Patterns of Relapse in Patients With Clinical Stage I Testicular Cancer Managed With Active Surveillance

Abstract

Active surveillance for CSI testis cancer leads to excellent outcomes. The vast majority of relapses occur within 2 years of orchiectomy for CSI nonseminoma and within 3 years for CSI seminoma. Late and advanced stage relapse are rarely seen. These data may inform further refinement of rationally designed surveillance schedules.

28-year late spermatic cord relapse of a testicular non-seminomatous germ cell tumour, managed robotically

“…Additionally, predicting the time to relapse past two years is difficult. 3 Fortunately, it appears that most patients with late-relapsing GCT present symptomatically, 9,11-14 most commonly with abdominal pain, as seen in this patient and other patients previously described. 1 Moreover, late relapses typically can be managed surgically.…”

“…To our knowledge, only two later cases have been reported 9,10 and only 1% of patients will relapse three or more years postorchiectomy. 3 This case and other rare late relapse cases raise the question of whether lifetime imaging surveillance should be performed for CSI NSGCT patients. With the documented risks of radiation exposure associated with CT scans, the cost to the healthcare system that would be incurred by serial imaging, and the relative rarity of late relapses, we and others continue to support a policy of discharging patients after five years of surveillance, knowing there is a small (<1%) risk of late relapse.…”

“…In a pooled analysis of 938 men with CSI NSGCT managed with active surveillance, only 1% experienced relapse after three years of post-orchiectomy surveillance. 3 Overall, the relapse rate for CSI NSGCT is 26-35%. 1,3,[6][7][8] The most likely site of relapse is the retroperitoneum, followed less frequently by the lung.…”

“…1,3,4 Relapses beyond two years are considered late relapse and are much less common. A 2007 systematic review of testicular GCT surveillance found only seven reported recurrences after five years of surveillance, with a maximum time to relapse of 14.25 years.…”

“…As a result, this approach has been recommended by several guidelines and adopted by many other centres worldwide. 1,[3][4][5] The current active surveillance protocol for CSI NSGCT at Princess Margaret involves regular and structured monitoring of tumour markers (alpha-fetoprotein [AFP], human chorionic gonadotropin [hCG], lactate dehydrogenase [LDH]) and computed tomography (CT) scans of the chest, abdomen, and pelvis, and has been previously outlined in the literature. 1,6 After two years of active surveillance, the intensity is tapered.…”