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Originally published as JCO Early Release 10.1200/JCO.2006.07.6075 on January 29 2007 © 2007 American Society of Clinical Oncology.
Role of the Urologist in Metastatic Testicular Cancer
Indiana University, Indianapolis, IN Testicular cancer is the quintessential disease for a multidisciplinary approach. Skilled radiologic assessment and pathologic diagnosis are necessary before initiation of any therapeutic strategy. Therapeutically, there are three excellent options for clinical stage I nonseminomatous disease: surveillance; retroperitoneal lymph node dissection (RPLND), usually nerve sparing; and primary chemotherapy. Stage II disease, with normal postorchiectomy tumor markers (serum human chorionic gonadotropin and alpha-fetoprotein) and a less than 3-cm maximal dimension of a nodal metastasis, is usually managed with RPLND. The cure rate for node-positive testis cancer with surgery alone is higher than with surgical treatment of nodal metastases from any other type of cancer. Other stage II, and all stage III, patients are treated initially with cisplatin-based combination chemotherapy. There are clearly patients who would be incurable with chemotherapy or surgery alone, but who are cured with chemotherapy followed by RPLND or thoracotomy. The very experienced investigators from Memorial Sloan-Kettering Cancer Center (MSKCC; New York, NY) report on 210 such patients in this issue of the Journal of Clinical Oncology.1 All patients received chemotherapy followed by postchemotherapy RPLND for resection of teratoma. This group of 210 teratoma patients was obtained from a larger group of 532 men who underwent postchemotherapy (PC) RPLND at MSKCC from 1989 to 2003. The presence of teratoma in the orchiectomy specimen is a strong determinant of teratoma in a persistent PC retroperitoneal nodal mass. In a retrospective review from Indiana University from 1987 to 2000, 644 patients were identified who had been treated with induction chemotherapy and PC RPLND. Three hundred seventy-five (58.2%) of 644 had teratomas in the orchiectomy specimen. Of those 375 patients, 321 (85.6%) had teratomas in the PC RPLND. In contrast, of the 269 patients without teratomas in the orchiectomy specimen, 130 patients (48%) had teratomas in the PC RPLND specimen.2 One hundred eleven of these 375 patients had PC retroperitoneal masses 10 cm or larger on abdominal computed tomography. One hundred five (95%) of these 111 patients had teratomas in their PC RPLND. In the MSKCC series, there were 210 PC RPLND patients with teratomas in the resected specimen. The median PC size was 3 cm (range, 1.5 to 5.3 cm). Seventeen (8%) of these 210 patients had malignant transformation of teratoma to non–germ-cell cancer. Patients’ probability of remaining disease free at 5 and 10 years was 83% and 80%, respectively. On multivariate analysis, residual mass size and International Germ Cell Consensus Classification Group (IGCCCG) risk classification at start of chemotherapy were predictors of disease recurrence. Malignant transformation of teratoma is a particularly vexing problem. Teratoma is a pluripotential tissue that can undergo malignant transformation along ectodermal, endodermal, or mesodermal elements. A common pathologic conversion is teratoma transformation to primitive neuroectodermal tumors.3 These transformed tumors have a lower cure rate compared with PC resection of teratoma. There may be some benefit to histologically adapted chemotherapy combined with optimal surgery for patients with malignant transformation of teratoma.4,5 The excellent results achieved at MSKCC and other tertiary centers are less likely to be achieved at centers that do not have significant experience. This not only includes expertise in pathology, radiology, and medical oncology, but especially includes surgical expertise. There are several reports of inferior survival rates in this setting in institutions that do not see significant numbers of patients with germ cell tumors.6-8 Bulky PC teratomas are curable only when completely resected, and the role of the experienced urologist is especially important in these complicated cases. Finally, regardless of the skill of the urologic oncologist, resected teratoma does have a propensity for recurrence just inferior or superior to the resected specimen. Therefore, in regard to postoperative surveillance, it is our opinion that patients with resection of teratomas larger than 2 cm should be followed with abdominal and pelvic computed tomography scans every 4 months for the first 2 postoperative years and every 6 months during years 3 to 5. AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author or immediate family members indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment: N/A Leadership: N/A Consultant: N/A Stock: Lawrence H. Einhorn, Amgen, Glaxo, Biogenidec Honoraria: N/A Research Funds: N/A Testimony: N/A Other: N/A NOTES published online ahead of print at www.jco.org on January 29, 2007 REFERENCES
1. Carver BS, Shayegan B, Serio A, et al: Long-term clinical outcome following post-chemotherapy retroperitoneal lymph node dissection in men with residual teratoma. J Clin Oncol 25:1033-1037, 2007 2. Beck SDW, Foster RS, Bihrle R, et al: Teratoma in the orchiectomy specimen and volume of metastasis are predictors of retroperitoneal teratoma in post-chemotherapy nonseminomatous testis cancer. J Urol 168:1402-1404, 2002[CrossRef][Medline] 3. Ganjoo KN, Foster RS, Michael H, et al: Germ cell tumor associated primitive neuroectodermal tumors. J Urol 165:1514-1516, 2001[CrossRef][Medline] 4. Rebischung C, Cottu PH, Daban A, et al: Germ cell tumors containing non-germ cell neoplasms: Teratoma with malignant transformation. Urol Oncol 6:239-242, 2001 5. Donadio AC, Motzer RJ, Bajorin DF, et al: Chemotherapy for teratoma with malignant transformation. J Clin Oncol 21:4285-4291, 2003 6. Harding MJ, Paul J, Gillis CR, et al: Management of malignant teratoma: Does referral to a specialist unit matter? Lancet 341:999-1002, 1993[CrossRef][Medline] 7. Stiller CA: Non-specialist units, clinical trials and survival from testicular cancer. Eur J Cancer 31A:289-291, 1995 8. Collette L, Sylvester RJ, Stenning SP, et al: Impact of the treating institution on survival of patients with "poor-prognosis" metastatic nonseminoma. J Natl Cancer Inst 91:839-846, 1999
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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