Risk-adapted treatment for patients with clinical stage I nonseminomatous germ cell tumor of the testis

Clinical characteristics and treatment outcomes of germ cell tumor in Jordan: A tertiary center experience

Objective

In the Middle East, there is a paucity of data regarding germ cell tumor characteristics and treatment outcomes. Herein, we aim to present the largest series in Jordan reporting our cancer center experience managing GCT.

Methods

Between 2010 and 2020, a total of 241 patients with a pathological diagnosis of GCT were treated at our cancer center. Demographic, epidemiologic, and pathological data were retrospectively collected. In addition, survival and relapse outcomes based on tumor stage and adjuvant treatment were collected.

Results

A total of 241 patients were diagnosed with GCT, of whom 108 (44.8%) had seminoma and 133 (55.2%) had non-seminoma tumors (NSGCT). Median age (interquartile range) at diagnosis was 31 years (25-36). Patients with seminoma (68.5%) had pT1 disease post orchiectomy, while only 37.5% of patients with NSGCT had pT1 on final pathology. Elevated tumor markers such as beta-human chorionic gonadotropin were present in 10% of seminomas. Following radical orchiectomy and staging, 88 (36.5%) went for active surveillance while 153 patients (63.5%) received adjuvant treatment. With regard to pathology slides read outside, rereading by our genitourinary pathologist yielded a discrepancy on GCT type in 41 (19.3%) out of 212 patients. The median follow-up was 36 (24-48) months. Twenty-two patients relapsed after an average follow-up time of 39 months. The 5-year overall survival for stage I, II, and III was 98%, 94%, and 87%, respectively, and 3-year recurrence-free survival for stage I, II, and III was 94.8%, 78%, and 67%, respectively.

Conclusion

Our data on testicular GCT including demographic, histological, and treatment outcomes were comparable to that of developed countries. In light of the pathology discrepancy rate revealed in our study, authors recommend a second review by expert genitourinary pathologists to ensure proper classification and management of GCT.

Management of Clinical Stage I Germ Cell Tumors

Experience demonstrates multiple paths to cure for patients with clinical stage I testicular cancer. Because all options should provide a long-term disease-free rate near 100%, overall survival is no longer relevant in decision making, allowing practitioners to factor in quality of life, toxicity, cost, and impact on compliance. Surveillance for clinical stage I seminoma and clinical stage I nonseminoma has become the preferred option. The contrarian view is that a risk-adapted approach should persist, with surveillance for low-risk individuals and active therapy high-risk individuals. However, results obtained in unselected patients provide a strong argument against the need for such an approach.

Outcomes of active surveillance of clinical stage I non-seminomatous germ cell tumors: sub-analysis of the multi-institutional nationwide case series of the Japanese Urological Association

Objective

To evaluate the survival rate and risk factors of distant metastasis in stage I non-seminomatous germ cell tumor (NSGCT) cases without adjuvant treatments.

Methods

A national testicular cancer survey of cases newly diagnosed in 2005 and 2008 was conducted by the Japanese Urological Association in 2011. In 159 stage I NSGCT cases, 132 were followed by active surveillance after high orchiectomy. Their recurrence-free survival rate (RFS) was compared with 27 cases that received adjuvant treatments, and clinical and pathological parameters were explored to identify significant risk factors of recurrence.

Results

Within a median follow-up period of 30.3 months (range: 0.3-65.6 months), 16 (12.1%) of the 132 surveillance cases relapsed at 2.8-51.2 months after high orchiectomy (median: 8.35 months). The 2-year RFS rate was 90%. Eleven (68.8%) cases relapsed within 1 year, and five (31.3%) cases relapsed in 3 years or more. Half (50%) of the recurrences were detected by imaging studies alone, 37.5% by imaging combined with tumor markers, and 12.5% by tumor marker elevation alone. The only significant risk factor of recurrence was the existence of embryonal carcinoma elements in the primary testicular tumor (P = 0.0068). There was no significant difference in RFS between cases with active surveillance and adjuvant treatments.

Conclusions

The present report is the first large scale study of clinical stage I NSGCTs in Japan. Active surveillance appears to be an effective treatment option for patients with clinical stage I NSGCTs.

Laparoscopic Retroperitoneal Lymph Node Dissection in the Management of Testis Cancer

BACKGROUND

The surgical approach to management of testis cancer has been traditionally through an open incision, but in the last decade, several centers have reported their experience with laparoscopic retroperitoneal lymph node dissection (LRPLND).

