548

Practical Urology: EssEntial PrinciPlEs and PracticE

chemotherapy. This is undertaken because of

but if there is residual disease left after surgery,

the risk of persistent active disease, the presence

the long­term outcome is worse.

of mature teratoma (problems associated with

development of the “growing teratoma syn­

drome”), and the potential for de­differentiation

Salvage Strategies

or sarcomatous change over time in residual

mature teratomatous masses: this can occur in

Salvage treatment is used for early (<2 years) or

up to 17% of residual masses left untreated.

late (>2 years) relapse. Early relapse is usually

PC­RPLND is not usually indicated in semi­

due to platinum resistance, which may be com­

noma,where the incidence of fibrosis is very high

plete at the outset or apparent after an initial

and the technical challenges are greater because

response to primary treatment. In establishing a

of fibrous fusion of the masses with the intima of

diagnosis of “relapse,” it is vital to be aware of

the great vessels. Resection is only indicated in

the pitfalls that can mimic disease persistence or

this setting if the residual mass is >3 cm in diam­

recurrence. These include the growing teratoma

eter and if the mass has positivity on FDG­PET

syndrome, whereby residual masses increase in

scanning, although there is uncertainty even in

size after chemotherapy because of cystic change

this scenario, where it has been shown that there

and transformation from active to mature tera­

is a high false positivity with PET scanning. Its

toma, false­positive marker relapse, new pulmo­

greatest value lies with a negative PET scan in the

nary nodules arising secondary to bleomycin,

presence of a residual mass; this has a very high

and elevations in tumor markers from a

degree of accuracy in predicting fibrosis rather

metachronous new primary testicular cancer.

than active tumor.28 In all other cases, the masses

Approaches to treatment involve rechallenge

should be closely followed by imaging investiga­

with cisplatinum­based chemotherapy,accelera­

tions and tumor marker assay.29 Resection is

tion of cisplatinum dose, use of newer drugs

indicated in NSGCT,2 where the residual masses

including combinations of ifosfamide, pacli­

will contain mature teratoma in 30–40% and

taxel, gemcitabine, and oxaliplatin, high dose

vital cancer in about 10–20%.8 Resections in this

chemotherapy, and “desperation” surgery. There

setting are usually curative if all the residual dis­

is evidence that high dose regimens may confer

ease is removed, and the overall outcome seems

a benefit of around 14%32 and that sequential

to be better if resection is undertaken early rather

high dose chemotherapy (HDC) may be advan­

than when residual lesions show signs of pro­

tageous.33 However, these are toxic regimens and

gression.30 Imaging is usually undertaken

they carry a significant mortality of themselves.

6–8 weeks after the last chemotherapy cycle and

Salvage “desperation” surgery is indicated but

surgery is not usually undertaken if the tumor

only in the very limited circumstances where

markers have not normalized. In these circum­

there is a feasible chance of resecting all residual

stances, further chemotherapy is given before

tumor tissue. Patients generally do not benefit

assessment of response and surgery if appropri­

from this type of extensive surgery if all disease

ate at that time. The surgery is technically chal­

cannot be removed.

lenging and should not be undertaken outside

specialist centers. It involves full mobilization of

Conclusion

the great vessels using the “split and roll” tech­

nique (Fig. 39.4e) and resection of concomitant

structures (kidney/bowel/caval resection/aortic

Testis cancer is an uncommon malignancy but it

replacement) is required in some circumstances.

is the most common cancer in young men. With

There is debate as to whether bilateral or

early diagnosis and appropriate treatment in

template­based PC­RPLND should be used.

expert centers, the long­term results are excel­

Bilateral procedures induce ejaculatory failure

lent in good prognosis cases. In intermediate

but there is a small risk of leaving vital disease

prognosis disease, the considerable majority of

using template methods in all cases. Data from

patients are cured long term, but in poor prog­

the USA and Europe has now shown that template

nosis testis cancer, mortality is still significant

techniques are quite safe when used in selected

and new approaches are required. By compari­

cases.8,31 Following resection, the long­term out­

son with the outcomes from recent history in

come is excellent if all disease can be resected,

this disease, the advances in the last 30 years of

testis cancer treatment are a testimony to the

18.

Oliver RTD et al. Radiotherapy versus single­dose

benefits of collaborative translational science,

carboplatin in adjuvant treatment of stage I seminoma:

clinical trial planning, and risk­adapted thera­

a randomised trial. Lancet. 2005;366(9482):293­300

19.

Warde P et al. Prognostic factors for relapse in stage

peutic approaches. As a consequence, this dis­

I seminoma managed by surveillance: a pooled analysis.

ease is now curable in the great majority.

J Clin Oncol. 2002;20:4448

20.

Aparicio J et al. Risk­adapted management for patients

with clinical stage I seminoma: the Second Spanish

References

Germ Cell Cancer Cooperative Group study. J Clin

Oncol. 2005;23:8717­8723

21.

Carver B et al. Improved clinical outcome in recent

1.

Horwich A, ed. Testicular Cancer—Investigation and

years for men with metastatic nonseminomatous germ

Management. 2nd ed. London: Chapman and Hall; 1996

cell tumors. J Clin Oncol. 2007;25(35):5603­5608

2.

EAU Guidelines on Management of Testis Cancer 2008;

22.

Collette L et al. Impact of the treating institution on sur­

www.uroweb.org

vival of patients with “poor­prognosis” metastatic non­

3.

