (BT) for squamous cell carcinoma (SCC) of the penis, strictly confined to the glans. Methods and Materials: A total of 144 patients with SSC of the glans penis were treated with BT. Inguinal nodal dissection was performed in 19% of patients (all N-). After circumcision, BT was performed using the hypodermic needle technique. Median iridium length per patients was 24 cm (range, 4 –108) and median dose was 65 Gy (range, 37–75). Median treated volume was 22 cm(3) (range, 5–110) and median reference isodose rate was 0.4 Gy/h (range, 0.2–1.2). Results: Median follow-up was 5.7 years (range, 0.5–29). The 10-year penile recurrence, inguinal lymph node recurrence, and inguinal nodal metastasis rates were: 20% (CI 95%, 11–29), 11% (CI 95%, 5–17), and 6% (CI 95%, 2–10), respectively. After salvage treatment, 86% patients with local failure were in a complete remission at last follow-up. The 10-year probability of avoiding penile surgery (for complication or local recurrence) was 72% (CI 95%, 62– 82). The 10-year cancer-specific survival rate was 92% (CI 95%, 87–97). Diameter of tumor significantly increased the risk of recurrence (p ⫽ 0.02). The 10-year painful ulceration and stenosis risk rates were: 26% (CI 95%, 17–35) and 29% (CI 95%, 18 – 40), respectively. Seven patients required excision for necrosis. Treated volume and reference isodose rate significantly increased the risk of complications. Conclusion: BT is an effective conservative treatment for SCC confined to the glans. Salvage local treatment is effective. Dose rate should be limited to decrease toxicity. Editorial Comment: This retrospective study included 144 patients with squamous cell carcinoma of the glans penis treated with brachytherapy. There was local recurrence in 20%, urethrostenosis in 29% and painful ulceration in 26% of patients. The main goal of therapy was prevention of functional loss and associated psychosocial morbidity. However, because the series covered an extensive period from 1970 to 2006, there was no evaluation of urinary or sexual functional results or psychosocial morbidity. The article did not convince me that the functional results would necessarily be superior to those obtained with some of the more innovative reconstructive procedures. James E. Montie, M.D.
559
TESTIS CANCER
prevalent in the EL group. There were no significant differences in 5-year survival (hazard ratio [HR] 1.09, 95% CI 0.78 –1.50; p⫽0.62), 5-year disease-free survival (HR 1.23, 95% CI 0.75–2.03, p⫽0.41), and local (OR 0.83, 95% CI 0.61–1.13; p⫽0.23) or distant recurrence (OR 0.93, 95% CI 0.72–1.21; p⫽0.60). Interpretation: Extended lymphadenectomy does not seem to confer a significant overall cancer-specific advantage, but does seem to be associated with increased urinary and sexual dysfunction. Funding: The National Institute for Health Research Biomedical Research Centre, London, UK. Editorial Comment: These authors are to be congratulated for their objective data set. In these data extended lymphadenectomy did not appear to produce a cancer specific advantage, but did produce a higher rate of sexual dysfunction. These data suggest that refinements in surgical lymph node approach might be important in this patient cohort, in that cancer survivorship is not impacted by modified lymphadenectomy while sexual function might benefit. Allen Seftel, M.D.
Urological Oncology: Testis Cancer Risk-Adapted Treatment in Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer: The SWENOTECA Management Program T. Tandstad, O. Dahl, G. Cohn-Cedermark, E. Cavallin-Stahl, U. Stierner, A. Solberg, C. Langberg, R. M. Bremnes, A. Laurell, H. Wijkstrom and O. Klepp Department of Oncology, St. Olav’s University Hospital, Trondheim, Norway J Clin Oncol 2009; 27: 2122–2128.
