The Role of Surgery in Testis Cancer NW Clarke Manchester UK
The Role of Surgery in Testis Cancer <ul><li>Primary   </li></ul><ul><ul><li>Orchidectomy </li></ul></ul><ul><ul><li>Contr...
Primary Surgery
Contra-Lateral Biopsy 186 Testis Cancer Cases Contra-Lateral Testicular Atrophy and Presenting Age <30 = One Third History...
Contra-Lateral Biopsy 2318 Testis Cancer Patients 5% Incidence of TIN Double Biopsy Improved the Diagnostic Yield by 18%
Testis Cancer – Organ Sparing Surgery Why ? Avoidance of  orchidectomy for benign lesions Preservation of form and functio...
Courtesy of Prof P Albers
Testis Cancer – Organ Sparing Surgery Heidenreich (GTCSG) J Urol 2001 (n = 73) Steiner (Innsbruck) Urology 2003 (n = 30) C...
Testis Preserving Surgery
Testis Cancer – Organ Sparing Surgery Standard EAU Guideline based approach in benign lesions Strict indication and severa...
Surgery and The Absent Testis
Surgery and Surveillance in Clinical Stage 1 Disease Primary RPLND  or  Observation  ±  Adjuvant Chemotherapy for High Risk
Rationale for Primary RPLND <ul><li>Ist Order Spread to RP </li></ul><ul><li>30% Stage 1 have metastases </li></ul><ul><li...
Rationale for Primary RPLND <ul><li>Safe Procedure </li></ul><ul><li>Templates Decrease  </li></ul><ul><li>Morbidity </li>...
Primary Surgery : Failure Rate <ul><li>Mc Cleod et al 1991 (US) </li></ul><ul><li>10% Recurrence rate in Retro - Peritoneu...
Primary RPLND Complications <ul><li>German Testis Study Group </li></ul><ul><li>209 Patients </li></ul><ul><li>Loss of Eja...
Open Surgery vs Laparoscopy <ul><li>Lymph node dissection possible </li></ul><ul><li>Is it as good as open surgery? </li><...
Open Surgery vs Laparoscopy <ul><li>Lymph node dissection possible </li></ul><ul><li>Is it as good as open surgery? </li><...
Open Surgery vs Laparoscopy <ul><li>Lymph node dissection possible </li></ul><ul><li>Is it as good as open surgery? </li><...
Surveillance
Progression on Surveillance Diagnosis
Progression on Surveillance Diagnosis 3 Months
Progression on Surveillance Diagnosis 3 Months 6 Months
Surveillance Studies <ul><li>16 Published Trials </li></ul><ul><li>1771 patients </li></ul><ul><li>28% Relapse Rate </li><...
Chemotherapy vs Primary RPLND
Post Chemotherapy RPLND <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul><ul><li>How ? </li></ul>
Post Chemotherapy RPLND <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
Post Chemotherapy Residual Mass <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
Post Chemotherapy Residual Mass <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
Post Chemotherapy Residual Mass <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
Post Chemotherapy RPLND
Post Chemotherapy RPLND
Post Chemotherapy RPLND <ul><li>Seminoma: </li></ul><ul><ul><li>Less than 3 cm follow-up (<10% viable cancer) </li></ul></...
Post Chemotherapy RPLND Journal of  Urology 2008
Post Chemotherapy RPLND Journal of  Urology 2008
Post Chemotherapy RPLND Journal of  Urology 2008
Post Chemotherapy RPLND in Small Masses
Post Chemotherapy RPLND in Small Masses
Post Chemotherapy RPLND “ CT criteria alone are not sufficiently reliable to distinguish viable tumour or teratoma from ne...
Post Chemotherapy RPLND Retroperitoneal Lymph Node Dissection After Chemotherapy Winter C, Raman J, Sheinfield J, Albers P...
Residual Mass: Fibrosis
Predicting Fibrosis in Residual Masses
Predicting Fibrosis in Residual Masses Albers P et al. J Urol 2004 Prediction of Fibrosis from AFP Reduction and Tumour Sh...
Predicting Fibrosis in Residual Masses
Predicting Fibrosis in Residual Masses
Predicting Fibrosis in Residual Masses
Predicting Fibrosis in Residual Masses
Post Chemotherapy RPLND <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>Post Chemotherapy Resec...
Inferior Survival with Delayed PC-RPLND <ul><ul><li>within 3 months after chemotherapy   5-yrs PFS 83% </li></ul></ul><ul>...