METHODS

We reviewed the English literature, summarized the outcomes, and included our initial experience with the LRPLND procedure.

RESULTS

Improvements in operative time, complications, and morbidity have occurred as surgical experience has increased. The procedure is more challenging in postchemotherapy patients. Outcomes at our institute are comparable to reported series from other institutions, and LRPLND is our current procedure of choice for RPLND.

CONCLUSIONS

LRPLND has been shown to be a safe, effective, minimally invasive procedure in the management of testicular cancer patients who require surgery to address the retroperitoneal lymph nodes.

Oncological Outcomes in Japanese Men Undergoing Orchiectomy for Stage I Testicular Germ Cell Tumor

BACKGROUND

The objective of this study was to retrospectively review oncological outcomes in patients with stage I testicular germ cell tumor (GCT).

PATIENTS AND METHODS

This study included 265 consecutive Japanese men undergoing orchiectomy for stage I testicular GCT, and a retrospective review of their records was performed.

RESULTS

Of these 265 patients, 192 and 73 were pathologically classified with seminoma and nonseminoma, respectively. Prophylactic radiation and chemotherapy were performed in 62 patients with seminoma and 6 with nonseminoma, respectively. Disease recurrence occurred in 12 seminoma patients, of whom 11 had not received prophylactic radiation therapy; however, all 12 achieved a complete response to bleomycin, etoposide and cisplatin therapy. Of the nonseminoma patients, 19 experienced disease recurrence and were then treated with bleomycin, etoposide and cisplatin followed additionally by the surgical resection of residual tumors and salvage chemotherapy in 7 and 4, respectively. There was no cancer-specific death in the 265 patients, and 5-year recurrence-free survival rates in patients with seminoma and nonseminoma were 92.6 and 72.8%, respectively. Furthermore, following factors appeared to be significantly associated with recurrence-free survival in these patients: age, T classification, microvascular invasion and adjuvant therapy for those with seminoma, and microvascular invasion for those with nonseminoma.

CONCLUSIONS

Despite a generally favorable prognosis in Japanese men with stage I testicular GCT, intensive follow-up or prophylactic therapy should be considered for men with possible risk factors of disease recurrence.

Management of Stage I Nonseminomatous Germ Cell Tumors

Testis cancer represents the model for a curable malignancy. Although there is consensus about the appropriate management of metastatic (clinical stage [CS] IIC-III) nonseminomatous germ cell tumor (NSGCT) in terms of the chemotherapy regimens, number of cycles, and the surgical resection of postchemotherapy residual masses, there remains controversy regarding the appropriate management of low-stage NSGCT (CSI-IIB). In this article, the benefits and drawbacks of each treatment option are reviewed; an evidence-based approach when confronted with such a patient and how to best select a treatment avenue based on the patient's clinical and pathologic features are also discussed.

Dimethyl sulfoxide induces chemotherapeutic resistance in the treatment of testicular embryonal carcinomas

Dimethyl sulfoxide (DMSO) is an amphipathic molecule that is used as a solvent in biological studies and as a vehicle for drug therapy. The present study was designed to evaluate the potential effects of DMSO as a solvent in the treatment of testicular embryonal carcinomas (ECs). DMSO was applied to two human EC cell lines (NEC8 and NEC14), with the treated cells evaluated in relation to cisplatin (CDDP) resistance, differentiation (using Vimentin, Fibronectin, TRA-1-60, and SSEA-1 and -3 as markers) and stemness (denoted by expression of SOX2 and OCT3/4). Furthermore, DNA methyltransferase (DNMT-1, -3A and -3L) expression and methylation status were analyzed. DMSO induced resistance to CDDP, aberrant differentiation and reduction of stemness-related markers in each of the EC cell lines. The expression levels of DNMT-3L and -3A were reduced in response to DMSO, while this treatment also affected DNA methylation. The data demonstrated that DMSO perturbed differentiation, reduced stemness and induced resistance to CDDP in human EC cells. Therefore, DMSO could reduce drug efficacy against EC cells and its use should be carefully managed in the clinical application of chemotherapy.

