Surveillance for Stage I Non-Seminomatous Germ Cell Tumours of the Testis: The Optimal Protocol has not yet been Defined

Abstract

Forty-six patients with clinical stage I testicular non-seminomatous germ cell tumours were followed up according to a protocol of active surveillance between 1979 and 1987. The median follow-up time was 40 + months. Thirteen patients (28%) relapsed, predominantly in retroperitoneum and/or lung. Ten of these relapses (76%) occurred within 8 months of orchiectomy. Relapses occurred in 7/35 T1 tumours and 5/10 T2 to T4 tumours. No correlation was detected between the histological type and relapse rate. Three late relapses were diagnosed at 23, 29 and 36 months. Eleven of the relapsed patients remain in prolonged complete remission after PVB chemotherapy +surgery; one patient, who initially refused treatment at the time of relapse, has died. Another relapsed with predominant elements of rhabdomyosarcoma intermingled with malignant teratoma in a bone metastasis. He had a partial response t o PVB chemotherapy but subsequently died. Thirty-four patients (74%) did not undergo lymphography (LG) and had a higher relapse rate (1 1/34) than those who had LG (2/12); this was not a statistically significant difference in this small series. The policy of active surveillance is not yet the "state of the art" and should be under constant scrutiny with respect to safety and practice.

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

“…The relapse rate for patients managed with surveillance ranges between 25% and 35% [13,14]; as the retroperitoneum is the most c o m m o n metastatic site, a lower rate of relapse in any surgical series (13% in the present series) is obviously a function of early clearance of the retroperitoneum as a potential relapse site by R P L N D itself. Although not statistically significant, the mortality related to cancer (or to treatment) is also lower in the surgical group (n = 3, 0.8%) than in surveillance series (range, 0.9%-4.4%) [14,15].…”

“…The other feature of RPLND was that it appeared to confer a clear advantage on patients who did subsequently relapse. Such patients proved to be uniformly curable, in marked contrast to those relapsing in series using abdominal radiation [14,15]. The reason for this was twofold.…”

Surveillance Study for Clinical Stage I Testicular Seminomas and Nonseminomatous Germ Cell Tumors

“…Tumor markers were elevated in 1 of 2 recurrent seminoma patients and in 9 of 10 in recurrent NSGCT patients at the time of recurrence. Although tumor markers were usehl for close follow-up especially in NSGCT patients, there was 1 patient who recurred in Peckham et al 1982"' Johnson et al 198W Pizzocaro et al 1985:' Hoshin et al 1986" Raghavan et al 1988" Dunphy et al 1988" Wishnow et al 1989" Freiha 8. Torti 1989"' Sturgeon et al 1992 the lung without any elevation of tumor markers (Table 4, no.…”

“…In previous studies, 3.5% of stage I NSGCT patients (91256) died of recurrent cancer. 16,17,[19][20][21][22][23][24][25][26][27][28][29] Seminoma is likely to have a low propensity for d i~s e m i n a t i o n .~l >~~ Surveillance for stage I seminoma could be the best treatment option because retroperitoneal lymph node involvement appears to be the common pattern ofrecurrence which can be detected by CT scan before it is large in volume, and good responses can be obtained using cisplatin-based Chemotherapy. Since seminoma is a highly radiosensitive tumor, low recurrence rates (less than 5%) are observed after radical orchiectomy and infradiaphragmatic lymph node irradiation in stage I patients.…”

Surveillance in stage I nonseminomatous germ cell tumours of the testis

“…In summary, several studies have shown that initial active surveillance after orchidectomy, with delayed treatment for relapse, is a safe option for patients with CS I NSGCT [9,19,22,24,27,32,38,42–46] (Table 1). Potential prognostic factors for relapse have been identified and risk‐adapted treatment policies are used by many groups [9,35,41,47,48].…”