Timing of Post Chemotherapy RPLND <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
Timing of Post Chemotherapy RPLND <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
Sequencing of Surgery <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
Sequencing of Surgery <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
Histology Following Multiple Site Resection <ul><li>Discordant pathology in 30% </li></ul><ul><li>Fibrosis in Pulmonary Le...
Surgical Approach <ul><li>Mid-Line </li></ul><ul><li>Chevron </li></ul><ul><li>Thoraco-Abdominal </li></ul>
Surgical Approach
Template Approaches to PC RPLND
Template Dissection in PC RPLND Carver B et al. JCO 25: 4365 (2007)   Heidenreich et al Eur Urol 55 (2009 )  <ul><li>Carve...
 
Split and Roll Technique
Final Excision
Resection of Associated Structures Hendry et al Cancer 2002
Resection of Associated Structures
Complications of Post Chemotherapy RPLND N=603 (1982-1992) 20.7% complications N=229 (1990-2002) wound infection 2.2 %  ch...
N=603 (1982-1992) 20.7% complications N=229 (1990-2002) wound infection 2.2 %  chylous ascites 1.7 % prolonged ileus 1.7 %...
Outcome of Post Chemotherapy RPLND
Outcome from Post Chemotherapy RPLND  High Volume Tumours <ul><li>Overall 5 year recurrence rate 25% </li></ul><ul><ul><li...
The Role of Surgery in Testis Cancer NW Clarke Manchester UK
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ECCLU 2011 - N. Clarke - Testicular cancer - Role of surgery in the management of testis cancer

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  • ECCLU 2011 - N. Clarke - Testicular cancer - Role of surgery in the management of testis cancer

    1. 1. The Role of Surgery in Testis Cancer NW Clarke Manchester UK
    2. 2. The Role of Surgery in Testis Cancer <ul><li>Primary </li></ul><ul><ul><li>Orchidectomy </li></ul></ul><ul><ul><li>Contra-Lateral Biopsy </li></ul></ul><ul><ul><li>Testis Conservation </li></ul></ul><ul><ul><li>Primary RPLND </li></ul></ul><ul><li>Post Chemotherapy </li></ul><ul><ul><li>Seminoma </li></ul></ul><ul><ul><li>Non-Seminoma </li></ul></ul>
    3. 3. Primary Surgery
    4. 4. Contra-Lateral Biopsy 186 Testis Cancer Cases Contra-Lateral Testicular Atrophy and Presenting Age <30 = One Third History of Cryptorchidism
    5. 5. Contra-Lateral Biopsy 2318 Testis Cancer Patients 5% Incidence of TIN Double Biopsy Improved the Diagnostic Yield by 18%
    6. 6. Testis Cancer – Organ Sparing Surgery Why ? Avoidance of orchidectomy for benign lesions Preservation of form and function in the solitary testis <ul><li>to improve body image </li></ul><ul><li> to reduce psychological distress </li></ul><ul><li> to avoid testosterone substitution </li></ul>
    7. 7. Courtesy of Prof P Albers
    8. 8. Testis Cancer – Organ Sparing Surgery Heidenreich (GTCSG) J Urol 2001 (n = 73) Steiner (Innsbruck) Urology 2003 (n = 30) Carmignani (Milan) J Urol 2003 (n = 15) benign tumors normal postoperative testosterone without local recurrence 85% 90% 100% Local recurrence 5.3% 3.3% 0 % Mean follow-up 91 ms 46 ms 10 ms
    9. 9. Testis Preserving Surgery
    10. 10. Testis Cancer – Organ Sparing Surgery Standard EAU Guideline based approach in benign lesions Strict indication and several precautions (adj. radiation, compliance) Alternative to orchidectomy in solitary testis
    11. 11. Surgery and The Absent Testis
    12. 12. Surgery and Surveillance in Clinical Stage 1 Disease Primary RPLND or Observation ± Adjuvant Chemotherapy for High Risk
    13. 13. Rationale for Primary RPLND <ul><li>Ist Order Spread to RP </li></ul><ul><li>30% Stage 1 have metastases </li></ul><ul><li>70% Node +ve cured long term </li></ul><ul><li>No Compliance Problems </li></ul>
    14. 14. Rationale for Primary RPLND <ul><li>Safe Procedure </li></ul><ul><li>Templates Decrease </li></ul><ul><li>Morbidity </li></ul><ul><li>Laparoscopy Possible </li></ul>
