Peter Albers, MD, started by noting that the survival rate for testis cancer patients is uniformly excellent, however, over the last several years there has been secondary malignancies and cardiovascular-related deaths secondary to treatments patients received for their testis cancer; ie radiotherapy for seminoma.1
Dr. Albers makes the argument that the same chemotherapy regimen (BEP x3) for all CS II tumors is likely over treating a vast majority of CSII patients. As a specific example, he notes a 39-year-old male with a seminoma/embryonal carcinoma, low risk, on active surveillance for 10 months who presented with a new 1.3 cm lesions behind the vena cava. Dr. Albers asks “Would you give this patient 3 cycles of BEP? I wouldn’t” Alternative treatment options according to Dr. Albers are also inferior or not feasible for this patient. Surveillance imaging would take months to show an appreciable change in mass size, CT-guided biopsy is not feasible given the mass size and location, and chemotherapy and radiotherapy would not be feasible without pathology given there is a possibility the mass is benign. The remaining options include robotic RPLND (according to Dr. Albers would be possible, but dangerous given the location of the mass) and open RPLND. Dr. Albers did an open RPLND on this patient revealing a 2.3 cm embryonal carcinoma with another 15 lymph nodes negative on his template, nerve-sparing RPLND.
Specific to seminoma, there are several clinical indications for possible RPLND:
- Initial clinical stage IIA (<2 cm) or IIB (<5 cm) disease
- CS IIA as a recurrence during active surveillance
- CS IIA as a recurrence after carboplatin (5% recurrence risk)
- CS IIA as a late relapse beyond 2 years
- PRIMETEST Trial (NCT 2015053664): 3 centers in Germany – patients may undergo robotic or open RPLND
- SEMS Trial (NCT 02537548): open RPLND in CS IIA seminoma at 15 centers in Canada and the US
Specific to CS II NSGCT, Dr. Albers highlighted the 1987 classic paper2 in which all patients underwent orchiectomy and RPLND and then were randomized to two cycles of BEP (n=97) or surveillance and treatment at recurrence (n=98). 6% of patients in the adjuvant treatment group recurred, with a 97% survival rate, whereas 49% of patients in the surveillance group recurred, with a 95% survival rate. Thus, RPLND with surveillance offered no difference in survival with less chemotherapy burden. The only comparative trial assessing RPLND (+ 2 cycles of chemotherapy; Arm A, n=109) or primary chemotherapy (3-4 cycles of chemotherapy; Arm B, n=78) in CS IIA/B NSGCT was reported in 2000 [3]. In arm A, 12% had pathological stage (PS) I, 70% PS II A/B, and 18% PS II C/III. In arm B, 67% achieved complete remission with chemotherapy alone, while 33% required a subsequent RPLND. After a median follow-up of 36 months, 7% of the patients in arm A and 11% in arm B had relapsed. There was no difference in quality of life between the two arms.
Dr. Albers summarized this talk advocating for RPLND in marker-negative CS II testis cancer with the following take-home messages:
- RPLND is frequently necessary to get histology
- RPLND in CS II seminoma: in a trial setting only (PRIMETEST or SEMS)
- RPLND in CS II NSGCT: is a valid option but only in experienced hands, with the trade-off of potentially unnecessary surgery vs the potential for long-term toxicity
- Laparoscopic or robotic RPLND is possible in very selected cases
Presented by: Peter Albers, MD, University Hospital Dusseldorf, Dusseldorf, Germany
Written By: Zachary Klaassen, MD, MSc, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic
Read the Opposing Side of the Debate: The Role of RPLND in Tumor Marker Negative Stage IIA-B: CON
References:
- Kvammen O, Myklebust TA, Solberg A, et al. Long-term relative survival after diagnosis of testicular germ cell tumor. Cancer Epidemiol Biomarkers Prev 2016 May;25(5):773-779.
- Williams SD, Stablein DM, Einhorn LH, et al. Immediate adjuvant chemotherapy versus observation with treatment at relapse in pathological stage II testicular cancer. N Engl J Med 1987 Dec 3;317(23):1433-1438.
- Weissbach L, Bussar-Maatz R, Flechtner H, et al. RPLND or primary chemotherapy in clinical stage IIA/B nonseminomatous germ cell tumors? Results of a prospective multicenter trial including quality of life assessment. Eur Urol 2000 May;37(5):582-594.