Contemporary options and future perspectives: three examples highlighting the challenges in testicular cancer imaging.

PURPOSE: One of the main issues in testicular germ cell tumors (TGCTs) management is to reduce the necessary amount of treatment to achieve cure. Excess treatment burden may arise from late diagnosis of the primary as well as from false positive or negative staging results. Correct imaging is of paramount importance for successful management of TGCT. The aim of this review is to point out the current state of the art as well as innovative developments in TGCT imaging on the basis of three common challenging clinical situations. METHODS: A selective literature search was performed in PubMed, Medline as well as in recent conference proceedings. RESULTS: Regarding small testicular lesions, recent studies using elastography, contrast-enhanced ultrasound or magnetic resonance imaging (MRI) showed promising data for differentiation between benign and malignant histology. For borderline enlarged lymph nodes FDG-PET-CT performance is unsatisfactory, promising new techniques as lymphotropic nanoparticle-enhanced MRI is the subject of research in this field. Regarding the assessment of postchemotherapeutic residual masses, the use of conventional computerized tomography (CT) together with serum tumor markers is still the standard of care. To avoid overtreatment in this setting, new imaging modalities like diffusion-weighted MRI and radiomics are currently under investigation. For follow-up of clinical stage I TGCTs, the use of MRI is non-inferior to CT while omitting radiation exposure. CONCLUSION: Further efforts should be made to refine imaging for TGCT patients, which is of high relevance for the guidance of treatment decisions as well as the associated treatment burdens and oncological outcomes.

Does the Identification of a Minimum Number of Cases Correlate With Better Adherence to International Guidelines Regarding the Treatment of Penile Cancer? Survey Results of the European PROspective Penile Cancer Study (E-PROPS).

BACKGROUND: Penile cancer represents a rare malignant disease, whereby a small caseload is associated with the risk of inadequate treatment expertise. Thus, we hypothesized that strict guideline adherence might be considered a potential surrogate for treatment quality. This study investigated the influence of the annual hospital caseload on guideline adherence regarding treatment recommendations for penile cancer. METHODS: In a 2018 survey study, 681 urologists from 45 hospitals in four European countries were queried about six hypothetical case scenarios (CS): local treatment of the primary tumor pTis (CS1) and pT1b (CS2); lymph node surgery inguinal (CS3) and pelvic (CS4); and chemotherapy neoadjuvant (CS5) and adjuvant (CS6). Only the responses from 206 head and senior physicians, as decision makers, were evaluated. The answers were assessed based on the applicable European Association of Urology (EAU) guidelines regarding their correctness. The real hospital caseload was analyzed based on multivariate logistic regression models regarding its effect on guideline adherence. RESULTS: The median annual hospital caseload was 6 (interquartile range (IQR) 3-9). Recommendations for CS1-6 were correct in 79%, 66%, 39%, 27%, 28%, and 28%, respectively. The probability of a guideline-adherent recommendation increased with each patient treated per year in a clinic for CS1, CS2, CS3, and CS6 by 16%, 7.8%, 7.2%, and 9.5%, respectively (each p < 0.05); CS4 and CS5 were not influenced by caseload. A caseload threshold with a higher guideline adherence for all endpoints could not be perceived. The type of hospital care (academic vs. non-academic) did not affect guideline adherence in any scenario. CONCLUSIONS: Guideline adherence for most treatment recommendations increases with growing annual penile cancer caseload. Thus, the results of our study call for a stronger centralization of diagnosis and treatment strategies regarding penile cancer.

Adherence to European Association of Urology and National Comprehensive Cancer Network Guidelines Criteria for Inguinal and Pelvic Lymph Node Dissection in Penile Cancer Patients-A Survey Assessment in German-speaking Countries on Behalf of the European Prospective Penile Cancer Study Group.

BACKGROUND: Urologists' adherence to European Association of Urology and National Comprehensive Cancer Network guideline recommendations to perform inguinal (ILND) and pelvic (PLND) lymph node dissection in penile cancer (PC) patients is not known. OBJECTIVE: To assess a German-speaking European cohort of urologists based on their criteria to perform ILND and PLND in PC patients. DESIGN, SETTING, AND PARTICIPANTS: A 14-item survey addressing general issues of PC treatment was developed and sent to 45 clinical centers in Germany (n = 34), Austria (n = 8), Switzerland (n = 2), and Italy (n = 1). INTERVENTION: Two of the 14 questions assessed the criteria to perform ILND and ipsilateral PLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Correct responses for ILND and PLND criteria were assessed. Based on a multivariate logistic-regression-model, criteria independently predicting guideline adherence were identified. RESULTS AND LIMITATIONS: In total, 557 urologists participated in the survey, of whom 43.5%, 19.3%, and 37.2% were residents in training, certified, and in leading positions, respectively. ILND and PLND criteria were correctly identified by 35.2% and 23.9%, respectively. Of the participants, 23.3% used external sources for survey completion. The use of auxiliary tools (odds ratio [OR] 1.57; p[bootstrapped] = 0.028) and participants outside of Germany (OR 0.56; p[bootstrapped] = 0.006) were predictors of ILND guideline adherence. The number of PC patients treated yearly (p = 0.012; OR 1.06) and the use of auxiliary tools (p < 0.001; OR 5.88) were predictors of PLND adherence. Department size, healthcare status, professional status, and responsibility for PC surgery did not predict endpoints. Limitations include sample size and results in comparison with retrospective studies. CONCLUSIONS: Our results demonstrate overall suboptimal knowledge of the correct indications to perform ILND and PLND in PC patients among the surveyed urologists. We propose that governments and healthcare providers should be encouraged to centralize PC management. PATIENT SUMMARY: The management of inguinal and pelvic lymph nodes is crucial for the survival of penile cancer patients. Disease rarity mandates referral to clinical practice guidelines for appropriate treatment selection.

Guideline-adherence in the treatment of symptomatic urolithiasis in children and adolescents in southwestern Germany.

BACKGROUND: Approximately 1% of urolithiasis cases in Germany affect children. Interdisciplinary groups have agreed on national and international guidelines for children to recommend appropriate treatment pathways. The aim of this retrospective and preliminary study is to analyze whether adherence to current guidelines for pediatric stone disease in southwestern Germany is feasible. METHODS: During 2014 to 2017 24 children and adolescents (nine female, 15 male, median age 9.7 years), were treated for symptomatic urolithiasis in our institutions. We retrospectively collected clinical and operative courses. Clinical pathways were compared to previous guideline recommendations of the EAU 2014 and the German S2k guideline 2015. RESULTS: 17 of the 24 patients were treated according to guideline recommendations (71%). Non-adherency was based on parental decisions in two and technical/medical considerations in five cases. In 11 children (45.8%) secondary or adjunctive treatments were necessary, in three of the seven non-adherently treated (43%) and in eight of the 17 adherently treated children (47%). CONCLUSION: Our daily treatment approach seems to comply well with current pediatric stone guidelines. Nevertheless, guideline-non-adherent decision making emphasizes their strength and limitations, as specific clinical situations in children may require an individual treatment plan, as non-predictable conditions may occur.