    15. 15. Primary Surgery : Failure Rate <ul><li>Mc Cleod et al 1991 (US) </li></ul><ul><li>10% Recurrence rate in Retro - Peritoneum </li></ul><ul><li>Detected on CT Only </li></ul><ul><li>J Urol 1991 </li></ul><ul><li>Baniel et al (US) </li></ul><ul><li>559 Patients 1965 – 94 </li></ul><ul><li>8% Relapse Rate (76% Pulmonary) </li></ul><ul><li>Marker detection possible in only 14% </li></ul><ul><li>4% Abdominal Complications </li></ul><ul><li>J Urol 1995 </li></ul><ul><li>Heidenreich et al 2003 (Eur) </li></ul><ul><li>5.8% Recurrence Rate (75% Extra / 25% Retro-Peritoneal) </li></ul><ul><li>J Clin Oncol 2003 </li></ul>
    16. 16. Primary RPLND Complications <ul><li>German Testis Study Group </li></ul><ul><li>209 Patients </li></ul><ul><li>Loss of Ejaculation in 7% </li></ul><ul><li>Major Early Complications (5.3%) </li></ul><ul><li>Late Complications (4.4%) </li></ul><ul><li>Chylous Ascites </li></ul><ul><li>Renal Artery / SMA Damage </li></ul><ul><li>Bowel Damage / Colectomy / Colostomy </li></ul><ul><li>Bowel Obstruction </li></ul><ul><li>Pulmonary Embolus </li></ul><ul><li>Heidenreich et al JCO 2003 </li></ul>
    17. 17. Open Surgery vs Laparoscopy <ul><li>Lymph node dissection possible </li></ul><ul><li>Is it as good as open surgery? </li></ul><ul><li>If there is no need to perform a primary lymph node dissection laparoscopy is not indicated ! </li></ul>
    18. 18. Open Surgery vs Laparoscopy <ul><li>Lymph node dissection possible </li></ul><ul><li>Is it as good as open surgery? </li></ul>Rassweiller et al Eur Urol 2008
    19. 19. Open Surgery vs Laparoscopy <ul><li>Lymph node dissection possible </li></ul><ul><li>Is it as good as open surgery? </li></ul><ul><li> If there is no need to perform a primary lymph </li></ul><ul><li>node dissection the use of laparoscopy is academic </li></ul>
    20. 20. Surveillance
    21. 21. Progression on Surveillance Diagnosis
    22. 22. Progression on Surveillance Diagnosis 3 Months
    23. 23. Progression on Surveillance Diagnosis 3 Months 6 Months
    24. 24. Surveillance Studies <ul><li>16 Published Trials </li></ul><ul><li>1771 patients </li></ul><ul><li>28% Relapse Rate </li></ul><ul><li>54% in Retroperitoneum </li></ul><ul><li>Median Time 6 months: 98% in 2 years </li></ul><ul><li>Overall Survival 98% </li></ul><ul><li> Survival on Surveillance = Survival after Surgery </li></ul>
    25. 25. Chemotherapy vs Primary RPLND
    26. 26. Post Chemotherapy RPLND <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul><ul><li>How ? </li></ul>
    27. 27. Post Chemotherapy RPLND <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
    28. 28. Post Chemotherapy Residual Mass <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
    29. 29. Post Chemotherapy Residual Mass <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
    30. 30. Post Chemotherapy Residual Mass <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
    31. 31. Post Chemotherapy RPLND
    32. 32. Post Chemotherapy RPLND
    33. 33. Post Chemotherapy RPLND <ul><li>Seminoma: </li></ul><ul><ul><li>Less than 3 cm follow-up (<10% viable cancer) </li></ul></ul><ul><ul><li>More than 3 cm (12-30% viable cancer): Pet-scan </li></ul></ul><ul><ul><ul><li>If Pet negative: follow-up </li></ul></ul></ul><ul><ul><ul><li>If Pet positive: Surgery </li></ul></ul></ul>
    34. 34. Post Chemotherapy RPLND Journal of Urology 2008
    35. 35. Post Chemotherapy RPLND Journal of Urology 2008
    36. 36. Post Chemotherapy RPLND Journal of Urology 2008
    37. 37. Post Chemotherapy RPLND in Small Masses
    38. 38. Post Chemotherapy RPLND in Small Masses
    39. 39. Post Chemotherapy RPLND “ CT criteria alone are not sufficiently reliable to distinguish viable tumour or teratoma from necrosis. No combination of variables can predict negative retroperitoneal pathology with sufficient accuracy after induction chemotherapy. Un-resected teratoma or viable GCT are at least partly chemo-refractory and if untreated, will progress. “ Retroperitoneal Lymph Node Dissection After Chemotherapy Winter C, Raman J, Sheinfield J, Albers P: BJUI 2009
