Impact of hospital case volume on testicular cancer outcomes and practice patterns

Objective To evaluate the prognostic significance of lymph node count (LNC) at post‐chemotherapy retroperitoneal lymphadenectomy (PC‐RPLND) in metastatic non‐seminomatous germ cell tumour (NSGCT) using the Surveillance, Epidemiology, and End Results (SEER) database and National Cancer Database (NCDB). Patients and methods SEER (2000–2013, n = 572) and NCDB (2004–2013, n = 731) identified patients undergoing PC‐RPLND for Stage II and III NSGCT. Correlation between linear or categorial variables and LNC was conducted using Spearman's rank correlation or Kruskal–Wallis test by ranks. Patients were stratified by ≤20, 21–40, and >40 LNs for Kaplan–Meier analysis. Cox proportional hazards models evaluated the association of LNC at PC‐RPLND with overall mortality (OM) in the NCDB and cancer‐specific mortality (CSM) in the SEER database. The relationship between LNC and OM or CSM was also modelled as a non‐linear function to determine a threshold for survival benefit. Results Amongst all patients, the median (interquartile range) LNC was 17 (3–26) LNs in the NCDB, and 18 (6–31) LNs in the SEER database. More recent diagnosis year, higher hospital volume, higher median income, private insurance status, and positive LNC were associated with greater total LNC in one or both databases (P < 0.05). On Kaplan–Meier analysis, >40 LNs was associated with 5‐year cancer‐specific survival (CSS) of 99% and overall survival (OS) of 96%, whereas ≤20 LNs had a 5‐year CSS of 91% and OS of 78% (CSS, P = 0.04; OS, P < 0.01). Risk‐adjusted Cox model showed increasing LNC (per node) was inversely associated with OM (hazard ratio [HR] 0.96, 95% confidence interval [CI], 0.94–0.98; P < 0.01) and CSM (HR 0.96, 95% CI, 0.94–0.99; P = 0.01). Non‐linear modelling showed the greatest benefit in OM at between 10 and 20 LNs, but continued survival benefit for OM and CSM beyond 20 LNs. Conclusions Greater LNC during PC‐RPLND appears to be associated with improved CSS and OS in NSGCT. Our data support the role of thorough RPLND for post‐chemotherapy metastatic NSGCT.

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“…Data from Woldu et al. indicated patients at higher‐volume hospitals were more likely to undergo PC‐RPLND for Stage II/III NSGCT.…”

Section: Discussionmentioning

confidence: 99%

“…A summary of baseline features is described in Table 1. The mean (IQR) age at diagnosis was 27 (22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34) years. The number of PC-RPLND cases increased over time, from 56 in 2004 to 95 reported in 2013.…”

Section: Ncdbmentioning

confidence: 99%

Lymph node count impacts survival following post‐chemotherapy retroperitoneal lymphadenectomy for non‐seminomatous testicular cancer: a population‐based analysis

et al. 2019

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“…Because of the multimodal strategies available to manage these tumors, patients with TGCTs tend to exhibit favorable clinical outcomes, with >80% 5‐year overall survival and fewer than 500 cancer‐specific deaths annually in the United States . Poor outcomes for patients with TGCTs are driven primarily by extranodal metastatic involvement (clinical stage III disease), and even among patients with metastatic disease, predictors of survival are multifactorial …”

Section: Introductionmentioning

confidence: 99%

Site of extranodal metastasis impacts survival in patients with testicular germ cell tumors