Heidenreich A et al. Organ sparing surgery for malignant

seminoma. European Organization for Research and

germ cell tumor of the testis. J Urol. 2001;166(6):2161­2165

Treatment of Cancer Genito­Urinary Tract Cancer

4.

Giannarini G et al. Organ­sparing surgery for adult tes­

Collaborative Group and the Medical Research Council

ticular tumours: a systematic review of the literature.

Testicular Cancer Working Party. J Natl Cancer Inst.

Eur Urol. 2010;57:780­790

1999;91(10):839­846

5.

Harland SJ et al. Intratubular germ cell neoplasia of the

23.

Culine S et al. Refining the optimal chemotherapy regi­

contralateral testis in testicular cancer: defining a high

men for good­risk metastatic nonseminomatous germ­

risk group. J Urol. 1998;160(4):1353­1357

cell tumors: a randomized trial of the Genito­Urinary

6.

Dieckmann KP et al. Diagnosis of contralateral testicu­

Group of the French Federation of Cancer Centers

lar intraepithelial neoplasia (TIN) in patients with tes­

(GETUG T93BP). Ann Oncol. 2007;18:917

ticular germ cell cancer: systematic two­site biopsies

24.

Motzer RJ et al.Phase III randomized trial of conventional­

are more sensitive than a single random biopsy. Eur

dose chemotherapy with or without high­dose chemo­

Urol. 2007;51(1):175­183

therapy and autologous hematopoietic stem­cell rescue as

7.

Krege S et al. European consensus conference on diagno­

first­line treatment for patients with poor­prognosis met­

sis and treatment of germ cell cancer: a report of the sec­

astatic germ cell tumors. J Clin Oncol. 2007;25(3):247­256

ondmeetingof theEuropeanGermCellCancerConsensus

25.

Travis LB et al. Second cancers among 40,576 testicular

group (EGCCCG): part I+II. Eur Urol. 2008;53(3):478­513

cancer patients: focus on long­term survivors. J Natl

8.

Heidenreich A et al. Postchemotherapy retroperitoneal

Cancer Inst. 2005;97(18): 1354­1365

lymph node dissection in advanced testicular cancer: radical

26.

Belt­Dusebout AW et al. Treatment­specific risks of sec­

or modified template resection. Eur Urol.2009;55:217­226

ond malignancies and cardiovascular disease in 5­year

9.

Read G et al. Medical Research Council prospective

survivors of testicular cancer. J Clin Oncol. 2007;25:4370

study of surveillance for stage I testicular teratoma.

27.

Huddart RA et al. J Clin Oncol. 2003;21(8):1513­1523

Medical Research Council Testicular Tumors Working

28.

Hinz S et al.The role of positron emission tomography in

Party. J Clin Oncol. 1992;10(11):1762­1768

the evaluation of residual masses after chemotherapy for

10.

Freedman L et al. Histopathology in the prediction of

advanced stage seminoma. J Urol. 2008;179(3):936­940

relapse of patients with stage I testicular teratoma treated

29.

Schmoll HJ, EGCCCG, et al. European consensus on

by orchidectomy alone. Lancet. 1987;2(8554):294­298

diagnosis and treatment of germ cell cancer: a report of

11.

Sternberg CN. The management of stage I testis cancer.

the European Germ Cell Cancer Consensus Group

Urol Clin North Am. 1998;25(3):435­449

(EGCCCG). Ann Oncol. 2004;15:1377­1399

12.

Albers P. Management of stage I testis cancer. Eur Urol.

30.

Hendry WF et al. Metastatic nonseminomatous germ

2007;51(1):34­43

cell tumors of the testis: results of elective and salvage

13.

Heidenreich A et al. J Urol. 2003;169:1710­1714

surgery for patients with residual retroperitoneal

14.

Tandstad T et al. Risk­adapted treatment in clinical

masses. Cancer. 2002;94:1668­1676

stage I nonseminomatous germ cell testicular cancer:

31.

Beck SD et al. The role of postchemotherapy surgery

the SWENOTECA management program. J Clin Oncol.

in managing metastatic germ cell tumors. Cancer.

2009;27(19):3263

2007;110(12):2601­2603

15.

Fossa SD et al. Optimal planning target volume for stage I

32.

Lorch A et al. J Urol. 2010;184(1):168­173

testicular seminoma: a Medical Research Council ran­

33.

Lorch A et al. Single versus sequential high­dose che­

domized trial.Medical Research Council Testicular Tumor

motherapy in patients with relapsed or refractory germ

Working Group. J Clin Oncol. 1999;17(9):3004­3005

cell tumors: a prospective randomized multicenter trial

16.

Jones W et al. Randomized trial of 30 versus 20 Gy in the

of the German Testicular Cancer Study Group. J Clin

adjuvant treatment of stage I Testicular Seminoma: a

Oncol. 2007;25(19):2778­2784

report on Medical Research Council Trial TE18,

34.

Albers P et al. Randomized phase III trial comparing

European Organisation for the Research and Treatment

retroperitoneal lymph node dissection with one course

of Cancer Trial 30942 (ISRCTN18525328). J Clin Oncol.

of bleomycin and etoposide plus cisplatin chemother­

2005;23(6):1200­1208

apy in the adjuvant treatment of clinical stage I

17.

Travis SM. Risk of second malignant neoplasms among

Nonseminomatous testicular germ cell tumors: AUO

long­term survivors of testicular cancer. J Natl Cancer

trial AH 01/94 by the German Testicular Cancer Study

Inst. 1997;89(19):1429­1439

Group. J Clin Oncol. 2008;26(18):2966­2972