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 to PVB chemotherapy but subsequently died. Thirty-four patients (74%) did not undergo lymphography (LG) and had a higher relapse rate (11/34) 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.

Long–Term Experience with Laparoscopic Retroperitoneal Lymph Node Dissection in the Management of Low–Stage Testis Cancer

“…Adjuvant chemotherapy, however, is associated with acute side effects such as nausea, mucositis, nadir sepsis [36, 37], and more importantly, long–term complications like pulmonary fibrosis and impaired spermatogenesis [41]. Moreover, about 70% of the patients in fact do not require any chemotherapy because of the absence of retroperitoneal or distant metastases [1, 2, 3, 4, 5, 6, 7, 18]. …”

“…Because of the insufficiency of clinical staging alone, surveillance without prior lymph node dissection has a relapse rate of 19–40% [1, 2, 3, 4, 5, 6, 7, 18]versus 5–10% for pathologic stage–I testicular cancer after retroperitoneal lymphadenectomy [9, 10, 13, 16]. Moreover, the most serious drawback of surveillance is not only a high relapse rate but the associated death rate of approximately 10% among these patients who do relapse.…”

“…Whereas some authors advocate continued surveillance based on the efficacy of chemotherapy in terms of tumor progression [1, 2, 3, 4, 5, 6, 7], others prefer a modified or nerve–sparing lymphadenectomy [8, 9, 10, 11, 12, 13, 14, 15, 16, 17]emphasizing early detection and subsequent chemotherapeutic treatment of retroperitoneal (micro)metastases which may coexist in approximately 30% of these patiens [2, 4, 6, 7, 18]. The ongoing surveillance strategy also requires optimal patient compliance [1, 5, 6, 7]. On balance, laparoscopic retroperitoneal lymph node dissection seems to offer a minimally invasive alternative for precise pathological lymph node staging of metastatic disease [19, 20, 21, 22, 23, 24, 25, 26].…”

An Unusual Late Relapse in Pathologic Stage I Non-Seminomatous Germ Cell Tumor: Case Report and Review of the Literature

“…Late relapses have been observed in patients with clini cal stage I NSGCT of the testis treated with inguinal orchiectomy and surveillance [10][11][12][13], inguinal orchiecto my and retroperitoneal lymph node irradiation [14,15], and inguinal orchiectomy and adjuvant chemotherapy [16], However, late relapses are particularly uncommon in patients with PSI NSGCT treated with inguinal or chiectomy and RPLND (table 1). Physicians must remain vigilant for such late recurrences since most can be sal vaged with chemotherapy.…”

Management of Non-Seminomatous Germ Cell Tumor of the Testis

“…There is concern that non-compliance may translate into a decrease in disease specific survival. (Colls et al, 1999;Gels et al, 1995;Kakehi, Kamoto, Kawakita, & Ogawa, 2002;Raghavan et al, 1988) Nevertheless, the true impact of non-compliance on survival is unknown. A national surveillance study in New Zealand failed to correlate non-compliance with compromise in cure.…”