Patterns of Relapse in Australian Patients With Clinical Stage 1 Testicular Cancer: Utility of the Australian and New Zealand Urogenital and Prostate Cancer Trials Group Surveillance Recommendations

Abstract

PURPOSE: International guidelines advocate for active surveillance as the preferred treatment strategy for patients with stage 1 testicular cancer after orchidectomy although a personalized discussion is required. MATERIALS AND METHODS: We conducted an analysis of individuals registered in iTestis, Australia's testicular cancer registry, to describe the patterns of relapse and outcomes of patients treated in Australia where the Australian and New Zealand Urogenital and Prostate Cancer Trials Group Surveillance Recommendations are widely adopted. RESULTS: A total of 650 individuals diagnosed between 2000 and 2020 were included, 63% (411 of 650) seminoma and 37% (239 of 650) nonseminoma. The median age was 34 years (range 14-74). 26% (106 of 411) with seminoma and 15% (36 of 239) nonseminoma received adjuvant chemotherapy. After a median follow-up of 43 months (range 0-267) postorchidectomy, relapse occurred in 10% (43 of 411) of seminoma and 18% (43 of 239) of nonseminoma. The two-year relapse-free survival was 92% (95% CI, 89 to 95) and 82% (95% CI, 78 to 87) in seminoma and nonseminoma, respectively. All relapses (86 of 86) were detected at a routine surveillance visit; 98% (85 of 86) were asymptomatic and detected solely through imaging (62 of 86, 72%), tumor markers (6 of 86, 7%), or a combination (17 of 86, 20%). The most common relapse site was isolated retroperitoneal lymphadenopathy (53 of 86, 62%). No nonpulmonary visceral metastases occurred. At relapse, 98% (84 of 86) had International Germ Cell Cancer Collaborative Group (IGCCCG) good prognosis; 2 of 86 intermediate prognosis (both nonseminoma). No deaths occurred. CONCLUSION: In our cohort of stage 1 testicular cancer, where national surveillance recommendations have been widely adopted, recurrences were detected at routine surveillance visits and, almost exclusively, asymptomatic with IGCCCG good-prognosis disease. This provides reassurance that active surveillance is safe.

Testicular Cancer: The Test is to Focus on Important Research

“…The reason is simple—it is a very well-conducted study of 650 patients, multicenter and multidisciplinary, with long follow-up and a real-world flavor in its measurement of outcomes. 1 In short, it adds to the published literature in a meaningful way and emphasizes the following:active surveillance in the hands of ANZUP investigators is safe, with predominantly good-risk patterns of relapse;most relapses these days are detected by imaging or the combination of imaging and measurement of serologic markers;both seminoma and NSGCT can be managed via active surveillance with safety.…”

“…In the article that accompanies this editorial, Conduit et al 1 have reported the Australian & New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP) experience of surveillance for stage I testis cancer, to our knowledge, perhaps one of the largest series to date. It seems appropriate to complete the circle of Commonwealth contribution in this domain as active surveillance for stage I testicular cancer largely arose from the United Kingdom and the antipodes more than 40 years ago.…”

Active surveillance: minimising treatment while maximising outcomes in testis cancer

“…First introduced in the 1980s, active surveillance for clinical stage 1 testicular cancer after orchidectomy has been embraced ( 5 , 6 ), and is now preferred to adjuvant therapy in most consensus guidelines ( 7 - 9 ). Whilst highly efficacious at preventing relapse ( 10 - 12 ), adjuvant treatment with chemotherapy or radiotherapy is associated with potential short- and long-term toxicities that may have persisting impacts on quality of life for long-term survivors and pertinently, is unnecessary for the majority ( 1 ).…”

“…Active surveillance delicately navigates the risk of over-investigation and over-treatment, with the risks of recurrent testicular cancer, using a protocolised approach encompassing physical examination, regular imaging, and serum tumour biomarkers evaluation ( 6 - 9 , 15 , 16 ). These recommendations have been designed to proactively detect recurrences in the unlikely event they occur.…”

“…Additionally, concerns regarding radiation exposure have been raised. Strategies to de-intensify imaging in seminoma, including use of magnetic resonance imaging in preference to computerised tomography, reduction in scan frequency, and omission of pelvic imaging have been proposed and may address some of these challenges, and is reflected by some recommendations ( 6 ). Microribonucleic acids (miRNA), pertinently plasma miR-371, may obviate the need for frequent imaging in follow-up with a growing volume of evidence demonstrating superiority to existing clinical instruments and clinical utility in surveillance of both seminoma and nonseminoma with early detection of recurrence and high specificity and positive predictive value ( 23 ).…”