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

Abstract

Surveillance after orchiectomy alone has become popular in the management of clinical stage I nonseminomatous germ cell testicular tumors (CSI NSGCTT). Efforts to identify patients at high risk of disease progression led to a search for risk factors in CSI NSGCTT. The aim of the present study was to analyse single-centre experience with risk-adapted therapeutic approaches (active surveillance versus adjuvant chemotherapy). From 1/1992 to 12/2013 a total of 431 CSI NSGCTT patients were included in the study and stratified into two groups according to risk-adapted therapeutic approaches. Group A (low-risk CSI NSGCTT) consisted of 276 patients who underwent active surveillance, progression of disease occurred in 46 (16.7%) patients with a median follow-up of 7.2 months. Six patients (2.2 %) of this group died with a median follow-up of 34.3 months. Group B (high-risk CSI NSGCTT) consisted of 155 patients who were treated with adjuvant chemotherapy, disease progression occurred in two (1.3 %) of them with a median follow-up of 56.2 months. One patient (0.6 %) died 139.4 months following orchiectomy. Overall survival rate of all CSI NSGCTT patients in both groups was 424/431 (98.4 %) with median follow-up of 130.4 months following orchiectomy. Surveillance policy is recommended only in patients with low-risk CSI NSGCTT. Key words: testicular cancer, surveillance, adjuvant chemotherapy, disease progressionThe introduction of cisplatin-based combination chemotherapy has revolutionized the treatment of metastatic testicular cancer [1]. Considering the high success rate in the salvage of disseminated cancer, it seemed reasonable to propose patients with orchiectomy alone followed by surveillance only [2] for managing clinical stage I nonseminomatous germ cell testicular tumors (CSI NSGCTT). Patients who relapse are treated with systemic chemotherapy, whereas those who do not relapse are spared unnecessary treatment.The surveillance after orchiectomy alone has gained a lot of popularity in the management of CSI NSGCTT. 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]. 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. Predominantly embryonal carcinoma histology and T2-4 stage were also frequently associated with rate of relapse. The results of our previous reports [6,10,11,12,13] indicate, that prognostic factors useful for stratification of CSI NSGCTT patients to different therapeutic approaches may be established. There have been identified risk factors which define a low risk and a high risk group of patients and which have led to a riskadapted approach of treatment favoring surveillance for patients with low risk and chemot...