Difficulties of a Surveillance Study Omitting Retroperitoneal Lymphadenectomy in Clinical Stage I Nonseminomatous Germ Cell Tumors of the Testis

Abstract

Between August 1981 and December 1984, 85 consecutive patients with clinical stage I nonseminomatous germ cell tumors of the testis who were suitable for close observation entered a surveillance study after orchiectomy alone. All patients had unequivocally negative chest x-ray, bipedal lymph-angiography, and computerized tomography of the abdomen and pelvis, and normal levels of alpha-fetoprotein and human chorionic gonadotropin before entering the study. Patients were followed closely for 24 to 64 months (median 42 months) with regular chest x-rays, plain films of the abdomen for lymphangiography control, and serum determinations of alpha-fetoprotein and human chorionic gonadotropin but it was difficult to obtain computerized tomography scans of the abdomen at scheduled intervals for such a long period. Followup was closed December 31, 1986. At that date 62 patients (73 per cent) were continuously free of disease after orchiectomy alone and 23 (27 per cent) suffered relapse. The over-all occurrence rate of retroperitoneal relapses was 16.5 per cent and they usually were detected late, 4 to 36 months (median 10 months) after orchiectomy. Lung metastases were detected much earlier, 2 to 10 months (median 3 months) after orchiectomy. Alpha-fetoprotein and human chorionic gonadotropin elevations preceded the radiographic demonstration of metastases in 8 patients only (35 per cent) and in 1 they were the only sign of relapse. All but 1 patient with relapse were cured with chemotherapy and/or surgery, with an over-all survival rate free of disease of 98.8 per cent. Invasion of the epididymis, rete testis and spermatic cord, primary scrotal surgery, peritumor vascular invasion and embryonal carcinoma were associated with a higher risk for relapse but it was impossible to find clear-cut indications to select patients for adjuvant chemotherapy, retroperitoneal lymphadenectomy or no treatment. Furthermore, the followup of retroperitoneal nodes proved to be much more difficult than expected. Unilateral or modified retroperitoneal lymphadenectomy facilitates management of clinical stage I nonseminomatous germ cell tumors of the testis: only the chest and markers must be followed, the status of the retroperitoneal nodes is known immediately and antegrade ejaculation is preserved in the majority of cases.

Testicular hilum and vascular invasion predict advanced clinical stage in nonseminomatous germ cell tumors

“…17,25 Subsequent studies confirmed the importance of the vascular invasion as an independent predictor for relapse in clinical stage I patients. 2,9,10,17,18,25 In contrast to most of the previous studies, we did not find dominant embryonal carcinoma histology to be associated with clinically metastatic disease. Our study evaluated patients of all clinical stages in contrast to most previous studies which included only clinical stage I patients.…”

“…We also confirmed that vascular invasion is a significant risk factor for metastasis in nonseminomatous germ cell tumors, which is well documented previously. [2][3][4]9,10,[13][14][15][16][17][18][19] Clinical stage is the most critical step in the management of patients diagnosed with nonseminomatous germ cell tumors. A current challenge is the appropriate management of clinical stage I disease because of the concerns related to the adverse effects of the chemotherapy treatment.…”

“…2,4,[17][18][19] Some previous studies focused only on patients with clinical stage I nonseminomatous germ cell tumors. 3,9,10 These early studies had either limited data on rete testis invasion 3 or correlated rete testis invasion with higher risk of relapse only on univariate analysis, 10 but not on multivariate analysis. 9 Two early studies performed in the 1980s also correlated primary tumor histology with metastastatic disease at presentation.…”

“…[2][3][4]9,10,[13][14][15][16][17][18][19] Since the initial data presented in the early 1980s by Peckham et al 24 in patients with stage I nonseminomatous germ cell tumors managed by surveillance, the presence of vascular invasion and predominant embryonal carcinoma component have been considered significant risk factors for retroperitoneal and visceral metastasis. 17,25 Subsequent studies confirmed the importance of the vascular invasion as an independent predictor for relapse in clinical stage I patients.…”

“…7,8 To our knowledge, there are only limited data on the prognostic value of rete testis invasion in nonseminomatous germ cell tumors. 3,9,10 Moreover, the significance of hilar soft tissue invasion in nonseminomatous germ cell tumors has not been previously studied. Therefore, we performed a comprehensive evaluation of the histopathologic variables in nonseminomatous germ cell tumors, aiming to investigate their prognostic significance for the clinical metastatic disease at the time of presentation, with an emphasis on tumor invasion into the hilum.…”