Stage I nonseminomatous germ-cell testicular cancer ? management options and risk-benefit considerations

Abstract

The results obtained with primary retroperitoneal lymph-node dissection (RPLND) in 464 patients with clinical stage A nonseminomatous germ-cell (NSGC) testicular cancer over a period of 25 years were reviewed. Results were analyzed in clinical terms and subdivided into early (1965)(1966)(1967)(1968)(1969)(1970)(1971)(1972)(1973)(1974)(1975)(1976)(1977)(1978) and contemporary (1979)(1980)(1981)(1982)(1983)(1984)(1985)(1986)(1987)(1988)(1989) findings so as to be comparable with series using radiotherapy or surveillance. Between 1965 and 1978 (86 clinical stage A patients), the overall relapse rate of 15% (n = 13) was similar to that obtained in radiotherapy series but the survival (98~8% after RPLND) was superior to that achieved with irradiation (87%). From 1979 to 1989, 378 clinical stage A cases had primary RPLND, of whom 29% (n = 111) had cancerous nodes. The relapse rate for pathological stage A patients (n = 267) was 11% and two patients died. The rate of relapse for pathological stage B patients who did not receive adjuvant chemotherapy was 32%. No relapse was seen among 46 pathological stage B patients given postoperative adjuvant chemotherapy. The mortality of 0.7% observed among 378 clinical stage A RPLND cases was lower than the 2% value reported in surveillance series. Although not statistically significant, these consistent results reported for two eras (pre-and postplatinum) spanning a period of 25 years suggest a sound basis for the surgical approach. The anatomic and medical principles in oncology, which have supported this approach, remain cogent today. They are discussed herein. Now that nerve-sparing techniques have been developed, the one long-term morbidity of RPLND (i.e., anejaculation) can be avoided. It would seem appropriate to have nerve-sparing RPLND techniques in any armamentarium dealing with clinical stage A disease.Almost 1200 nonseminomatous germ-cell (NSGC) testicular cancer patients underwent retroperitoneal lymphnode dissection (RPLND) at Indiana University between 1965 and 1989. This represents the largest institutional series of surgical testicular cancer cases and it is therefore timely to review the results we obtained for each stage of disease. This paper deals with a subgroup of patients who underwent primary RPLND (n = 638), specifCorrespondence to: J. P. Donohue, M.D.ically with those who were considered clinically to have stage A disease before surgery (n = 464, no demonstrable metastases as determined by clinical, radiological, and serological methods).The options for managing clinical stage A NSGC testicular cancer after orchiectomy include the surgical approach involving primary RPLND [1]. Alternatively, the nonsurgical options include routine abdominal irradiation or selective combination chemotherapy [2]. The most conservative approach involves surveillance or a "wait-andsee" policy after orchiectomy [3]. In the latter approach, chemotherapy is reserved for those patients who subsequently relapse.

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

“…The disadvantages of RPLND are that, even with modifical techniques, the operation may result in a considerable morbidity rate of 11-23% and in a mortality rate of approximately 0.3% [23]. Despite a previous RPLND, tumour recurrences in the retro peritoneum occurred in 7-12% of patients after 2 years [24][25][26], and despite major improvements in nervesparing techniques, still has some risk of ejaculation loss depending on the surgeon's expertise [27]. Thus, these patients can benefit from earlier chemotherapy with 2-3 cycles and optimal chance for cure [9].…”

Surgery versus surveillance in stage I non-seminoma testicular cancer

“…Thus, the approach of adjuvant chemotherapy to high risk clinical Stage I patients constitutes over-treatment in at least half of cases. On the other hand, however, by using this approach almost 50% of patients who would in fact have relapsed are cured with two cycles of chemotherapy instead of at least three that would be required at relapse [7,33].…”

“…Over the past 2 decades, several modifications of surgical techniques by down-scaling the surgical template and development of nerve-sparing techniques have considerably reduced the morbidity of primary RPLND without comprising the high cure rate. In centers in the U.S. that have a strong urological surgical tradition, primary RPLND is still recommended as standard approach to clinical Stage I NSTGCT [7].…”

Die kontralaterale Biopsie beim Hodentumor

“…Tatsache ist aber, daß es sich noch niemals in der Geschichte der Onkologie als vorteilhaft erwiesen hat, einen bösartigen Tumor eher später und nicht so früh wie möglich zu behandeln [15]. Die Rate der falsch-negativen Befunde liegt im Promillebereich.…”