Stage I testicular tumor: How frequently to scan?

Abstract

380 Background: Testicular malignancy is the most common cancer affecting men aged between 15 and 44 years. In our centre, almost all low-risk seminoma (LRS) stage-I and non-seminomatous germ cell tumours (NSGCT) stage I (high and low-risk) tumours are followed-up on a surveillance program (SP) for a minimum of 5 years. LRS patients are scanned at 4, 6, and 12 monthly intervals during years 1, 2, and 3 to 5 years respectively. NSGCT undergo computer tomography (CT) scan at 3 monthly intervals in years 1 and 2, 4 monthly in year 3 and 6 monthly thereafter. Clinical examination, Chest X-ray (CXR) and tumour markers (TM) are performed at each visit. This retrospective audit examined if relapses were first detected by raised TM or radiologically, and if there was any difference in detection rate between these investigations to recommend reducing the frequency of CT scans, especially in lower risk groups, and therefore cumulative radiation exposure. Methods: The patient population was obtained from hospital electronic database. Metastatic patients, clinical trials patients and those who received adjuvant treatment upfront were excluded. Results: 396 patients were enrolled from 1999 to September 2013. 153 patients were followed-up in SP. 33 relapses (mean age 37 years, range 17-56) detected in SP. The mean relapse free survival period was 55.3 months (range 9.6-43.3) from date of diagnosis. No relapses were first detected on CXR. 4 patients had only TM elevated and 6 had CT abnormality found post TM elevation. 11 had simultaneous CT and TM abnormalities. For 12 patients, CT abnormality was detected with no TM raise. Of these, 8 were high risk (7 NSGCT and 1 pure seminoma) and 4 were low risk NSGCT. Patients were treated with standard BEP/EP chemotherapy regimen on relapse. All patients are alive to date and continue to be followed-up regularly. Conclusions: 12 patients in our study had relapses detected radiologically with no TM rise. 25% of these patients had low risk NSGCT. Without the CT scan, these patients would have faced potential delay in diagnosis and treatment. Results of prospective randomised trials are awaited to produce evidence to place confidence in less number of CT-scans for these patients during follow- up. Until then we recommend the current standard protocol be followed.