title: Effect of the timing of orchiectomy on survival in patients with metastatic germ cell tumors of testis.
abstract: OBJECTIVE
  Classically, orchiectomy (OE) is the first step of treatment in patients with metastatic germ cell tumors (mGCTs) of testis. However, some patients have severe symptoms of disease, which require immediate beginning of chemotherapy (CT) followed by OE. This retrospective analysis was performed to find the effect of time constraints of delayed OE on survival in patients with mGCT.
  
  
  METHODS
  We analyzed the data of 1,483 CT-naive patients with advanced mGCT of the testis treated in our Department from 1986 to 2009. Delayed OE was performed on 71 (4.8%) patients: seminoma in 8 patients (11.2%), nonseminomatous tumor in 50 patients (70.4%), and unknown tumor histology in 13 patients (18.4%). Twenty percent, 40%, and 40% of patients belonged to good, intermediate, and poor International Germ Cell Cancer Consensus Group prognostic groups, respectively. Median time from the beginning of the CT to OE was 18 (range, 1-250) days. OE was performed on 39 (55%), 21 (29.5%), and 11 (15.5%) patients during cycle 1, cycle 2 to completion of CT, and after the finishing of induction CT, respectively. Median follow-up time was 156 (range, 3-241) months. Etoposide and cisplatin-based CTs were received by 66 patients (93%).
  
  
  RESULTS
  Three-year overall survival (OS) of all 1,483 patients was 75%. An excellent primary tumor response to CT was observed among the patients, who had delayed OE after completion of CT (n = 11): only mature teratoma (n = 4) and tumor necrosis (n = 7) were found. The 3-year OS in patients with delayed OE was 63%. OE performed after completion of CT was associated with better prognosis. The 3-year OS in patients with delayed OE performed during the cycle 1 (group 1) was 67%, cycle 2 to completion of CT (group 2) was 39%, and after finishing of CT (group 3) was 88% (groups 1 vs. 3: hazard ratio 3.7, 95% confidence interval 0.69-10.1, P = 0.15; groups 2 vs. 3: P = 0.01, hazard ratio 8.1, 95% confidence interval 1.32-18.,72). It seems that if OE had been performed during CT, the beginning of the successive cycle was delayed and dose intensity of CT was decreased.
  
  
  CONCLUSIONS
  In case of severe symptoms of disease, which require an immediate start of CT, performing OE simultaneously with other surgeries after completion of induction CT was associated with better OS, when compared with performing OE during induction CT.
authors.affiliation: Department of Clinical Pharmacology & Chemotherapy, N. N. Blokhin Russian Cancer Research Center, Moscow, Russia. Electronic address: fedianinmu@mail.ru.
authors.forename: Mikhail
authors.initials: M
authors.lastname: Fedyanin
authors.affiliation: Department of Clinical Pharmacology & Chemotherapy, N. N. Blokhin Russian Cancer Research Center, Moscow, Russia.
authors.forename: Alexey
authors.initials: A
authors.lastname: Tryakin
authors.affiliation: Department of Clinical Pharmacology & Chemotherapy, N. N. Blokhin Russian Cancer Research Center, Moscow, Russia.
authors.forename: Anatoly
authors.initials: A
authors.lastname: Bulanov
authors.affiliation: Department of Surgical Radiology, N. N. Blokhin Russian Cancer Research Center, Moscow, Russia.
authors.forename: Igor
authors.initials: I
authors.lastname: Fainshtein
authors.affiliation: Department of Pathology, N. N. Blokhin Russian Cancer Research Center, Moscow, Russia.
authors.forename: Tatiana
authors.initials: T
authors.lastname: Zakharova
authors.affiliation: Department of Urologic Oncology, N. N. Blokhin Russian Cancer Research Center, Moscow, Russia.
authors.forename: Vsevolod
authors.initials: V
authors.lastname: Matveev
authors.affiliation: Department of Clinical Pharmacology & Chemotherapy, N. N. Blokhin Russian Cancer Research Center, Moscow, Russia.
authors.forename: August
authors.initials: A
authors.lastname: Garin
authors.affiliation: Department of Clinical Pharmacology & Chemotherapy, N. N. Blokhin Russian Cancer Research Center, Moscow, Russia.
authors.forename: Sergei
authors.initials: S
authors.lastname: Tjulandin
mesh_terms: D000293:Adolescent; D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D006063:Chorionic Gonadotropin / Q000097:blood; D006801:Humans; D007770:L-Lactate Dehydrogenase / Q000097:blood; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D009373:Neoplasms, Germ Cell and Embryonal / Q000401:mortality* / Q000601:surgery*; D009919:Orchiectomy / Q000379:methods*; D011379:Prognosis; D012189:Retrospective Studies; D016019:Survival Analysis; D013736:Testicular Neoplasms / Q000401:mortality* / Q000601:surgery*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult; D000509:alpha-Fetoproteins / Q000378:metabolism
chemical_list: D006063:Chorionic Gonadotropin; D000509:alpha-Fetoproteins; D007770:L-Lactate Dehydrogenase
keywords: Chemotherapy; Delayed orchiectomy; Germ cell tumors