28-year late spermatic cord relapse of a testicular non-seminomatous germ cell tumour, managed robotically

We present a patient who relapsed symptomatically 28 years post-orchiectomy, initially followed by active surveillance for clinical stage I non-seminomatous germ cell tumour (CSI NSGCT). His relapse was localized to the pelvis, managed with robotic surgery, and achieved a complete resection with tumour markers normalized. We highlight the current Princess Margaret guidelines for followup of CSI NSGCT and discuss the trade-off between lifelong radiographic surveillance to detect the very small risk of late relapse. We discuss the incidence and presentation of late relapse, treatment options, and outcomes, highlighting that these tumours are typically refractory to chemotherapy and can often be managed with surgery alone.

Late relapse of germ cell tumors

This article highlights relevant aspects of the rare late relapses of malignant germ cell tumors (MGCTs), which by definition occur at least 2 years after successful treatment. In most reports, 1% to 6% of patients with MGCT experience a late relapse. Surgery is the most important part in the treatment of late relapses. Viable MGCT or teratoma with malignant transformation may require multimodal treatment with chemotherapy, radiotherapy, and/or surgery. Salvage chemotherapy should be based on a representative biopsy. Referring patients with late relapse to high-volume institutions ensures the best chances of cure and enables multimodal treatment.

Late relapse of germ cell tumors

OBJECTIVE

To assess the main characteristics of late relapsing malignant germ cell tumors (MGCTs). These tumors are rare and occur by definition 2 years or later after successful treatment.

METHODS

We present relevant literature on relapsing MGCT in order to highlight the following issues: incidence, impact of initial treatment on the subsequent risk of late relapse, treatment, and survival.

RESULTS

A pooled analysis of 5,880 patients with MGCT revealed late relapses in 119 of 3,704 (3.2%) and in 31 of 2,176 (1.4%) patients with non-seminoma and seminoma, respectively. The retroperitoneal space is the predominant site of relapse in both histological types. The initial treatment is important for the risk and localization of late relapses. Patients with single site teratoma are usually cured by surgery alone, whereas viable MGCT or teratoma with malignant transformation may require multimodal treatment with chemo- and/or radiotherapy as well as surgery. Surgery is the most important part in the treatment of late relapses. Salvage chemotherapy should, if feasible, be based on a representative biopsy. Five-year cancer-specific survival is above 50% in the recent large series and reaches 100% in case of single site teratoma.

CONCLUSIONS

Treatment of late relapsing MGCT patients is challenging and should be performed in experienced centers only. Referral of late relapsing patients to high-volume institutions ensures the best chances of cure and enables multimodal treatment, and contributes to increased knowledge of tumor biology as well experience with the clinical course of these patients.