    40. 40. Post Chemotherapy RPLND Retroperitoneal Lymph Node Dissection After Chemotherapy Winter C, Raman J, Sheinfield J, Albers P: BJUI 2009
    41. 41. Residual Mass: Fibrosis
    42. 42. Predicting Fibrosis in Residual Masses
    43. 43. Predicting Fibrosis in Residual Masses Albers P et al. J Urol 2004 Prediction of Fibrosis from AFP Reduction and Tumour Shrinkage
    44. 44. Predicting Fibrosis in Residual Masses
    45. 45. Predicting Fibrosis in Residual Masses
    46. 46. Predicting Fibrosis in Residual Masses
    47. 47. Predicting Fibrosis in Residual Masses
    48. 48. Post Chemotherapy RPLND <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>Post Chemotherapy Resection 6-8 Weeks After Cessation of Chemotherapy
    49. 49. Inferior Survival with Delayed PC-RPLND <ul><ul><li>within 3 months after chemotherapy 5-yrs PFS 83% </li></ul></ul><ul><ul><li>surveillance – re-induction chemotherapy </li></ul></ul><ul><ul><li>salvage surgery 5-yrs PFS 62% </li></ul></ul><ul><ul><li>Hendry WF Cancer 2002 94:1668-76 </li></ul></ul>n = 442 (330 vs 112),
    50. 50. Timing of Post Chemotherapy RPLND <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
    51. 51. Timing of Post Chemotherapy RPLND <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
    52. 52. Sequencing of Surgery <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
    53. 53. Sequencing of Surgery <ul><li>Who ? </li></ul><ul><li>When ? </li></ul><ul><li>Where ? </li></ul>
    54. 54. Histology Following Multiple Site Resection <ul><li>Discordant pathology in 30% </li></ul><ul><li>Fibrosis in Pulmonary Lesions predicts Fibrosis in the contra-lateral chest </li></ul><ul><li>Besse et al JThorac Cardiovasc Surg 2009 </li></ul>Eur J Cancer 1997
    55. 55. Surgical Approach <ul><li>Mid-Line </li></ul><ul><li>Chevron </li></ul><ul><li>Thoraco-Abdominal </li></ul>
    56. 56. Surgical Approach
    57. 57. Template Approaches to PC RPLND
    58. 58. Template Dissection in PC RPLND Carver B et al. JCO 25: 4365 (2007) Heidenreich et al Eur Urol 55 (2009 ) <ul><li>Carver et al: n = 532 pts (76% with full bilateral) PC-RPLND (1989-2003) </li></ul><ul><ul><li>8% Out of Boundary Recurrence </li></ul></ul><ul><li>Heidenreich et al: 150 Patients randomised to full bil RPLND or Template </li></ul><ul><li>Template Resection is Possible in Selected Patients </li></ul><ul><li>Normal Ejaculation in 85% Template vs 25% Bilateral </li></ul><ul><li>5% Recurrence outside the boundaries </li></ul>
    59. 60. Split and Roll Technique
    60. 61. Final Excision
    61. 62. Resection of Associated Structures Hendry et al Cancer 2002
    62. 63. Resection of Associated Structures
    63. 64. Complications of Post Chemotherapy RPLND N=603 (1982-1992) 20.7% complications N=229 (1990-2002) wound infection 2.2 % chylous ascites 1.7 % prolonged ileus 1.7 % pneumonitis 1.2 % pancreatitis 0.8 % acute renal failure 0.4 % neurological 0.4 % other 2.2 % all complications 10.6% <ul><ul><li>Baniel J et al. J Urol 1995, 153: 976 / Mosharafa AA et al. J Urol 2004, 171:1839 </li></ul></ul>
    64. 65. N=603 (1982-1992) 20.7% complications N=229 (1990-2002) wound infection 2.2 % chylous ascites 1.7 % prolonged ileus 1.7 % pneumonitis 1.2 % pancreatitis 0.8 % acute renal failure 0.4 % neurological 0.4 % other 2.2 % all complications 10.6% <ul><ul><li>Baniel J et al. J Urol 1995, 153: 976 / Mosharafa AA et al. J Urol 2004, 171:1839 </li></ul></ul>Complications of Post Chemotherapy RPLND
    65. 66. Outcome of Post Chemotherapy RPLND
    66. 67. Outcome from Post Chemotherapy RPLND High Volume Tumours <ul><li>Overall 5 year recurrence rate 25% </li></ul><ul><ul><li>RP Only 86% at 2 years </li></ul></ul><ul><ul><li>2 Sites 79% </li></ul></ul><ul><ul><li>3 Sites 41% </li></ul></ul>Journal of Urology 2009
    67. 68. The Role of Surgery in Testis Cancer NW Clarke Manchester UK

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