Management of clinical stage I nonseminomatous germ cell tumors

Therapeutic options for clinical stage I nonseminomatous germ cell tumor include active surveillance, adjuvant chemotherapy and retroperitoneal lymph node dissection (RPLND). Lymphovascular invasion (LVI) determines risk of recurrence, as those without LVI have 15% risk of relapse on surveillance while those with LVI have a 50% risk. This stratifies patients into high risk(LVI+) and low risk(LVI-) groups which direct treatment recommendations. Surveillance is preferred for those with low risk disease, and is an option for those with high risk disease, as at least half are over-treated with other options. Adjuvant chemotherapy is an option for all patients as it can eradicate micrometastatic disease and reduce recurrence by at least 90%. RPLND benefits patients with low volume retroperitoneal disease with a cure rate of RPLND alone at approximately 70%. All three treatment modalities have similar survival rates approaching 100% but differing potential morbidities, which, along with patient preferences and compliance, should guide treatment decisions.

Current management of testicular cancer

Germ cell tumors (GCTs) of the testis are rare, but are the most common cancer in young men. GCTs may consist of one predominant histologic pattern or may represent a mixture of multiple histologic types. For treatment purposes, two broad categories are recognized: 1) pure seminoma and 2) others, which together are termed nonseminomatous GCTs (NSGCTs). In general, seminoma tends to be less aggressive, to be diagnosed at an earlier stage, and to spread predictably along lymphatic channels to the retroperitoneum before spreading hematogenously to the lung or other organs. Compared with NSGCTs, seminoma is exquisitely sensitive to radiation therapy and platinum-based chemotherapy. NSGCTs are usually mixed tumors and teratoma often exists at the sites of metastasis with other GCT elements; cure often requires chemotherapy to kill the chemosensitive-components and surgery to remove the teratomatous components. The main factors contributing to excellent cure rates of GCTs are careful staging at diagnosis; adequate early treatment using chemotherapeutic combinations, with or without radiotherapy and surgery; and very strict follow-up and salvage therapy. We review several clinical studies and summarize the current trends in the management of GCTs.

Minimally invasive retroperitoneal lymph node dissection for testicular cancer

Testicular cancer is the most common solid organ malignancy in young men between the ages of 15 and 35. Although much of this increase in survival can be attributed to improvements in systemic chemotherapy, surgery retains a critical role in the diagnostic and therapeutic management of testicular cancer. Laparoscopic retroperitoneal lymph node dissection is an effective staging and therapeutic procedure in patients with low-stage testicular cancer. It is an attractive alternative to the open approach, with faster recovery, improved cosmesis, and reduced post-operative morbidity driving its application. In experienced hands, it can be used in postchemotherapy patients.

Defining the Optimal Treatment for Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer Using Decision Analysis

Purpose

There is equipoise regarding the optimal treatment of clinical stage (CS) I nonseminomatous germ cell testicular cancer (NSGCT). Formal mechanisms that enable patients to consider cancer outcomes, treatment-related morbidity, and personal preferences are needed to facilitate decision making between retroperitoneal lymph node dissection (RPLND), primary chemotherapy, and surveillance.

Methods

Decision analysis was performed using a Markov model that incorporated likelihoods of survival, treatment-related morbidity, and utilities for seven undesired post-treatment health states to estimate the quality-adjusted survival (QAS) for each treatment option. Utilities were obtained from 24 hypothetical NSGCT patients using a visual analog (rating) scale and standard gamble.

Results

Overall, QAS associated with each treatment was high and differences in QAS were small. Surveillance was the preferred intervention for patients with a risk of relapse less than 33% and 37% using the rating scale and standard-gamble method of utility assessment, respectively. Active treatment was favored over surveillance for patients with relapse risk on surveillance greater than 33% and 37% by the rating scale (RPLND preferred) and standard-gamble methods (primary chemotherapy preferred), respectively. Substantial differences in average utilities were seen depending on the method used. By the rating scale, patients substantially devalued life in six of seven undesired health states but they were surprisingly tolerant of treatment-related morbidity using standard gamble.

Conclusion

A decision model has been developed for CS I NSGCT that estimates QAS for RPLND, primary chemotherapy, and surveillance by considering cancer outcomes, morbidity, and patient preferences. Surveillance was the preferred intervention for all except those patients at high risk for relapse.

