[Show abstract][Hide abstract] ABSTRACT: In 2006, the German Testicular Cancer Study Group initiated an extensive evidence-based national second-opinion network to improve the care of testicular cancer patients. The primary aims were to reflect the current state of testicular cancer treatment in Germany and to analyze the project's effect on the quality of care delivered to testicular cancer patients. A freely available internet-based platform was developed for the exchange of data between the urologists seeking advice and the 31 second-opinion givers. After providing all data relevant to the primary treatment decision, urologists received a second opinion on their therapy plan within <48 h. Endpoints were congruence between the first and second opinion, conformity of applied therapy with the corresponding recommendation and progression-free survival rate of the introduced patients. Significance was determined by two-sided Pearson's χ2 test. A total of 1,284 second-opinion requests were submitted from November 2006 to October 2011, and 926 of these cases were eligible for further analysis. A discrepancy was found between first and second opinion in 39.5% of the cases. Discrepant second opinions led to less extensive treatment in 28.1% and to more extensive treatment in 15.6%. Patients treated within the framework of the second-opinion project had an overall 2-year progression-free survival rate of 90.4%. Approximately every 6th second opinion led to a relevant change in therapy. Despite the lack of financial incentives, data from every 8th testicular cancer patient in Germany were submitted to second-opinion centers. Second-opinion centers can help to improve the implementation of evidence into clinical practice.
[Show abstract][Hide abstract] ABSTRACT: Currently, seminomas account for about 60% of newly diagnosed testicular cancers in Germany, with an increasing trend. In lower tumor stages the main focus is on the avoidance of over therapy. This is of special interest in stage I where radiotherapy, carboplatin monotherapy and surveillance are available therapies as well as in stage IIA/B. Due to high late toxicity, radiotherapy of the retroperitoneal space is obsolete for young patients with clinical stage I and, in its present form, discussed controversially for patients with clinical stage IIA/B. The cause for this paradigm shift is the high percentage of secondary malignancies resulting after radiotherapy of the retroperitoneal space. Furthermore, 10-25% of the patients receiving radiotherapy alone for clinical stage IIA/B seminoma suffer from a relapse of the disease due to tumor recurrence in extraregional lymph nodes. Therefore, an ongoing study is investigating if a combined treatment with neoadjuvant carboplatin and radiotherapy with a limited target volume can reduce toxicity without jeopardizing the cure rate. Patients with residual tumors >3 cm should undergo 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) computed tomography scanning after a minimum interval of 6 weeks after chemotherapy. In the case of a positive FDG-PET-CT result, the further therapeutic strategy should be the subject of interdisciplinary discussions.
Der Urologe 04/2014; 53(4):563-76. · 0.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: With a mean global incidence of 1:14500, congenital adrenal hyperplasia (CAH) is the most common disorder of sexual differentiation (DSD). In case of female karyotype, the prenatal surplus of androgens causes virilization of the external genitalia. This includes clitoral hypertrophy and an increasing higher confluence of the urethra and normal developed proximal vagina, creating the urogenital sinus. Internal genitalia are female.
Until recently feminizing surgery was performed within the first 18 months of life, at least concerning clitoroplasty. Though the cosmetic result of this kind of surgery is quite good, functional shortcomings like clitoral hyposensibility were often reported.
The latest discussion about treatment of intersex patients resulted in recommendations to prevent early surgery and observe the development of the child, until the child can decide for itself, if and in what direction it wants to undergo surgery. Though CAH patients are seen as a special group within intersex disorders, these recommendations should also be considered for them. The appropriateness of this change in treatment strategy is supported by publications concerning the long-term follow-up of patients, who finally chose a gender that was different from what physicians and parents had expected.
[Show abstract][Hide abstract] ABSTRACT: Testicular cancer currently shows excellent rates of curing and even in advanced stages of disease about 70% can be achieved. This was possible due to continuously carrying out studies. To reduce long-term toxicity the focus is now put on reduction of treatment. In nonseminomatous germ cell cancer this is discussed especially for stage I disease where different therapeutic strategies can be offered. Concerning advanced disease the aim is a further improvement of treatment results. Polychemotherapy and surgical procedures are equally important in this scenario. Concerning residual tumor resection it should always be considered that the procedure can be extended by adjuvant surgery, e.g. cava resection. Therefore, those resections should only be performed at centers where all possibly needed surgical disciplines are available.
