DR. MOUL: For the urologists, radiation oncologists, and the medical oncologists in the audience, I would just like to ask with a show of hands, how many of you have treated at least one patient with testicular tumor in the last year, just as a denominator? Just a show of hands. So obviously, the vast majority of the audience.

Now, let me focus that and just ask, how many of you have recommended surveillance for at least one seminoma patient in the last 12 months? It looks to be about 40 percent, I would say, 30-40 percent.

And then how many have recommended surveillance for at least one non-seminoma germ cell patient in the last year? It looks to be again probably 60-70 percent.

Mary, do you want to just make a comment on that? What was your take on that response from our group?

DR. GOSPODAROWICZ: It is apparent in other disease sites too that it takes about ten years to change clinical practice. Physicians are not really keen to change well entrenched practice. Radiotherapy for stage 1 seminoma has been the classical treatment. The results are excellent. The morbidity is low. And there is this inherent belief that it is safe, and there is no need to watch patients.

There is a great deal of worry that patients will get lost to follow-up, and then recur with some bulky disease and die of disease. So there is a lack of trust between almost the contract that needs to be made between physician and the patient, that the patient on surveillance will be compliant.

There are barriers to adoption of seminoma surveillance, but we have observed that it's been adopted in Canada now. In a population-based study of radiation oncologists who participate in RTOG, about a third never offer seminoma surveillance to their patients. So it's still out there.

There is a new treatment coming in, which is adjuvant carboplatin. It may be that this will take over, because it's so easy to do.

DR. MOUL: Let's just ask a follow-up question. How many in the audience who raised your hands for any of those questions have actually treated a patient with primary carboplatin in the last year? So again, it hasn't caught on.

PARTICIPANT: Just one question for Mary. The data you showed on secondary malignancies following radiation therapy, was I mistaken, but some of those patients had gotten much higher doses of radiation therapy to the retroperitoneum for treatment of non-seminoma tumors. What that not correct?

DR. GOSPODAROWICZ: That is correct. So the overall risk is low, but it is there.

DR. MOUL: I would like to ask again, related to Dr. Bartsch's talk, for the urologic surgeons in the audience, how many have performed any RPLMBs in the last 12 months? Okay, so a large percentage.

How many have performed a laparoscopic RPLND in the last 12 months? So again, it looks like I would estimate 10 percent.

And maybe I could just ask Dr. Bartsch, and I guess I'll personalize this, one of the challenges for example we face in the military is we see quite a few testicular tumors, yet it has been a challenge. We have many young guys who are out of their training, either military or civilian. They want to do cases.

They are seeing some, but they are not to the point where they can probably have the competence to do a laparoscopic when they get out at some of these smaller hospitals.

Of course your approach is they all come back to the referral center. Do you want to just comment on that?

DR. BARTSCH: Well, actually, our way to do laparoscopic surgery is not going out of endourology. Our way of laparoscopic surgery is laparoscopic surgery is a part of surgery in oncology, in reconstructive surgery, and pediatric hematology. So it's quite different.

And for three years we have the residents working in laparoscopic surgery. So it's not the specialty in our department of urology. If you go back, transurethral prostatectomy was the first laparoscopic approach ever in medicine. This is not a specialty of its own, so I think we have just to train residents, and we should not make a specialty out of laparoscopic surgery.

DR. MOUL: Is there anybody in the audience from Indiana University, by any chance? In fact, we talked to them recently. We called them about a case. Many times we will bounce ideas. I know that at that institution, they are still holding fast to the open RPLND for stage 1.

DR. BARTSCH: But if you have a patient, you can send them to the Mayo Clinic. There is somebody who is doing now laparoscopic retroperitoneal lymph node dissections.

DR. MOUL: Yes, sir?

PARTICIPANT: This is a question for Dr. Bartsch. When you do RPLND, and if the lymph node is negative, do you still give them chemotherapy, or do you give chemotherapy only to 2A patients?

DR. BARTSCH: Well, we have been very anxious when we started this project. Up until March 2000, when we had a 2A, we give two cycles of chemotherapy. Therefore, we cannot evaluate those patients for oncologic efficacy.

Since March 2000, we are just doing a bilateral lymph node dissection, nerve sparing. And as you have seen, we have just started doing this in 2C lesions, doing nerve sparing, and we have 75 percent of those patients preservation of the nerves. So it's much better than in the open approach.

PARTICIPANT: So the oncological results you presented today are patients who, if the nodes were negative, you did not give them any chemotherapy?

DR. BARTSCH: No, nothing. Our philosophy is to spare chemotherapy.

DR. MOUL: And we're almost out of time, but I want to ask one question to the audience regarding Dr. Greene's talk. For the clinicians in the audience who care for patients with testicular cancer, how many of you all have cared for a patient who you believe has familial testis cancer in the last year? So it's looks like about maybe 10 or 15 percent.

Maybe if I could ask, what is the limitation? How far out from treatment can they be? Any time?

DR. GREENE: That's one of the nice things about the sort of etiologic studies we do. And particularly in a disease like testis, where the survival rate is so good, that there is no time limit on when these men may have been diagnosed.

We do require that there be either two living family members with disease, or if the family members with testicular cancer are deceased, that their spouse and children be willing to participate in the study. From a genetic point of view, we can infer the genotype of the deceased individual if we have information on the spouse and the children.

But my expectation is the majority of the families that we see, the testis cancer cases will have been previously treated up to years in the past, and that's not a problem for us.

DR. MOUL: So for example, we could go to the DOD active tumor registry and pull out the testicular cancer patients, and look for family history, and send them to you all for 20 years?

DR. GREENE: Nothing would make me happier. In fact, on the list of referral sources is the testicular cancer case control study that Kathryn McGlin in our division is doing. This is based in the Department of Defense, and is accruing about 1,100 newly diagnosed cases, and a similar number of controls. That study has built into it, a mechanism to refer families that are identified to us for consideration for our study.

DR. MOUL: Great.

One final question. Yes, sir?

PARTICIPANT: I have a question about the post-chemotherapy laparoscopic node dissections. What is the range of the tumor sizes that you have been able to do laparoscopically?

DR. BARTSCH: Well, actually we are doing 2C lesions. This can be about 7-10 centimeters. This is no problem. Therefore, for instance we are also doing positive nodes with radical nephrectomy without difficulty. And it's better, because you see better.

PARTICIPANT: I agree that you see better.

DR. BARTSCH: What we don't do is if you have a CT scan showing that the order and the vena cava is totally overgrown by tumor. This is not the case. And we are not going into seminoma.

PARTICIPANT: If you have a tumor that is interaortocaval and paracaval, would you have to flip the patient over, and immobilize the colon to the other side?

DR. BARTSCH: That's right. You just go with the trocar to the other side, and flip the table over.

DR. MOUL: One final comment from Dr. Greene.

DR. GREENE: For those of you who aren't familiar with how the intramural clinical research program at NCI works, I would mention that one of the advantages of folks joining our project is that NCI foots the bill for these people to come to Bethesda for study.

Their care here is free. We bring them and their families. We usually try and tie it so that come in on a Monday, and they can be here over the weekend, and enjoy themselves in Washington. So the burden of participating is their time and the travel, but the cost is on us.

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