Wednesday, May 28, 2014

AUA Highlights: Testis Cancer, by Dr. Pierorazio

Although a relatively rare malignancy, testis cancer affects approximately 9k men and boys each year.  While not as common or popular as some other urological malignancies, representation in the scientific sessions at the 2014 American Urological Association (AUA) Annual Meeting in Orlando, Florida was excellent.  Here are some of the thematic highlights, click on the links below to read the abstracts:

1. Access to care, epidemiological variation and cost-effectiveness in the treatment of testis cancer.

Because testis cancer is a rare disease, understanding of early symptoms, screening and access to health care can have huge implications regarding the treatment and eventual outcomes of disease.  The following presentations addressed some of these issues.  

In a study of nearly 6,000 men in the SEER (Surveillance, Epidemiology, End Results) database, uninsured men were more likely to present with advanced or metastatic disease, get radiation therapy if they had Seminoma (indicating advanced disease) and die of testis cancer.
PD5-02: The impact of lack of insurance on testicular cancer prognosis in young patients in the United States. Data from the SEER data base. Mohamed Kamel*, Mohammed Elfaramawi, Supriya Jadhav, Rodney Davis, Little Rock, AR.

In another study involving the National Cancer Database Registry, investigators from Vanderbilt University looked at compliance rates with the National Comprehensive Cancer Network (NCCN) Guidelines - which recommend serum tumor markers be drawn prior orchiectomy.  The authors found that young patients, low income patients, those treated at an academic center outside of the South or Midwest were more likely to be treated in compliance with the NCCN Guidelines.
MP10-03: The Influence of Access to Care on Adherence to Clinical Practice Guidelines for Testis Cancer.  C.J. Stimson*, Zachary Reardon, Nashville, TN, Sanjay Patel, Chicago, IL, Harras Zaid, Samuel Kaffenberger, Daniel Barocas, Matthew Resnick, Sam Chang, Nashville, TN

In a second study using the National Cancer Database Registry, researchers looked at over 75k men with testis cancer and found that non-Caucasian men had higher rates of advanced (Stage III) disease and worse overall survival.  African-American men had the highest rates of testis cancer-specific death.
MP10-05: Influence of race on outcomes in testicular cancer: Analysis of 75902 patients in the National Cancer Database.  Claudio Jeldres*, Craig R. Nichols, Khanh Pham, Seattle, WA, Sia Daneshmand, Los Angeles, CA, Christian Kollmannsberger, Vancouver, Canada, Brandon Hayes-Lattin, Portland, OR, Erika Wolff, Katherine Odem-Davis, Christopher R. Porter, Seattle, WA

In a cost-effectiveness analysis, researchers from Kansas City, Kansas examined the role of testicular self-examination in asymptomatic men.  Using Medicare reimbursements to estimate costs, they calculated that the cost of treating an advanced stage testis cancer was roughly $50k, while the costs of office evaluation ranged from $150-600, and the cost of an orchiectomy for early-stage disease is approximately $20k.  Therefore, they concluded - contrary to the recommendation of the US Preventative Services Task Forces (USPSTF) - that testicular self-examination is cost-effective and should not be discouraged.
MP10-11: TESTICULAR SELF-EXAMINATIONS: A COST ANALYSIS. Michael Aberger*, Bradley Wilson, Jeffrey Holzbeierlein, Tomas Griebling, Ajay Nangia, Kansas City, KS

2. Treatment of early stage disease.

The treatment of Clinical Stage 1 testis cancer is evolving (click here to see our blog on the treatment of clinical stage 1 NSGCT).  Most patients are cured with orchiectomy alone, and the remainder can be salvaged with chemotherapy and/or surgery.  Therefore active surveillance is emerging as the most common management strategy for these patients with primary retroperitoneal lymph node dissection (RPLND) and chemotherapy as second options.  However, given the young age and relatively good health of men with testis cancer, the long-term implications of each management strategy are not fully realized.  These presentations address this topic.