[Show abstract][Hide abstract] ABSTRACT: Imaging studies are an integral and important diagnostic modality to stage, monitor, and follow-up patients with metastatic urogenital cancer. The currently available guidelines on diagnosis and treatment of urogenital cancer do not provide the clinician with evidence-based recommendations for daily routine. It is the aim of the current manuscript to develop scientifically valid recommendations with regard to the most appropriate imaging technique and the most useful time interval in metastatic urogenital cancer patients undergoing systemic therapy.
Therapeutic response of soft tissue metastases is evaluated with the use of the RECIST criteria. In skeletal metastases, bone scans with validated algorithms must be performed to assess response. In patients with testicular germ cell tumors, computed tomography (CT) of the chest, the retroperitoneum, and the abdomen represents the standard imaging technique of choice usually performed prior to and at the end of systemic chemotherapy. Only in seminomas with residual tumors > 3 cm in diameter should FDG-PET/CT be performed about 6 weeks after chemotherapy. Metastatic renal cell carcinomas treated with molecular targeted therapies are routinely evaluated by CT scans at 3 month intervals. In specific cases, FDG-PET/CT is able to predict responses as early as 8 weeks after initiation of treatment. In patients with metastatic urothelial carcinomas, imaging studies should be performed after every second cycle of cytotoxic therapy. In patients with metastatic prostate cancer, the modality and the frequency of imaging studies depends on the type of the treatment. In men undergoing androgen deprivation therapy, no routine imaging studies are recommended except for patients with new onset symptoms or significant PSA progression prior to change of treatment. In men with metastatic castration-resistant PCA who are treated with cytotoxic regimes, routine imaging studies in the presence of decreasing or stable PSA serum concentrations are not indicated. In men treated with lyase inhibitor or inhibitors of the androgen receptor signaling cascade, imaging studies should be performed at 3 month intervals due to the low correlation of PSA serum concentrations with clinical response.
Imaging studies to assess therapeutic response to systemic treatment in metastatic cancers of the urogenital tract must be chosen depending on the treatment regime, primary organ, and potential consequences of the findings. Routine imaging studies without specific clinical or therapeutic relevance are not justified.
Der Urologe 11/2013; 52(11):1564-73. · 0.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Standard chemotherapy with gemcitabine and cisplatin in advanced urothelial cancer of the bladder results in median overall survival of 14 months (1). Triplet chemotherapy regimens or high-dose chemotherapy failed to improve OS (2-4). The success of targeted therapies in some tumor entities as renal cell cancer, hepatocellular carcinoma or breast cancer led to studies in almost all other tumor entities. Based on the fact that these novel agents bind to specific receptors it seemed rationale to choose a target overexpressing its specific receptor in the tumor to be treated. In urothelial cancer the vascular endothelial growth factor receptor (VEGFR), epidermal growth factor receptor (EGFR) and Her-2/neu , a transmembrane tyrosine-kinase growth factor receptor, are known to be overexpressed in a substantial amount (5-9).
[Show abstract][Hide abstract] ABSTRACT: Die bildgebende Diagnostik stellt einen integralen Bestandteil der Diagnostik, der Verlaufskontrolle sowie der Nachsorge von Patienten mit einem metastasierten Malignom des Urogenitaltrakts dar. Die aktuellen Leitlinien sprechen nur eine selten evidenzbasierte Empfehlung bezüglich der optimalen Modalität und Zeitintervalle der Bildgebung unter medikamentöser Tumortherapie (MTT) aus. Es ist Zielsetzung der vorliegenden Arbeit, den uroonkologisch tätigen Mediziner mit wissenschaftlich belegten Empfehlungen zur bildgebenden Diagnostik unter MTT urogenitaler Malignome auszustatten.Grundlage der Beurteilung des therapeutischen Ansprechens von Weichteilmetastasen unter MTT stellen die RECIST-Kriterien (,,response evaluation criteria in solid tumors“) dar, das Ansprechen ossärer Metastasen erfolgt mittels Skelettszintigraphie (SZ) und objektiven Algorithmen. Bei Patienten mit metastasierten testikulären Keimzelltumoren (KZT) stellt die Computertomographie (CT) des Thorax, des Abdomens und kleinen Beckens die Bildgebung der Wahl nach abgeschlossener Systemtherapie dar. Lediglich bei seminomatösen KZT mit einem retroperitonealen Residualtumor ≥ 3 cm wird eine Fluordesoxyglukose-Positronenemissionstomographie (FDG-PET)/CT gefordert. Beim metastasierten Nierenzellkarzinom unter molekularer Therapie ist die bildgebende Diagnostik mittels CT in dreimonatlichen