Disease relapse in patients with stage I nonseminomatous germ cell tumor of the testis on active surveillance.

Abstract

Thirty-six patients with apparent stage I nonseminomatous germ cell tumor (NSGCT) of the testis were treated by inguinal orchidectomy and intensive follow-up only. Assessment included measurement of serum alpha fetoprotein (alpha FP) and beta human chorionic gonadotropin (beta HCG) (tumor markers) and chest x-ray monthly for 1 year, then twice monthly for 1 year, with computed tomographic (CT) scans of abdomen and chest repeated three times monthly for the first year and six times monthly for the second year. Median follow-up was 36 months (range, 14 to 92 months). Relapse occurred in 12 patients (33.3%) at a median of 7 months (range, 2 to 28 months). Elevated markers were of limited importance in relapse detection, confirming the need for close clinical and radiological follow-up. Of nine histological factors examined in the primary tumor only the presence of lymphatic invasion was associated with a significantly higher relapse rate. All patients were treated at relapse with cisplatin-based chemotherapy. Four underwent surgery in addition, two before and two after chemotherapy. Eleven were rendered disease-free, but four had a second relapse. One patient has died, one is alive with disease, and ten are disease-free. Chemotherapy failed to cure six patients who had relapsed but bulk of disease was not a factor. Despite the good overall result reported here, optimal postorchidectomy management of apparent stage I disease remains to be defined.

Management of patients with clinical stage I nonseminomatous germ cell testicular cancer: Active surveillance versus adjuvant chemotherapy – single-centre experience

“…Options include surveillance (with salvage treatment for relapse), adjuvant cisplatin-based combination chemotherapy, or retroperitoneal lymph node dissection (RPLND). Differentiated managements of CSI NSGCTT patients were studied since the late 80´s to early 90´s [5,6,7,8,9], and were accepted later to the several national and international guidelines [14,15]. All mentioned options provide cure rates of approximately 99% [17].…”

“…Preliminary results were enthusiastic [2,3,4], but critical voices arose against general use of this option as a routine management [5]. With longer observation, the relapse rate increased up to 25 % or more after orchiectomy [6,7].…”

“…With longer observation, the relapse rate increased up to 25 % or more after orchiectomy [6,7]. Several studies [5,7,8,9] identified statistically significant predictors of relapse in CSI NSGCTT patients who might therefore benefit from a program other than surveillance. Vascular invasion of the primary tumor was the most consistent prognostic feature identified.…”

Controversies in the Management of Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer

“…Preliminary results were enthusiastic [2][3][4], but critical voices have been raised against general use of this option as routine management [5]. With longer observation, relapse rate has been found to increase up to 25% or more after orchiectomy [6,7].…”

How safe is surveillance in patients with histologically low-risk non-seminomatous testicular cancer in a geographically extended country with limited computerised tomographic resources?

“…In this context the surveillance policy (wait and see) (Peckham et al, 1982;Hoskin et al, 1986;Pizzocaro et al, 1986;Freedman et al, 1987;Dunphy et al, 1988;Thompson et al, 1988;Germalluch et al, 1991;R0rth et al, 1991;Read et al, 1992;Sturgeon et al, 1992) has been introduced in clinical stage I as an alternative to retroperitoneal lymph node dissection (RLND) (Aass et al, 1990;Weissbach et al, 1990;Klepp et al, 1991). However, the advantages and drawbacks of the surveillance policy as compared with primary RLND have remained a matter of discussion.…”