Surgical management of low-stage nonseminomatous germ cell testicular cancer

The optimal treatment of low-stage nonseminomatous germ cell testicular cancer (NSGCT) is controversial. For clinical stage (CS) I NSGCT, retroperitoneal lymph node dissection (RPLND), two cycles of chemotherapy and surveillance are all accepted treatment options. For CS IIA-B, standard treatments include RPLND (+/- adjuvant chemotherapy) and induction chemotherapy (+/- RPLND). The long-term survival rate is >97% for CS I and 95% for CS IIA-B NSGCT, regardless of the treatment received. The risk of retroperitoneal metastasis varies by clinical stage (25-35% for CS I, 65-85% for CS IIA-B), and the presence of lymphovascular invasion and percentage of embryonal carcinoma in the primary tumour. Patients with elevated serum tumour markers (STMs) and adenopathy of >3 cm are at high risk of having occult systemic disease. Compared with chemotherapy, RPLND is associated with a considerably more favourable long-term morbidity profile and is the most effective method for controlling the retroperitoneum. Surveillance is associated with the lowest risk of long-term complications. As such, we favour surveillance for low-risk CS I, induction chemotherapy for those at high risk of systemic disease (elevated STM, adenopathy >3 cm), and RPLND for all others. Modified template dissections reduce the risk of ejaculatory dysfunction, but might increase the risk of local recurrence. Therefore, we favour a full-bilateral template dissection with nerve-sparing in patients with low-stage NSGCT. The therapeutic efficacy of laparoscopic RPLND is not proven and currently should be considered a staging procedure only. Adjuvant chemotherapy after RPLND is typically restricted to patients with pathological stage N2-3 disease.

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

Testis cancer is the most common cancer in young men and its incidence continues to rise. Even if prognosis is considered as good, a group with bad prognosis still remains. We aimed to evaluate whether two courses of chemotherapy after orchiectomy in patients with clinical stage I, non-seminomatous germ cell testicular tumour at high risk of relapse, will spare patients additional chemotherapy or surgery. High-risk patients had one or more of the following: preorchiectomy alpha-fetoprotein level of 80 ng/dl, 80% embryonal cell carcinoma or greater, vessel invasion in the primary tumour and tumour stage pT2 or greater. Low-risk patients had none of these factors or had 50% teratoma or more without vessel invasion. High-risk patients were offered two 21-day courses of outpatient chemotherapy consisting cisplatin, etoposide and bleomycin (BEP). Low-risk patients were observed. Of the 108 patients, we classified 71 as high risk and 37 as low risk of relapse. All of the high-risk patients received two courses of BEP chemotherapy. Low-risk patients were kept on close-up. The median follow-up was 26 months (range 10-60). Of the 71 patients in high-risk group, 3 relapsed with viable cancer and required additional chemotherapy and 1 patient with normal biomarkers and a late-appearing mass underwent retroperitoneal lympadenectomy for mature teratoma. All 4 relapsed patients were in high-risk group and presently they are free of disease. None of the 37 patients at low risk of recurrences developed relapse. We recommend two courses of adjuvant chemotherapy after postorchiectomy for high-risk patients with stage I non-seminomatous germ cell tumour of the testis. Adjuvant chemotherapy for these patients results in a low relapse and morbidity, wich compares favourably with the results of surveillance or RPLND. This well-tolerated approach may spare patients additional surgery or protracted chemotherapy, reduce the cost and eliminate the compliance problems associated with intensive follow up of high-risk patients.

Current management of stage I testicular non-seminomatous germ cell tumours

Testicular germ cell tumors represent the most common malignancies in young males between the ages of 15 and 35; 50% of those with non-seminomatous germ cell tumors (NSGCT) have clinical stage I at diagnosis. Predictors for relapse include lymphovascular invasion, percentage of embryonal-cell carcinoma component, absence of yolk-sack histology and MIB1 proliferation rate. Therapeutic options following orchidectomy in stage I NSGCT comprise nerve-sparing retroperitoneal lymph node dissection (RPLND), surveillance or adjuvant cisplatin-based chemotherapy. Using a risk adapted approach, in about 50% of patients with clinical stage I NSGCT surveillance is favored in patients with good compliance. Adjuvant chemotherapy is recommended for patients at high risk for developing metastatic disease. Non-seminomatous germ cell testicular cancer is a curable neoplasia. All available treatment modalities produce excellent results, with a long-term survival of almost 100%. Consequently, therapy-induced toxicity is an important concern in the management of these patients. An individually tailored approach that takes into account the prognostic factor profile, as well as the patients' preferences and their ability to comply with treatment, is the key for the successful management of stage I testicular cancer.

Histologic type, staging, and distribution of germ cell tumors in Korean adults

OBJECTIVES

To investigate the presentation of germ cell tumors (GCT) in terms of histology and stage, to better clarify the epidemiology of this disease in eastern Asia.