To investigate the use of active surveillance for Stage 1 testis cancer, researchers in this study used data from the 75k men in the National Cancer Database Registry with testicular cancer.  For Clinical Stage 1 Seminoma, they found the rates of active surveillance increased from 25% to 55% over the time period from 1998-2011 with a concomitant decrease in radiation from 72% to 28%.  Interestingly, for non-seminomatous germ cell tumors the rates of active surveillance remained stable (58-66%) while rates of primary chemotherapy increased (28%) and retroperitoneal lymph node dissection (RPLND) decreased (12.9%) in 2011.  However, in 2011, 50% of patients with cT1a disease received chemotherapy and not active surveillance.
PD5-04: United States trends in patterns of care in clinical stage I testicular cancer: Results from the National Cancer Data Base (1998-2011).  Claudio Jeldres*, Craig R. Nichols, Khanh Pham, Seattle, WA, Sia Daneshmand, Los Angeles, CA, Christian Kollmannsberger, Vancouver, Canada, Brandon Hayes-Lattin, Portland, OR, Erika Wolff, Katherine Odem-Davis, Christopher R. Porter, Seattle, WA

In a retrospective study of 48 men with clinical stage 1 seminoma on active surveillance, only 2 patients recurred giving a 95% recurrence free survival at 3 years.
MP10-06: Lower-Than-Expect Relapse Rate Among Contemporary Patients with Clinical Stage I Seminoma Managed on Surveillance.  Cesar Ercole*, Cleveland, OH, Estefania Linares, Madrid, Spain, Maria Mir, Yaw Nyame, Daniel Greene, Timothy Gilligan, Andrew Stephenson, Cleveland, OH

In an update of prospective, single arm, phase II clinical trial, 40 patients with high-risk clinical stage 1 non-seminomatous germ cell tumors received one cycle of BEP (Bleomycin, Etoposide and Cisplatinum chemotherapy).  With 15-years of follow-up, one patient recurred and died of metastases, three developed a contralateral testis tumor and three developed a secondary malignancy.
MP10-09: Fifteen years after treatment with one adjuvant cycle of Etoposide, Bleomycin and Cisplatin chemotherapy outcomes in patients with high risk nonseminomatous germ cell tumors clinical stage I. Extended follow up of a prospective single arm clinical trial cohort. Alvaro Vidal Faune*, George N. Thalmann, Martin Fey, Urs E. Studer, Bern, Switzerland

3. Retroperitoneal lymph node dissection (RPLND) for advanced (retrocrural) disease

While the overall survival rate for patients with testis cancer is excellent, after chemotherapy, some patients will develop chemotherapy-resistant teratoma that must be resected surgically.  One of the more challenging locations for a teratoma is behind the diaphragm in the retrocrural space.  At Johns Hopkins, we do these surgeries with either thoracic or vascular surgeons depending on the location and appearance of the tumor.

Two of the leading centers in the treatment of advanced testicular cancer, Indiana University and Memorial Sloan Kettering Cancer Center in New York, presented their experiences with retrocrural metastases.  In both series, the majority of tumors were teratoma.  A variety of incisions were described, with the most common being an abdominal approach with trans-diaphragmatic access when necessary.  Both centers prescribed to joint surgery involving both urology and thoracic surgery.  At Johns Hopkins, we do these surgeries with either thoracic or vascular surgeons depending on the location and appearance of the tumor.
PD5-05: SURGICAL MANAGEMENT OF RETROCRURAL DISEASE IN TESTIS CANCER: OUTCOMES AND EVOLUTION OF PRACTICE.  Hristos Kaimakliotis*, K Clint Cary, Jose Pedrosa, Timothy Masterson, Richard Bihrle, Kenneth Kesler, Richard Foster, Indianapolis, IN
PD5-06: Retrocrural dissection during retroperitoneal lymph node dissection for testicular cancer.  Itay Sternberg*, Brett Carver, Melanie Bernstein, Joel Sheinfeld, New York, NY

Read the entire abstracts:
For podium presentations (PD5-), click here.
For poster presentations (MP10-), click here.

Phillip M. Pierorazio, MD is the Director of the Division of Testicular Cancer at the Brady Urological Institute at Johns Hopkins.  


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