Intervallen sinnvoll. Eine FDG-PET/CT kann bereits 8 Wochen nach Therapiebeginn Aussagen über ein therapeutisches Ansprechen zulassen. Beim metastasierten Urothelkarzinom sollte eine Bildgebung nach jedem 2. Zyklus der systemischen Chemotherapie erfolgen. In Abhängigkeit der Metastasenlokalisation stehen CT, SZ oder konventionelles Röntgen zur Verfügung. Beim metastasierten Prostatakarzinom (PCA) unter Androgendeprivation ist eine bildgebende Diagnostik nur bei symptomatischer Progression oder geplanter Therapieänderung erforderlich; ansonsten gilt der PSA-Verlauf (prostataspezifisches Antigen) als valider Surrogatmarker für Ansprechen oder Progression. Bei kastrationsresistentem PCA unter Chemotherapie werden bildgebende Untersuchungen mittels CT oder Magnetresonanztomographie auch nur bei Änderung der Symptomatik oder geplanter Therapieänderung erforderlich. Regelmäßige bildgebende Verlaufskontrollen bei PSA-Ansprechen sind nicht indiziert. Wird das metastasierte kastrationsresistente PCA (KRPCA) mit Lyaseinhibitoren oder Inhibitoren der Androgenrezeptor Signalkaskaden therapiert, sind bildgebende Verlaufskontrollen aufgrund der fehlenden Verlässlichkeit des PSA als Surrogatmarker des Ansprechens in 3-monatlichen Intervallen indiziert.Die bildgebenden Untersuchungen zur Beurteilung des therapeutischen Ansprechens urogenitaler Malignome unter MTT sind abhängig von der Tumortherapie, der Art des Karzinoms und den möglichen therapeutischen Konsequenzen individuell zu wählen.
[Show abstract][Hide abstract] ABSTRACT: In November 2011, the Third European Consensus Conference on Diagnosis and Treatment of Germ-Cell Cancer (GCC) was held in Berlin, Germany. This third conference followed similar meetings in 2003 (Essen, Germany) and 2006 (Amsterdam, The Netherlands) [Schmoll H-J, Souchon R, Krege S et al. European consensus on diagnosis and treatment of germ-cell cancer: a report of the European Germ-Cell Cancer Consensus Group (EGCCCG). Ann Oncol 2004; 15: 1377-1399; Krege S, Beyer J, Souchon R et al. European consensus conference on diagnosis and treatment of germ-cell cancer: a report of the second meeting of the European Germ-Cell Cancer Consensus group (EGCCCG): part I. Eur Urol 2008; 53: 478-496; Krege S, Beyer J, Souchon R et al. European consensus conference on diagnosis and treatment of germ-cell cancer: a report of the second meeting of the European Germ-Cell Cancer Consensus group (EGCCCG): part II. Eur Urol 2008; 53: 497-513]. A panel of 56 of 60 invited GCC experts from all across Europe discussed all aspects on diagnosis and treatment of GCC, with a particular focus on acute and late toxic effects as well as on survivorship issues.The panel consisted of oncologists, urologic surgeons, radiooncologists, pathologists and basic scientists, who are all actively involved in care of GCC patients. Panelists were chosen based on the publication activity in recent years. Before the meeting, panelists were asked to review the literature published since 2006 in 20 major areas concerning all aspects of diagnosis, treatment and follow-up of GCC patients, and to prepare an updated version of the previous recommendations to be discussed at the conference. In addition, ∼50 E-vote questions were drafted and presented at the conference to address the most controversial areas for a poll of expert opinions. Here, we present the main recommendations and controversies of this meeting. The votes of the panelists are added as online supplements.
[Show abstract][Hide abstract] ABSTRACT: Germ cell tumours (GCTs) of the testis are the most common cancer in young men; they are also one of the most curable cancers. Standard treatment of metastatic GCTs has evolved on the basis of randomised trials and prognostic factors.
This review summarises the evolving role of chemotherapy in the treatment of previously treated and untreated patients with metastatic GCTs and outlines the current standard treatment.
Randomised and nonrandomised trials of first-line, salvage, and palliative therapy were reviewed.
Three cycles of standard bleomycin, etoposide, and platinum (BEP) can be considered the gold-standard treatment in good-risk patients, and four cycles of the same combination can result in cure in approximately 80% of intermediate-risk and 50% of poor-risk patients. The routine use of high-dose chemotherapy in patients with intermediate- or poor-prognosis GCT has not improved treatment outcome, but the role of tumour marker decline during the first cycles may provide useful prognostic information. Prognostic variables in patients who experience treatment failure after cisplatin-based chemotherapy can be used to guide salvage strategies, and many new drugs or combinations have shown activity in this setting. Patients and physicians should be aware of the risk of short- and long-term toxicity of treatments, and guidelines for screening and prevention of this risk should be established.
