Presentation on theme: "Testis Cancer The Management of Residual Masses Post-chemotherapy"— Presentation transcript:
1Testis Cancer The Management of Residual Masses Post-chemotherapy Dr Manish I. PatelUrologic OncologistWestmead Hospital / University of Sydney
2Questions to be Answered. Do all masses have to be resected or can the histology be accurately predicted?Do normal (or minimal) residual masses in the RP need resection?Is a modified template safe?Is nerve sparing safe?Is there a place for surgery post salvage chemo?When do you resect a post-chemo seminomatous mass?Is there any way to predict the histology?
3NSGCT-Resection of tumor is important. Teratoma:Chemo-resistant (Baniel et al. JCO 1995)Resection is curative.Unpredictable malignant potential- TMT.Late relapse.Median relapse time is 5-7 years.-flawed by short FU studies.
4Resection of Viable Cancer is Important. Predicitive Factors of OutcomeIn patients with viable cancer onMultivariate analysis.Complete resectionProportion of viable cancer cellsGood risk IGCCC criteriaComplete resection for viable GCTMay be curativePrognostic
5Surgery for necrosis is not beneficial. Need to accurately predict those with necrosis.Minimise morbidity of surgery.
6Accurately predicting the histology of PC residual masses has been difficult. ReHit Study Group716 PC RPLND Histology from 6 centers.>90% residual masses >5mmHistology of mass not resected by various policiesInstit.PolicyNNecrosisTeratomaCancerResect None71645%42%13%Indiana<10mm or >70%red+ 10 T. -ve23772%23%5%Mass <10mm20470%25%SteyerbergPrediction model >70% necrosisSteyerberg JCO (1):18181%7%NetherlandsMass < 10mm and 10 T. -ve11476%17%MSKCC (old)<10mm + prechemo <=30mm11365%30%NRH<20mm+ 10 T. –ve+ prechemo markers normal5288%4%8%
7Malignant Transformation PC-RPLND Good Risk (IGCCCG) Patients Histology of Residual Retroperitoneal Mass Size: MSKCCResidual RPMass SizeTotalCancerTeratomaMalignant TransformationNecrosisNo Mass4115 (37%)26 (63%)<2cm1017 (7%)26 (26%)2 (2%)66 (65%)> 2cm and <5cm3 (7%)21 (51%)17 (42%)>5cm and <10cm173 (18%)10 (59%)4 (24%)>10cm and <20cm53 (60%)1 (20%)1(20%)20513 (6%)75 (37%)3 (2%)114 (56%)Patel et.al. presented AUA 2003
8Teratoma in Retroperitoneum PC-RPLND Good Risk (IGCCCG) Patients Presence of Teratoma in the Residual RP Mass Residual Mass <2cm and Histology of Primary TumorResidual RetroperitonealMass SizeTeratoma in PrimaryTotalTeratoma in RetroperitoneumNo Mass+-182310 (56%)5 (22%)>0cm and <0.5cm61 (17%)2 (33%)>0.5cm and <1.0cm8162 (25%)4 (25%)>1.0cm and <1.5cm73 (38%)1 (14%)>1.5cm and >2.0cm125 (83%)466421 (46%)12 (19%)Patel et.al. presented AUA 2003
987 patients with PC masses <=20mm. 23 patients mass<=5mmAll had RPLNDIncreasing incidence of teratoma with size of mass.No significant pre or post PC factor predicted necrosis.
10Decision analysis model predicts increased survival with resection of minimal residual masses. Decision analysis model for estimating survival achieved by resection or observation of minimal residual masses.According to the model:Survival=+2 years with resection of masses 10-20mm.Survival=+1 year with resection of masses 0-10mm.