Purpose: To offer minimized risk-adapted adjuvant treatment on a nationwide basis for patients with clinical stage 1 (CS1) nonseminomatous germ-cell testicular cancer (NSGCT). The aim was to reduce the risk of relapse and thereby reducing the need of later salvage chemotherapy while maintaining a high cure rate. Patients and Methods: From 1998 to 2005, 745 Norwegian and Swedish patients were included into a prospective, community-based multicenter Swedish and Norwegian Testicular Cancer Project (SWENOTECA) management program. Treatment strategy depended on the presence or absence of vascular tumor invasion (VASC). VASC-positive patients were recommended brief adjuvant chemotherapy (ACT) with bleomycin, etoposide, and cisplatin (BEP), whereas VASC-negative patients could choose between ACT and surveillance. Results: At a median follow-up of 4.7 years, there have been 51 relapses. On surveillance, 41.7% of VASC⫹ patients relapsed, compared with 13.2% of VASC- patients. After one course of BEP, 3.2% of VASC⫹ and 1.3% of VASC- patients relapsed. The toxicity of adjuvant BEP was low. Eight patients have died, none died from progressive disease. Conclusion: One course of adjuvant BEP reduces the risk of relapse by approximately 90% in both VASC⫹ and VASC- CS1 NSGCT, and may be a new option as initial treatment for all CS1 NSGCT. One course of adjuvant BEP for VASC⫹ CS1 reduces the total burden of chemotherapy compared with surveillance or two courses of BEP. SWENOTECA currently recommends one course of BEP as standard treatment of VASC⫹ CS1 NSGCT, whereas both surveillance and one course of BEP are options for VASC- CS1 NSGCT. Editorial Comment: The authors applied a risk adaptive treatment program using presence or absence of vascular invasion to decide on chemotherapy versus surveillance. For patients with vascular invasion 1 course of adjuvant bleomycin, etoposide and cisplatin was recommended versus 1 course of chemotherapy or surveillance for patients without vascular invasion. This prospective, community based, multicenter trial included 745 patients. Relapse occurred in 51 patients, including 41.7% of those who were vascular positive and did not elect to receive chemotherapy, and 13% of those who were vascular negative. Among patients who received 1 cycle of bleomycin, etoposide and cisplatin relapse occurred in 3% of those who
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
were vascular positive and 1.3% of those who were vascular negative. There was no differentiation in these groups regarding percentage of embryonal carcinoma. Cases that relapsed were managed by salvage chemotherapy with 1 or 2 additional courses of bleomycin, etoposide and cisplatin. A third cycle was administered in cases of complete relapse, and more intensified treatment with ifosfamide in cases of incomplete relapse. Although not randomized, this study consists of a large population that includes many patients diagnosed with stage I disease and multiple participating hospitals. It is clear that patients with vascular invasion should not be offered surveillance. Jerome P. Richie, M.D.
Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Long-Term Results of Brachytherapy for Carcinoma of the Penis Confined to the Glans (N- or NX) R. de Crevoisier, K. Slimane, N. Sanfilippo, A. Bossi, M. Albano, I. Dumas, P. Wibault, K. Fizazi, A. Gerbaulet and C. Haie-Meder Department of Radiation Oncology, Institut Gustave-Roussy, Villejuif, France Int J Radiat Oncol Biol Phys 2009; 74: 1150 –1156.
Purpose: To analyze the results of exclusive interstitial low-dose-rate brachytherapy (BT) for squamous cell carcinoma (SCC) of the penis, strictly confined to the glans. Methods and Materials: A total of 144 patients with SSC of the glans penis were treated with BT. Inguinal nodal dissection was performed in 19% of patients (all N-). After circumcision, BT was performed using the hypodermic needle technique. Median iridium length per patients was 24 cm (range, 4 –108) and median dose was 65 Gy (range, 37–75). Median treated volume was 22 cm(3) (range, 5–110) and median reference isodose rate was 0.4 Gy/h (range, 0.2–1.2). Results: Median follow-up was 5.7 years (range, 0.5–29). The 10-year penile recurrence, inguinal lymph node recurrence, and inguinal nodal metastasis rates were: 20% (CI 95%, 11–29), 11% (CI 95%, 5–17), and 6% (CI 95%, 2–10), respectively. After salvage treatment, 86% patients with local failure were in a complete remission at last follow-up. The 10-year probability of avoiding penile surgery (for complication or local recurrence) was 72% (CI 95%, 62– 82). The 10-year cancer-specific survival rate was 92% (CI 95%, 87–97). Diameter of tumor significantly increased the risk of recurrence (p ⫽ 0.02). The 10-year painful ulceration and stenosis risk rates were: 26% (CI 95%, 17–35) and 29% (CI 95%, 18 – 40), respectively. Seven patients required excision for necrosis. Treated volume and reference isodose rate significantly increased the risk of complications. Conclusion: BT is an effective conservative treatment for SCC confined to the glans. Salvage local treatment is effective. Dose rate should be limited to decrease toxicity. Editorial Comment: This retrospective study included 144 patients with squamous cell carcinoma of the glans penis treated with brachytherapy. There was local recurrence in 20%, urethrostenosis in 29% and painful ulceration in 26% of patients. The main goal of therapy was prevention of functional loss and associated psychosocial morbidity. However, because the series covered an extensive period from 1970 to 2006, there was no evaluation of urinary or sexual functional results or psychosocial morbidity. The article did not convince me that the functional results would necessarily be superior to those obtained with some of the more innovative reconstructive procedures. James E. Montie, M.D.
559