METHODS

Six hundred ninety-eight patients diagnosed with GCT between 1995 and 2004 were analyzed. Clinical parameters at the time of initial diagnosis were classified in terms of the American Joint Committee on Cancer (AJCC) tumor, nodes, metastasis staging (TNMS) system, the International Germ Cell Cancer Collaborative Classification (IGCCC), for high-risk stage I nonseminomatous GCT (NSGCT) of testis.

RESULTS

The anatomic distributions for the primary sites of the observed tumors were as follows: testis 471 cases (67%); central nervous system (CNS) 137 cases (20%); mediastinum 78 cases (11%), and retroperitoneum 12 cases (2%); 239 (51%) of 471 tumors with testicular primary were seminoma. High risk vs. non-high risk stage I NSGCT cases were 62 vs. 58. Of NSGCT of testis, 129 (58%), 73 (33%), and 21 (9%) of tumors presented with good, intermediate, and poor prognosis, respectively, based on IGCCC, whereas 231 (99%) patients were classified with a good prognosis and 3 (1%) with an intermediate prognosis amongst seminomas of testis; 193 (82%) cases presented as stage I testicular seminoma whereas 120 (54%) cases presented as stage I NSGCT.

CONCLUSIONS

Extragonadal primary GCTs are very common in Korean. Incidence of high risk NSGCT of testis with stage I disease was lower than in the Western report. NSGCT presents itself as a more aggressive form whereas seminoma is a very indolent tumor when compared with cases in Western countries.

State-of-the-art surgical management of testicular tumors

Testicular cancer is the most common malignancy in men aged 20-35 years and accounts for approximately 1% of all male malignancies. Testicular cancer has a propensity to spread via the lymphatic system to the retroperitoneal lymph nodes, and retroperitoneal lymph node dissection remains an essential component in the cure of these patients. This review summarizes the basic principles of surgical management of germ cell tumors.

An overview of testicular germ cell tumors

CONTEXT

More than 90% of testicular neoplasms originate from germ cells. Testicular germ cell tumors (GCTs) are a heterogeneous group of neoplasms with diverse histopathology and clinical behavior.

OBJECTIVE

To help the readers distinguish various subtypes of GCTs, to highlight the clinical manifestations and pathologic features of these tumors, and to review several newly developed immunohistochemical markers for GCTs.

DATA SOURCES

Review of the pertinent literature and our experience.

CONCLUSIONS

The etiology of GCTs is largely unknown. Cytogenetic studies suggest a different pathogenesis for each group of infantile/prepubertal GCTs, postpubertal GCTs, and spermatocytic seminoma. Unclassified intratubular germ cell neoplasia is the precursor of all GCTs, excluding spermatocytic seminoma and infantile/prepubertal GCTs. Seminoma, the most common GCT in adults, does not occur before 5 years of age. Spermatocytic seminoma, a tumor of elderly men, typically has an indolent clinical behavior, but rarely it undergoes sarcomatous transformation associated with an aggressive behavior. Embryonal carcinoma is the most common component in mixed GCTs. Eighty percent or more of embryonal carcinoma component and vascular invasion are recognized predictors of occult metastasis for clinical stage I mixed GCTs. Most patients with prepubertal yolk sac tumor, the most common pediatric GCT, have stage I disease at presentation. Most choriocarcinomas present with metastatic symptoms because of the propensity for rapid hematogenous dissemination. Teratomas in children regardless of maturity and dermoid cysts in adults are benign; in contrast, teratomas in adults have a malignant behavior. With appropriate therapy, the majority of testicular GCTs are curable.

Management of Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer

The optimal management of patients who have clinical stage I nonseminomatous germ cell tumors remains controversial. Surveillance, retroperitoneal lymph node dissection (RPLND), and chemotherapy with two cycles of bleomycin-etoposide-cisplatin are established treatment options and all are associated with long-term cancer control rates of 97% or greater. Studies have consistently identified the presence of lymphovascular invasion and a predominant component of embryonal carcinoma in the primary tumor as risk factors for occult metastatic disease in these patients. Patients who do not have these risk factors are optimally managed by active surveillance given the low risk for relapse. For patients at high risk for relapse and who are not candidates for surveillance, we believe the evidence supports RPLND over primary chemotherapy.

Significance of Primary Tumor Size and Preorchiectomy Serum Tumor Marker Level in Predicting Pathologic Stage at Retroperitoneal Lymph Node Dissection in Clinical Stage A Nonseminomatous Germ Cell Tumors

OBJECTIVES

To determine whether the size of the primary tumor and degree of preorchiectomy serum alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-hCG) elevation predict for retroperitoneal pathologic findings in patients with clinical Stage A nonseminomatous germ cell tumor undergoing primary retroperitoneal lymph node dissection.

