Risk-adapted management for patients with clinical stage I non-seminomatous germ cell tumour of the testis

Abstract

Testis cancer is the most common cancer in young men and its incidence continues to rise. Even if prognosis is considered as good, a group with bad prognosis still remains. We aimed to evaluate whether two courses of chemotherapy after orchiectomy in patients with clinical stage I, non-seminomatous germ cell testicular tumour at high risk of relapse, will spare patients additional chemotherapy or surgery. High-risk patients had one or more of the following: preorchiectomy alpha-fetoprotein level of 80 ng/dl, 80% embryonal cell carcinoma or greater, vessel invasion in the primary tumour and tumour stage pT2 or greater. Low-risk patients had none of these factors or had 50% teratoma or more without vessel invasion. High-risk patients were offered two 21-day courses of outpatient chemotherapy consisting cisplatin, etoposide and bleomycin (BEP). Low-risk patients were observed. Of the 108 patients, we classified 71 as high risk and 37 as low risk of relapse. All of the high-risk patients received two courses of BEP chemotherapy. Low-risk patients were kept on close-up. The median follow-up was 26 months (range 10-60). Of the 71 patients in high-risk group, 3 relapsed with viable cancer and required additional chemotherapy and 1 patient with normal biomarkers and a late-appearing mass underwent retroperitoneal lympadenectomy for mature teratoma. All 4 relapsed patients were in high-risk group and presently they are free of disease. None of the 37 patients at low risk of recurrences developed relapse. We recommend two courses of adjuvant chemotherapy after postorchiectomy for high-risk patients with stage I non-seminomatous germ cell tumour of the testis. Adjuvant chemotherapy for these patients results in a low relapse and morbidity, wich compares favourably with the results of surveillance or RPLND. This well-tolerated approach may spare patients additional surgery or protracted chemotherapy, reduce the cost and eliminate the compliance problems associated with intensive follow up of high-risk patients.

During twenty years of Cisplatin-based therapy the face of nonseminomatous testicular germ cell tumors is still changing: an evaluation of presentation, management, predictive factors and survival

“…Other studies reported on a higher rate of metastatic disease in tumors containing less than 50% of teratoma elements (26). In our study collective higher pT-stage was associated with the presence of metastasis at diagnosis.…”

Testicular Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

“…35 Several other studies using 2 cycles of BEP as primary treatment of stage I nonseminoma have similarly reported relapse-free survival rates .95%. 59,65,[69][70][71][72] However, late consequences of cisplatin-based chemotherapy, such as hearing damage and loss, cardiovascular conditions, hypertension, and neuropathy, have been reported during long-term follow-up. [73][74][75][76][77][78][79][80][81] Therefore, 1 cycle of BEP is recommended due to its lower toxicity.…”

Dimethyl sulfoxide induces chemotherapeutic resistance in the treatment of testicular embryonal carcinomas

“…Chemotherapy containing CDDP has been introduced as an adjuvant treatment option for micrometastatic disease, thereby reducing the risk of relapse to 2% (10). The percentage of EC component in the primary tumor is an important predictive factor for occult metastasis in stage I NSGCTs (7,(11)(12)(13), and adjuvant chemotherapy should be performed in such a way that resistance is minimized (14). Therefore, EC component control without induction of chemotherapeutic resistance is crucial for the appropriate clinical management of NSGCTs when considering the fact that ECs are a putative cancer stem component of NSGCT (15).…”