Patel

Singla

Ghandour

et al. 2019

Cancer

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Background Using a large, nationally representative, population‐based cancer registry, this study systematically evaluated the impact of the location and burden of extranodal testicular germ cell tumor (TGCT) metastases on survival. Methods Men with stage III TGCTs captured by the Surveillance, Epidemiology, and End Results registry from 2010 to 2015 with distant extranodal metastases were identified. Clinicopathologic information was collected, and patients were subdivided according to the specific organ site or sites of metastatic involvement (lung, liver, bone, and/or brain). Kaplan‐Meier analysis and multivariable Cox regression were used to evaluate cancer‐specific survival (CSS), and model performance was assessed with Harrell's C statistic. Results Nine hundred sixty‐nine patients with stage III TGCTs were included with predominantly nonseminomatous histology (84%). Most patients (91%) had pulmonary metastases, whereas 20%, 10%, and 10% had liver, bone, and brain metastases, respectively. Over a median follow‐up of 21 months, 19% of these men died of TGCTs. When they were grouped by the primary site of metastasis, patients with more than 1 extrapulmonary metastasis exhibited the worst CSS (hazard ratio [HR] vs isolated pulmonary involvement, 4.27; 95% confidence interval [CI], 2.60‐7.00; P < .01). Among patients with isolated extrapulmonary involvement, those with brain metastases had the poorest survival (HR, 3.24; 95% CI, 1.98‐5.28; P < .01), and they were followed by patients with liver (HR, 2.29; 95% CI, 1.56‐3.35; P < .01) and bone metastases (HR, 1.97; 95% CI, 1.11‐3.50; P = .02). Harrell's C statistic (multivariable) was 0.71. Conclusions The site of metastatic involvement affects survival outcomes for patients with TGCTs, and this may reflect both the aggressive biology and the challenging treatment of these tumors. Further incorporation of organotropism into current prognostic models for metastatic TGCTs warrants attention.

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“…Most of these parameters have been evaluated mainly in relation to treatment outcome either selectively or in various combinations of some of the factors and most of the reports relate to patient cohorts treated in the last century [8, 14-16]. Furthermore, due to the rarity of GCT, only <10% of all general hospitals comprise a volume of more than 10 cases of this disease annually [17]. Accordingly, the majority of clinical publications on GCT stem from institutions that usually represent secondary or even tertiary referral centres with highly selected patient samples featuring clinical profiles not generalizable to unselected cohorts of patients with GCT at the primary care level.…”

Section: Introductionmentioning

confidence: 99%

Testicular Germ-Cell Tumours: A Descriptive Analysis of Clinical Characteristics at First Presentation

et al. 2018

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Introduction: Clinical characteristics of testicular germ cell tumours (GCTs) apparently change over time, and some vary geographically. The aim of this study is to document the clinical profile of contemporary GCT patients. Patients and Methods: Four hundred twenty-two Caucasian GCT-patients treated in one German centre during 2000–2017, were analysed in terms of patient-age, laterality, histology, tumour-size, clinical stages (CS), pathological (pT)-stages and serum biomarker expression. The results were analysed descriptively and compared with the literature. Results: Median age was 36 years and 60.2% had seminoma. Βeta-human chorionic gonadotropin was expressed in 37.9% and alpha Fetoprotein in 25.6%. CS1 presenting stage was 66.6% of all GCT patients, 79.1% in seminoma, and 47.6% in nonseminoma. Tumour size was significantly associated with pT-stages and CS. Patients >50 years had significantly more seminoma (77.6%) than younger ones (57.9%). Comparison with literature data revealed a shifting towards higher age, lower CS, higher proportion of seminoma and striking differences of characteristics among geographic regions. Conclusions: A typical contemporary clinical profile of testicular GCTs is presented in this study. Median age, relative incidence of seminoma and proportion of CS1 appear to be increasing over time. Striking differences among ethnic groups regarding the characteristics of GCT require further investigation.

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Impact of hospital case volume on testicular cancer outcomes and practice patterns

Cited by 59 publications

References 21 publications

Lymph node count impacts survival following post‐chemotherapy retroperitoneal lymphadenectomy for non‐seminomatous testicular cancer: a population‐based analysis

Lymph node count impacts survival following post‐chemotherapy retroperitoneal lymphadenectomy for non‐seminomatous testicular cancer: a population‐based analysis

Site of extranodal metastasis impacts survival in patients with testicular germ cell tumors

Testicular Germ-Cell Tumours: A Descriptive Analysis of Clinical Characteristics at First Presentation

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