METHODS

The testicular cancer database was queried to identify patients with clinical Stage A nonseminomatous germ cell tumor with normalization of serum tumor markers after orchiectomy who had undergone retroperitoneal lymph node dissection. A total of 779 patients were identified. The preorchiectomy serum tumor marker level was recorded and categorized into the following subsets: AFP: less than 20 (normal), 20 to 100, 100 to 1000, and more than 1000 ng/dL; and beta-hCG: less than 5.0 (normal), 5 to 100, 100 to 1000, and more than 1000. The association between AFP, beta-hCG, and primary tumor size and retroperitoneal pathologic findings was determined.

RESULTS

The retroperitoneal pathologic examination revealed metastatic disease in 207 patients (26.6%). The preorchiectomy serum beta-hCG level, as a categorical variable, was not predictive of positive retroperitoneal pathologic findings (P = 0.187). The preorchiectomy serum AFP did predict for positive retroperitoneal pathologic findings, with lower serum AFP levels associated with a greater incidence of retroperitoneal metastasis (P <0.001). The primary tumor size was not predictive of positive retroperitoneal pathologic findings (P = 0.113).

CONCLUSIONS

Neither the primary tumor size nor the preorchiectomy beta-hCG level was predictive of retroperitoneal metastases. However, a normal preorchiectomy AFP level was associated with a greater incidence of retroperitoneal metastases.

Management of Stage I Testis Cancer

OBJECTIVE

Over the last 5 years the management of stage I testis cancer has changed tremendously. This review focuses on the latest changes in diagnostics and treatment of clinical stage I non-seminomatous and seminomatous germ cell tumors.

METHODS

A non-structured literature search (MEDLINE) was performed, including recently published papers (up to March 2006) on the subject.

RESULTS

Organ-sparing surgery has become an accepted approach to treat malignant and nonmalignant tumours in a solitary testis. With certain precautions and adjuvant radiotherapy, this approach has proven to be as effective as orchidectomy. Prognostic factors strongly influence the decision for or against adjuvant treatment in seminoma and non-seminoma. With the help of a risk-adapted approach, about 50% of patients with clinical stage I testis cancer will favour close surveillance instead of immediate adjuvant treatment. Several well-conducted trials have helped to substantiate the management. Surgical staging by retroperitoneal lymph node dissection became an exception. Patients with non-seminoma with high risk for occult metastatic disease will favour adjuvant chemotherapy and in patients with seminoma radiotherapy with reduced dosage will be challenged by carboplatin monotherapy.

CONCLUSION

With adequate diagnostics and treatment, 100% of patients with stage I testis cancer will survive. Future research will focus on quality control, adherence to guideline recommendations, and further reduction of treatment to diminish the risk of late sequalae for patients with adjuvant radiotherapy or chemotherapy.

Controversies in the Management of Clinical Stage I Testis Cancer

During the last two decades, definitive primary treatments and surveillance with definitive treatment deferred until relapse have demonstrated 98% to 99% cure rates in patients with stage I testis cancer, and these options have obtained firm positions in standard management. The development of optimal management strategies in various countries were at least partly guided by available surgical expertise in retroperitoneal lymph node dissection in the United States, and easy access to reference hospitals in densely populated countries in Western Europe that facilitated close surveillance programs; hence, treatment preferences differ on the two sides of the Atlantic. The success of both approaches is highly dependent on the skills of the practitioner, particularly of surgery and of scrutinized surveillance. As a result, local expertise and familiarity with a chosen modality has strengthened over the years, and investigators have been reluctant to embark on randomized trials designed to compare one modality with another. Such expertise with one particular technique, with the other approach being less familiar territory, has created controversy, because both physicians and patients seek evidence-based data coming from randomized clinical trials on which to make management decisions. Moreover, the reduced risk of relapse resulting from the use of radiotherapy or carboplatin in stage I seminoma and of cisplatin-based chemotherapy in stage I nonseminoma must be balanced against the potential long-term adverse effects in this population of patients with a normal life expectancy. The purpose of this review is to present the currently available data and discuss the merits and the disadvantages of the various approaches, yielding to the possible conclusion that all options appear to be equal in terms of efficacy, but that modality-associated adverse effects differ.

Testicular germ cell tumors

PURPOSE OF REVIEW

An overview of many of the preclinical and clinical developments in germ cell tumors over the past year is presented.

