ORLANDO, FL, USA (UroToday.com) - Noel Clarke reviewed penile, urethral, and testis cancer advancements during 2014. He commenced with a discussion on penile cancer, where he was emphatic in stating that pathology must be accurate and reproducible. To wit, he used the example of central review in the UK (all cases are sent there for review): upstaging and downstaging are frequent at the time of second review in the 155 cases in the study, often resulting in treatment changes. However, in another clever study, 90 cases on a tissue microarray were reviewed by 12 dedicated uropathologists. The rate of changing between T1a and T1b was 41 to 87% (increasing their risk and surgical categories). The authors concluded that the current TNM classification is not sufficient for clinical decision making due to the subjectivity in staging by experts.
He also discussed CIS and organ preservation in penile cancer. In 57 patients reviewed, circumcision or 5FU topical was curative in almost all patients. In T1T2 disease, organ preservation has been used more frequently over the last decade, and the overall survival is high with this management strategy. However, risk stratification is important as poorly differentiated cases are intuitively at higher risk for death.
He also highlighted French data on brachytherapy for low-stage disease showing that overall survival is high and toxicity is low. However, it is rarely used in the USA according to SEER data, and he opined that brachytherapy usage rates are similarly low in Europe.
Several nomograms were published in the last decade to predict outcomes in patients with inguinal nodal disease. A Dutch study showed that extranodal extension is a new variable that can be added to existing nomograms, although it requires validation and the clinical impact is unclear.
Dr. Clarke reviewed two neoadjuvant chemotherapy retrospective studies for advanced disease in the U.S. and Europe showing conflicting results: The U.S. study used a variety of treatments (almost 10 regimens) resulting in pathologic complete response in 10/61 patients, whereas the European study used docetaxel/cisplatin/5FU exclusively in 26 patients with a 60% radiographic response, lower pathologic complete response, and only 12% progression-free survival. Clearly there was selection bias in both studies, and no definitive statement can be made regarding neoadjuvant use in these patients.
Primary urethral cancer is so rare that very few studies on the disease were published this year. A case series consisting of 29 patients with primary urethral squamous cell carcinoma treated with radiation to the perineum/genitalia/inguinal nodes/external iliac nodes and mitomycin-C with 5FU was published: 19/26 evaluable patients had radiologic complete responses. Of the 19 radiologic responders, 8 had disease recurrence at a median of 1 year.
In testis cancer, epidemiology studies show that incidence is going up but so is survival. However, in poorer countries mortality is stable. Prosthesetic implant use at the time of radical orchiectomy was studied in 885 patients, > 200 of which had a prosthesis, with similar surgical complications in both groups.
He also highlighted several recent publications that show surveillance for CS1 is being widely adopted, and this movement is evidence-based. Relapses in NSGCT patients treated initially with active surveillance occurred within 2 years, with near universal chemosensitivity. He stated that follow up beyond 3 years is hard to justify. Late relapses were also all chemosensitive. He cautioned that RPLND is still necessary in 26% of post-chemo patients, especially in high-risk cases.
In seminoma, a new nomogram derived from risk-adapted studies in 744 patients showed that there was an 11% relapse rate in patients managed with active surveillance, and, again, almost all were salvaged with chemotherapy. The nomogram used tumor diameter (4cm cutoff), rete testis invasion, and T stage to estimate relapse risk at 3 years. He stated that the decisions need to be personalized to each patient.
He reviewed the European guidelines which are very ambiguous for management of a 1 cm post chemotherapy retroperitoneal mass. In a retrospective analysis of 47 patients treated by the Boston group, 3 patients relapsed. In a metaanalysis from the same publication, the rate of relapse in 455 patients with postchemotherapy masses < 1 cm was 5%. From the Indiana database, the relapse rate is 9% with 15.5 years median follow up. He concluded by stating that surgery in these patients should only be considered in exceptional circumstances.
Presented by Noel W. Clarke, MBBS, FRCS (Urol), ChM at the 2015 Genitourinary Cancers Symposium - "Integrating Biology Into Patient-Centric Care" - February 26 - 28, 2015 - Rosen Shingle Creek - Orlando, Florida USA
The Christie NHS Foundation Trust, Manchester, United Kingdom
Reported by Phillip Abbosh, MD, PhD, medical writer for UroToday.com