Management of Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer
Section snippets
Risk assessment
Considerable attention has been devoted to identifying clinical and pathologic parameters associated with the presence of occult metastasis in the retroperitoneum or at distant sites to better select patients for additional therapy after orchiectomy. The retroperitoneum continues to be the most difficult area to stage clinically and a consistent 25% to 35% rate of clinical understaging has been reported over the last 4 decades for CS I NSGCT despite the advent of third- and fourth-generation
Surveillance
Early interest in surveillance for CS I NSGCT was based on two key developments: (1) the finding that 65% to 75% of patients who had CS I NSGCT were cured by orchiectomy alone and therefore did not need any additional therapy, and (2) the demonstration that cisplatin-based chemotherapy could cure almost all patients who had favorable-prognosis metastatic disease. Surveillance thus seemed to offer the promise of minimizing treatment toxicity by restricting treatment to those who had a proven
Retroperitoneal lymph node dissection
In the United States and parts of Europe, the conventional approach to patients who have CS I NSGCT has been bilateral infrahilar RPLND. The main factors in favor of RPLND are that the retroperitoneum is the initial site of metastatic spread in 70% to 80% of patients who have occult metastasis, retroperitoneal lymph nodes often harbor chemotherapy-resistant teratomas, and there is a low rate of relapse following RPLND [12]. The argument for RPLND is thus that the therapeutic focus for CS I
Primary chemotherapy
In distinction to adjuvant chemotherapy given to men who have PS II disease after RPLND, primary chemotherapy refers to treatment administered to men who have CS I NSGCT after orchiectomy. The goal of primary chemotherapy is to minimize the risk for relapse and to allow men to avoid RPLND and the longer course of chemotherapy administered for patients who relapse on surveillance. The rationale underlying this approach derives from the 30% relapse rate seen during surveillance and the 20% to 25%
Summary
CS I NSGCT can be effectively managed with surveillance, RPLND, or primary chemotherapy. Each is associated with a roughly 1% risk for death from testis cancer and no randomized trials have been conducted to evaluate whether one approach is superior. Surveillance offers 70% of patients the benefit of avoiding any postorchiectomy therapy but is associated with a higher risk for relapse and a more burdensome follow-up schedule. The ideal surveillance patients are those who do not have risk
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