Long-term clinical outcome after postchemo RPLND in men with residual teratoma

[Karen]

J Clin Oncol. 2007 Mar 20;25(9):1033-7. Epub 2007 Jan 29.

Long-term clinical outcome after postchemotherapy retroperitoneal lymph node dissection in men with residual teratoma.Carver BS, Shayegan B, Serio A, Motzer RJ, Bosl GJ, Sheinfeld J.
Department of Urology and Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. [email protected]

PURPOSE: The histologic finding of teratoma occurs in approximately 40% of all postchemotherapy retroperitoneal lymph node dissections (PC-RPLND). We evaluated patients at our institution undergoing initial PC-RPLND for teratoma to determine their clinical outcome. PATIENTS AND METHODS: We identified 210 patients from 1989 to 2003 with nonseminomatous germ cell tumors (NSGCT) who underwent initial PC-RPLND and were found to have only teratoma in the retroperitoneum. Clinical and pathologic information was obtained from our prospective surgical database, and clinical outcome was reported. RESULTS: Of the 210 patients in our series, 192 (92%) received only induction chemotherapy, and 18 (9%) required additional chemotherapy regimens. PC-RPLND pathology revealed mature teratoma in 178 patients (85%), immature teratoma in 15 patients (7%), and teratoma with malignant transformation in 17 patients (8%). With a median follow-up time for survivors of 37 months, disease recurred in 30 patients. The probability of remaining free of disease recurrence at 5 and 10 years was 83% and 80%, respectively. Of the 30 patients with disease recurrence, 10 (33%) had recurrence with teratoma, five (17%) had recurrence with teratoma with malignant transformation, and 15 (50%) had recurrence with viable germ cell tumor. On multivariable analysis, residual mass size and International Germ Cell Cancer Collaborative Group (IGCCCG) risk classification were predictors of disease recurrence (P < .0005 and = .001, respectively). CONCLUSION: PC-RPLND remains critical in the management of patients with NSGCT. Patients found to have teratoma at PC-RPLND have a 10-year probability of freedom from recurrence of 80%. The size of the residual mass and IGCCCG risk classification were significant predictors of disease recurrence.

[JoePSU]

J Clin Oncol. 2007 Mar 20;25(9):1033-7. Epub 2007 Jan 29.

Long-term clinical outcome after postchemotherapy retroperitoneal lymph node dissection in men with residual teratoma.Carver BS, Shayegan B, Serio A, Motzer RJ, Bosl GJ, Sheinfeld J.
Department of Urology and Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. [email protected]

PURPOSE: The histologic finding of teratoma occurs in approximately 40% of all postchemotherapy retroperitoneal lymph node dissections (PC-RPLND). We evaluated patients at our institution undergoing initial PC-RPLND for teratoma to determine their clinical outcome. PATIENTS AND METHODS: We identified 210 patients from 1989 to 2003 with nonseminomatous germ cell tumors (NSGCT) who underwent initial PC-RPLND and were found to have only teratoma in the retroperitoneum. Clinical and pathologic information was obtained from our prospective surgical database, and clinical outcome was reported. RESULTS: Of the 210 patients in our series, 192 (92%) received only induction chemotherapy, and 18 (9%) required additional chemotherapy regimens. PC-RPLND pathology revealed mature teratoma in 178 patients (85%), immature teratoma in 15 patients (7%), and teratoma with malignant transformation in 17 patients (8%). With a median follow-up time for survivors of 37 months, disease recurred in 30 patients. The probability of remaining free of disease recurrence at 5 and 10 years was 83% and 80%, respectively. Of the 30 patients with disease recurrence, 10 (33%) had recurrence with teratoma, five (17%) had recurrence with teratoma with malignant transformation, and 15 (50%) had recurrence with viable germ cell tumor. On multivariable analysis, residual mass size and International Germ Cell Cancer Collaborative Group (IGCCCG) risk classification were predictors of disease recurrence (P < .0005 and = .001, respectively). CONCLUSION: PC-RPLND remains critical in the management of patients with NSGCT. Patients found to have teratoma at PC-RPLND have a 10-year probability of freedom from recurrence of 80%. The size of the residual mass and IGCCCG risk classification were significant predictors of disease recurrence.

I'm curious - how many stage II NSGCT patients require RPLND after chemo?

[David07]

I'm curious - how many stage II NSGCT patients require RPLND after chemo?

This is what I am also wondering about. I don't think it is as common for someone like you (or I) because we dont have teratoma in the pathology report.

After chemo, there should be no residual masses, and hopefully no need for an RPLND.

This is what I am thinking though, and have no idea if I am actually correct in this.

[JoePSU]

This is what I am also wondering about. I don't think it is as common for someone like you (or I) because we dont have teratoma in the pathology report.

After chemo, there should be no residual masses, and hopefully no need for an RPLND.

This is what I am thinking though, and have no idea if I am actually correct in this.

Vaughn told me that sometimes the chemo treatment itself can amplify the mutagenic factors involved with cancer patients, and thus create teratoma where there was none before. There's no way to really know until after treatment. Truthfully, I can deal with the RPLND and teratoma if the malignancy is gone.
I find myself thinking a lot "What if this stuff isn't working?"

[dadmo]

If no teratoma is present then the RPLND should be avoidable. Look at Lance, he had it about as bad as it get and he was able to avoid the RPLND even thought they had to open his skull.

[David07]

JoePSU: They tested my AFP after the first cycle was over and it was on the decline. Hopefully you can have the same test and see the same results. Then you would know its working. I'm sure its working anyways.



dadmo: yeah, thats a good point and I have definitely thought about that.

[Already Bald]

Vaughn told me that sometimes the chemo treatment itself can amplify the mutagenic factors involved with cancer patients, and thus create teratoma where there was none before. There's no way to really know until after treatment. Truthfully, I can deal with the RPLND and teratoma if the malignancy is gone.
I find myself thinking a lot "What if this stuff isn't working?"

I did not know that chemo could create teratoma, probably very rare but disturbing nonetheless. However RPLND will take care of it anyway.
Try not to get bogged with "what if" situations, you have no control over that and it will just play tricks on your head. In my heart I believe your treatments will work, medicine and science has really really got a handle on this disease.
LiveSTRONG

[Fed]

Vaughn told me that sometimes the chemo treatment itself can amplify the mutagenic factors involved with cancer patients, and thus create teratoma where there was none before.

The vast majority of chemo agents work by damaging the DNA of cells that are undergoing division (that's when the DNA is most vulnerable). Bleomycin fragments DNA by oxidizing it; etoposide blocks an enzyme (topoisomerase II) that helps DNA unwind by nicking it; and cisplatin sticks to DNA like glue, altering its 3D structure. Almost all of the time, the damage caused by these agents is so overwhelming that the cells will die; however, the possibility exists in which the damage may actually confer a selective advantage to the cell (think about it as "evolution in action", similar to the way bacteria evolve resistance to antibiotics). This is very unlikely because, as I said above, the DNA damage caused by the BEP combo is massive (a while ago I was using etoposide as a positive control in a cellular assay, and it completely pulverized the cells).

As Already Bald has stated, all of this is beyond your control. Also, the science on these agents has been worked out so well, that the benefits clearly outweigh the minuscule chance of a mutation being able to propagate (case in point, the high cure rates of TC). Thinking about the "what ifs" is likely inevitable, but dwelling on them will just give you headaches and do no good to your mental health.