RECENT FINDINGS

Recent epidemiologic studies show changes in the ethnic incidence of germ cell tumors; in particular, African-Americans have seen an increase. Additionally, risk factors for the development of germ cell tumors continue to be identified. Work on the molecular pathways involved in the progression to malignancy continues to expand. First line treatment for the disease is highly effective. In an effort to limit unnecessary treatments and treatment-related toxicities, risk-adapted adjuvant therapies are being explored in early stage germ cell tumors. Identification of more effective second-line treatments for advanced relapsing and refractory disease remains a priority.

SUMMARY

Germ cell tumors are highly treatable, but significant challenges remain for recurrent and refractory disease. Recent studies on the molecular pathogenesis of germ cell tumors further highlight the complexity of the disease. As these processes are better understood, the therapeutic options will continue to evolve.

Long-term outcome of retroperitoneal lymph node dissection in the management of testis cancer

In low volume testicular cancer, (clinical stage A/B1) retroperitoneal lymph node dissection has maintained its therapeutic benefit while minimizing morbidity with the reduction of the surgical template from a full bilateral dissection to a unilateral nerve-sparring surgery. The optimal treatment for low stage disease is largely patient driven with surgery and surveillance considered the primary treatment modalities. In the post chemotherapy population, patients with complete radiographic resolution of retroperitoneal disease are observed at Indiana University as the relapse rate in this population is approximately 5%. Residual masses after chemotherapy should be resected. A modified post chemotherapy dissection is adequate in low volume disease restricted to the primary landing zone of the affected testicle. In chemo-refractory disease, aggressive surgery provides a 5 year survival of 31% for patients with active cancer. Excluding chemo-naïve patients, late relapse disease is managed surgically with 50% being cured of disease.

Management of patients with low-stage nonseminomatous germ cell testicular cancer

Management options for patients with clinical stage (CS) I nonseminomatous germ cell testicular cancer (NSGCT) include surveillance, retroperitoneal lymph node dissection (RPLND), or two cycles of bleomycin-etoposide-cisplatin (BEP x 2) chemotherapy. The optimal management of these patients is controversial, as cure rates of 97% or greater are reported with each of these treatment modalities. Patients without evidence of lymphovascular invasion, a predominant component of embryonal carcinoma, or advanced pathologic (p) T stage (pT 2 or greater) are at low risk for occult metastases and are optimal candidates for surveillance. Compliance with diagnostic testing and imaging is essential for a successful surveillance strategy to detect and treat metastases at an early stage. For patients who are not candidates for surveillance, RPLND offers several advantages over chemotherapy. RPLND alone is curative in 50% to 80% of CS I patients with pathologic stage (PS) II, and an estimated 75% of CS I patients avoid chemotherapy (as adjuvant therapy or for treatment of relapse). Virtually all patients are cured following two cycles of adjuvant chemotherapy for PS II disease, which is reserved for patients with high-volume (PN2-3) retroperitoneal disease. The poor outcome of patients with late retroperitoneal recurrence from unresected, chemorefractory germ cell testicular cancer indicates that RPLND is a vital component to the long-term cure of patients with NSGCT. Approximately 20% to 30% of patients with PS II disease have retroperitoneal teratoma (which is chemoresistant), and an estimated 5% of PS II patients have chemoresistant viable cancer following BEP x 2 as primary therapy. When RPLND is omitted, these patients are at risk for late recurrence with potentially lethal consequences. Patients who relapse after RPLND are "chemotherapy-naïve" and cured in virtually all cases with good-risk chemotherapy regimens. When nerve-sparing techniques are employed to preserve ejaculation, RPLND is also associated with a more favorable long-term toxicity profile compared with chemotherapy. In the absence of conclusive evidence from a randomized trial, we believe RPLND is the treatment of choice for patients with CS I NSGCT who are not candidates for surveillance, as it offers the greatest likelihood of long-term cure with considerably less morbidity than primary chemotherapy.

Retroperitoneal lymph node dissection in patients with low stage testicular cancer with embryonal carcinoma predominance and/or lymphovascular invasion

PURPOSE

The outcome after primary retroperitoneal lymph node dissection (RPLND) was analyzed in patients with clinical stage I-IIA nonseminomatous germ cell testicular cancer with embryonal carcinoma predominance (ECP) or lymphovascular invasion (LVI).

MATERIALS AND METHODS

Between 1989 and 2002, 267 patients with clinical stage I-IIA nonseminomatous germ cell testicular cancer, and ECP and/or LVI underwent RPLND. Patient information was obtained from a prospective database. Median followup was 53 months.