A risk-based strategy offers the best chance of cure, even in patients with refractory GCT.
European Urology 03/2012; 61(6):1212-21. · 10.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study is to thoroughly report on surgical outcomes from 332 patients who underwent male to female gender reassignment surgery (GRS).
Records from 332 patients who underwent GRS from 1995 to 2008 were reviewed. All patients were submitted to penile inversion vaginoplasty with glans-derived sensate clitoroplasty. Mean age was 36.7 years (range 19-68 years). Surgical complications were stratified in 5 main groups: genital region, urinary tract, gastrointestinal events, wound healing disorders and unspecific events.
Progressive obstructive voiding disorder due to meatal stenosis was the main complication observed in 40% of the patients, feasibly corrected during the second setting. Stricture recurrence was found in 15%. Stricture of vaginal introitus was observed in 15% of the cases followed by 12% and 8% of vaginal stenosis and lost of vaginal depth, respectively. Rectal injury was seen in 3% and minor wound healing disorders in 33% of the subjects.
Regarding male to female GRS, a review of the current literature demonstrated scarce description of complications and their treatment options. These findings motivated a review of our surgical outcomes. Results showed a great number of adverse events, although functionality preserved. Comparision of our outcomes with recent publications additionally showed that treatment options provide satisfying results. Moreover, outcomes reaffirm penile inversion vaginoplasty in combination with glans-derived sensate clitoroplasty as a safe technique. Nevertheless, discussing and improving surgical techniques in order to reduce complications and their influence on patient's quality of life is still strongly necessary and theme of our future reports.
International braz j urol: official journal of the Brazilian Society of Urology 01/2012; 38(1):97-107.
[Show abstract][Hide abstract] ABSTRACT: The management of testicular cancer has already been standardized to the greatest extent by consistent performance of clinical trials. While the current aim is to reduce the therapy for early stage disease without jeopardizing the high cure rates, for patients in advanced stages the goal is to achieve further improvement of survival rates. This overview presents new aspects of organ-preserving primary tumor resection, prognostic factors in seminoma, secondary malignancies, high-dose therapy, residual tumor resection, aftercare, and PET/CT.
Der Urologe 09/2011; 50 Suppl 1:187-91. · 0.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To report our experience with an Internet-based multicentre database that enables tumour documentation, as well as the collection of quality-related parameters and follow-up data, in surgically treated patients with prostate cancer. The system was used to assess the quality of prostate cancer surgery and to analyze possible time-dependent trends in the quality of care.
An Internet-based database system enabled a standardized collection of treatment data and clinical findings from the participating urological centres for the years 2005-2009. An analysis was performed aiming to evaluate relevant patient characteristics (age, pathological tumour stage, preoperative International Index of Erectile Function-5 score), intra-operative parameters (operating time, percentage of nerve-sparing operations, complication rate, transfusion rate, number of resected lymph nodes) and postoperative parameters (hospitalization time, re-operation rate, catheter indwelling time). Mean values were calculated and compared for each annual cohort from 2005 to 2008. The overall survival rate was also calculated for a subgroup of the Berlin patients.
A total of 914, 1120, 1434 and 1750 patients submitted to radical prostatectomy in 2005, 2006, 2007 and 2008 were documented in the database. The mean age at the time of surgery remained constant (66 years) during the study period. More than half the patients already had erectile dysfunction before surgery (median International Index of Erectile Function-5 score of 19-20). During the observation period, there was a decrease in the percentage of pT2 tumours (1% in 2005; 64% in 2008) and a slight increase in the percentage of patients with lymph node metastases (8% in 2005; 10% in 2008). No time trend was found for the operating time (142-155 min) or the percentage of nerve-sparing operations (72-78% in patients without erectile dysfunction). A decreasing frequency was observed for the parameters: blood transfusions (1.9% in 2005; 0.5% in 2008), postoperative bleeding (2.6%; 1.2%) and re-operations (4.5%; 2.8%). The mean hospitalization time decreased accordingly (10 days in 2005; 8 days in 2008). The examined subcohort had an overall mortality of 1.5% (median follow-up of 3 years).
An Internet-based database system for tumour documentation in patients with prostate cancer enables the collection and assessment of important parameters for the quality of care and outcomes. The participating centres show an improvement in the quality of surgical management, including a reduction of the complication rate.