11Indiana University Outcomes of patients with RP disease who underwent induction chemotherapy Median FU approx 4 years.A: No residual mass (n=78). OBSERVE5/78 NED patients: recurrent disease. 4/5 in RPB: Unresectable (n=50). Mainly marker elevation.C: Residual mass, 10 Teratoma +ve (n=90).RPLND10 did not have RPLND.8/86 NED patients relapsed. 6 distant, 2 in RP.D: Residual mass, 10 Teratoma –ve, <90% radiographic PR (n=50).RPLND5/48 NED patients relapsed. 1 in RPE: Residual mass, 10 Teratoma –ve, >90% radiographic PR (n=27).OBSERVE2/23 NED patients relapsedSurvival
12Complete Resection after Salvage Chemotherapy is Paramount! 580 PC-RPLND at Indiana University.417 after induction chemo.(markers normal)10% viable cancer rate.163 after salvage chemotherapy (markers normal)55% (90) viable cancer rate.53/90 were able to be completely resected.25 had adjuvant chemotherapy: only 9 (36%) cNED28 had no adj. Chemotherapy: 23 (43%) cNEDAll incompletely resected patients died.Imperative to resect all post-salvage chemo masses.Must attempt complete resection as post-op Chemo does not appear effective.Fox et.al. JCO 1993; 11(7): 1294
13Desperation Surgery Has A Place. When all chemotherapy options have been exhausted, surgical resection is an option.Solitary RP masses have a much better outcome.2 studies Murphy and Wood.63 patients underwent desperation surgery.50/63 had a complete resection.17/50 (34%) are cNED with no further therapy.6/50 (12%) are NED with further chemotherapy.Murphy et.al.J Clin Oncol, 11:324, 1993Wood et al. Cancer, 70: 2354, 1992
14What type of surgery is required? With extensive prechemo disease in the RP, a full bilateral dissection is required.The incidence of tumor away from the primary landing zone or main mass is common. (Donohue 1982 JUrol 127)The dissection may be limited when the prechemo disease is minimal and limited to the primary landing zone.Advantage: limited morbidityDisadvantage: RP recurrence
15Only a small number of non-palapable tumors will be located outside the modified dissection template.Herr et.al. J Urol. 1992;148(6):1812-5Studied 113 patients.PC RPLND for initial bulky disease.Tumor was located outside the boundaries of a modified retroperitoneal lymph node dissection in 14/ 60 with residual disease.But tumor was present within a palpable mass in 6/14 patients.If the residual mass was removed and a modified retroperitoneal lymph node dissection was performed only 8% would have tumor left in the retroperitoneum.Rabbani et.al. BJU. 1998; 81(2):50 patients undergoing PC-RPLND39=BRPLND. 1 patient had tumor outside modified template.9= modified RPLND. No recurrence with 55month FU.2= lumpectomy. 1 pt had recurrence.
16Frozen section maybe useful during PC-RPLND. Does necrosis on frozen-section analysis of a mass after chemotherapy justify a limited retroperitoneal resection in patients with advanced testis cancer?HERR, H. W. BJU. 1997; 80(4):62 PC-RPLND patients. Underwent modified RPLND if residual mass showed necrosis only.89% concordance between FS and final parraffin section.4 false negatives, all specimen confined.6 years media FU: 14 relapses, 1 in the RP.
17Nerve-sparing PC-RPLND is safe. Ejaculatory status of 81 patients after nerve sparing PC-RPLND.35 months FU6 recurrences0 in RP.This data confirmed by SD Fossa’s dataBJC (1/2):Lumber nerve roots sparedAntegrade EjaculationTotal PatientsAll Right80%303 right92%122 right67%61 right0%1All Left70%203 Left32 Left75%4Bilateral All5Coogan CL.JUrol. 1996; 156(5) :
1875%-89% incidence of necrosis in lung if necrosis in RP. Brenner et.al. JCO (6): 176524 patients with simultaneous PC-RP and chest + neck resection.6 (25%) patients had discordent pathology.Toginini et.al. JUrol (6): 1833143 patients with simultaneous PC-RP and chest resection.77.5% had the same pathological condition in the chest.7/40 patients showing RP necrosis has viable cancer in their chest.Steyerberg et.al.JUrol (2): 474159 patients undergoing PC-RP and thoracotomy.Neither size nor degree of shrinkage was predicitive of chest pathology.Necrosis in RP correlated with necrosis in chest 89%.Steyerberg et.al. Cancer (2).215 patients, 6 centers (ReHit study).- Predictors of necrosis.no teratoma in primary, normal prechemo markers and single unilateral mass.RP histology is not sufficiently accurate to eliminate the need to resect chest masses.
19Management of Post-Chemo Seminomatous Mass.-MSKCC Surgery n=28Observation n=46Surgery n=27Necrosis=28Relapsed in RPN=2No relapseSeminoma=6Teratoma=2Herr et.al. JUrol (3): 860Puc et.al JCO (2): 454
20Complete Resection is Important. 55 patients PC-RPLND23 well defined masses18 C. Resection.(78%)6 positive histology.32 poorly defined mass.14 C. Resection.(44%)2 positive histology.Ravi et.al BJU 1999Advocated not resecting ill defined masses.All who relapse DODAll incomplete resections DOD
21Management of Post-Chemo Seminomatous Mass.-Indiana University NED n=11relapse n=1Relpase n=1Approx 50% of non-resected masses completely resolveda median of 12 months form chemotherapySchultz et.al. JCO (4): 756
22Prospective studies show a low relapse rate for residual masses =>3cm. DeSantis. JCO 2004; 22:
23FDG-PET is useful in masses >3cm. FDG PET studies in 51 patients with metastatic pure seminoma who had radiographically defined postchemotherapy residual masses, were correlated with either the histology of the resected lesion or the clinical outcomeSupported by other studies in post induction chemotherapy patients.DeSantis. JCO 2004; 22:
24Best Practise.Resect all radiographically visible NSGCT residual masses.Consider resecting normal RP if the primary tumor is teratoma positive.Modified template dissection is safe in small masses in the landing zone.Nerve sparing is safe, works and should be performed where possible.Surgery post salvage chemotherapy is very important.There is a place for desperation surgery.
25Best Practise.Retroperitoneal pathology will not sufficiently accurately predict histology at other sites.PC seminoma residual masses <3cm should be observed.PC seminoma residual masses => 3cm should be imaged with FDG-PET.Complete resection is very important for outcome.