RESULTS

Overall 42% of patients had pathological stage (PS) II disease, of whom 54% had low volume (PN1) disease and 16% had retroperitoneal teratoma. The 5-year progression-free probability was 90% overall, 90% for PS I and 86% for PN1. All patients with relapse were continuously free of disease following standard chemotherapy with or without resection of residual masses and the 10-year actuarial overall survival was 100%. When adjuvant chemotherapy was restricted to patients with PN2 disease, the estimated 5-year relapse rate was 9% and an estimated 72% of patients avoided chemotherapy.

CONCLUSIONS

The low risk of systemic relapse in patients with PS I and PN1 after RPLND alone combined with the 16% incidence of retroperitoneal teratoma and the favorable morbidity profile supports RPLND over primary chemotherapy for the treatment of patients with low stage disease with ECP and/or LVI who are not candidates for surveillance. An estimated 72% of patients are spared the potential toxicity of chemotherapy if adjuvant therapy is restricted to patients with PN2. After primary RPLND and selective adjuvant chemotherapy late recurrence is distinctly uncommon and long-term cancer control is anticipated in essentially all patients.

The Efficacy of Different Follow-Up Strategies in Clinical Stage I Non-Seminomatous Germ Cell Cancer: A Markov Simulation Study

OBJECTIVE

There is no universally accepted standard protocol for surveillance of patients with clinical stage I Non Seminomatous Germ Cell Tumors (CS I NSGCT). Prospective studies to compare different follow-up policies have not been performed, even though a great deal of time and resources is spent in surveillance. In this study, we constructed a Markov model to evaluate the impact of different follow-up strategies on disease-specific mortality (DSM) and life expectancy (LE) of patients with CS I NSGCT.

METHODS

A discrete time non-homogeneous semi-Markov model was used to simulate different follow-up strategies for a hypothetical population of CS I NSGCT patients. Estimates of the model parameters were based on the literature. Output parameters were DSM and LE. Three different strategies were compared: (1) the intensive The Netherlands Cancer Institute/Antoni van Leeuwenhoek hospital (NCI/AvL) protocol; (2) the European Association of Urology (EAU) protocol; and (3) a hypothetical minimal protocol (i.e. follow-up limited to the first two years). Furthermore, we evaluated the impact of abdominal CT scans and chest X-rays on DSM.

RESULTS

Comparing with the EAU protocol (DSM: 3.05%; LE: 53.3 years), the intensive NCI/AvL protocol leads to a 1.2% lower DSM and a 6 months higher LE (DSM: 1.81%; LE: 53.9 years). The hypothetical follow-up scenario during the first two years shows a DSM of 6.83% and an LE of 51.4 years. Abdominal CT scans of the retroperitoneal lymph nodes appear to be important, while chest X-rays have little impact on DSM.

CONCLUSION

A follow-up policy limited to the first two years will result in an unacceptable high percentage of death from disease (6.83%). The relatively small benefit of an intensive follow-up protocol as proposed by the NCI/AvL, compared to that of the EAU, must be weighed against its economic and psychological costs. Our model suggests that CT-scanning is essential for a low DSM, whereas the large number of X-rays seem to have little additional effect.

The role of retroperitoneal lymph node dissection in the management of testicular cancer

Despite continued refinement in terms of technique and the integration of retroperitoneal lymph node dissection (RPLND) in the management of patients with testicular cancer, RPLND remains an essential component in the ultimate cure of these patients. The failure to eradicate all disease in the retroperitoneum exposes patients to the risk of late relapse events with potentially lethal consequences. For patients with low-stage nonseminomatous germ cell tumor (NSGCT), primary RPLND is an important staging tool to define subsequent treatment requirements, simplify the follow-up of patients by obviating the need for routine abdominal imaging, and limit the exposure of patients to the long-term toxicity of chemotherapy. RPLND alone is curative in up to 90% of patients with low-volume retroperitoneal disease. In the post-chemotherapy setting, the inability to reliably exclude the presence of teratoma or viable germ cell cancer in the retroperitoneum mandates that post-chemotherapy RPLND be performed for all NSGCT patients with residual masses. With improvements in surgical technique and perioperative care, RPLND is associated with minimal short- and long-term morbidity in the hands of experienced surgeons at dedicated centers. This article reviews the role of RPLND in the management of patients with NSGCT at all stages and its role in advanced seminoma.