BJU International 08/2011; 109(3):355-9. · 3.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Clear treatment recommendations for patients with testicular cancer exist and their stringent application has led to significant improvements in remission and survival rates. Moreover, active surveillance has become a cornerstone in the management of clinical stage I seminomatous and nonseminomatous germ cell tumors. On the other hand, the existing recommendations for the follow-up of testis cancer patients differ widely and have been changed frequently in recent years.
Follow-up recommendations in this young patient population have to be as evidence-based as possible, feasible in order to ensure adherence, and should not be harmful. Primarily, attention has to be paid to the negative impact of unnecessary radiation exposure.
Recently, new evidence has become available regarding the relapse pattern of different disease stages of testicular cancer, the use of imaging at follow-up, and the risks of excessive radiation due to imaging, in particular that of CT scans. An interdisciplinary multinational working group consisting of urologists, medical oncologists, and radiation oncologists has reviewed and discussed the current evidence and on this basis formulated new recommendations for patients with germ cell tumors of the testis.
Der Urologe 04/2011; 50(7):830-5. · 0.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Alpha-fetoprotein (AFP), human choriogonadotropin (hCG) and lactate dehydrogenase (LDH) are established tumour markers of testicular germ cell tumours (TGCT) which are used according to the guidelines for primary diagnosis, staging, monitoring of therapeutic response and follow-up. Placental alkaline phosphatase and neurone-specific enolase play no role at all in the diagnosis and management of TGCT.Metastasized TGCT are classified according to the IGCCCG classification system into tumours with good, intermediate and poor prognosis depending on their serum concentration. The risk classification has a direct impact on therapy and determines the intensity of chemotherapy. In rare cases AFP and hCG might be elevated due to non-testicular reasons which have to be taken into consideration for the differential diagnosis especially if marker concentration and clinical presentation do not match. Response to chemotherapy is monitored with AFP and hCG which are determined the day before initiation of the next treatment cycle. Marker increases during or shortly after discontinuation of chemotherapy indicate a poor prognosis and make the immediate initiation of salvage treatment regimes necessary. Only 40-50% and 30% of relapses in patients under active surveillance for clinical stage I disease and after systemic chemotherapy are associated with marker increases. The remainder will be diagnosed by imaging studies or clinical symptoms. Marker increases have to be validated by imaging studies. However, about 10% of all relapsing patients have marker increases only without any imaging evidence of metastatic disease. Residual masses of any size and location have to be treated by postchemotherapy resection once the marker concentration is normalized or once it has reached a stable plateau. So-called desperation surgery in the presence of rising tumour markers is only indicated if no curative chemotherapy is available, all residual masses are completely resectable and no hCG elevation are observed. For follow-up, AFP, hCG and LDH should be evaluated for advanced TGCT and clinical stage I nonseminomas, whereas clinical stage I seminomas should be monitored without any markers.
Der Urologe 02/2011; 50(3):313-21. · 0.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To provide guidance regarding follow-up procedures after initial treatment of early stage testicular seminoma (clinical stages (CS) I-II A/B) based on current published evidence complemented by expert opinion.
An interdisciplinary, multinational working group consisting of urologists, medical oncologists, and radiation oncologists analyzed the published evidence regarding follow-up procedures in various stages of seminomatous and nonseminomatous testicular cancers. Focusing on radiooncological aspects, the recommendations contained herein are restricted to early stage seminoma (with radiotherapy being a standard treatment option). In particular, extent, frequency, and duration of imaging at follow-up were analyzed concerning relapse patterns, risk factors, and mode of relapse detection.
Active surveillance, adjuvant carboplatin or radiotherapy are equally accepted options for CS I seminoma but they result in different relapse rates and patterns. Usually relapses occur within the first 2(-6) years. Routinely performed follow-up using computerized tomography (CT) after adjuvant treatment yield only low detection rates of recurrences. Therefore, there is no evidence to maintain routine examinations every 3-4 months. After treatment of stage IIA/B, detection rates of relapses or progression identified solely by routinely performed CT during follow-up are low.
Considering lifelong cure rates of up to 99% for patients treated for seminoma CS I-IIA/B, the negative impact of unnecessary ionizing radiation exposure has to be considered. The presented recommendations for various follow-up scenarios for early stage seminoma strongly promote the restrictive use of imaging procedures that utilize ionizing radiation (especially CT), due to its potential to induce secondary malignancies.
Strahlentherapie und Onkologie 02/2011; 187(3):158-66. · 4.16 Impact Factor