Comparative Effectiveness of Surveillance, Primary Chemotherapy, Radiotherapy, and Retroperitoneal Lymph Node Dissection for the Management of Early-Stage Testicular Germ Cell Tumors: A Systematic Review.

Cancer-specific survival for men with early-stage (Stage I-IIB) testicular germ cell tumors (TGCT) is greater than 90% with any management strategy. The data regarding the comparative effectiveness of surveillance, primary chemotherapy, radiotherapy, and retroperitoneal lymph node dissection (RPLND) was synthesized with a focus on oncologic outcomes, patient-reported outcomes, and short- and long-term toxicities.

PubMed, Embase® and the Cochrane Central Register of Controlled Trials were searched from 1980 to 2018 for studies addressing the effectiveness of surveillance, chemotherapy, radiotherapy, and RPLND, according to pathology and clinical stage, for men with an early-stage TGCT.

Cancer-specific survival ranged from 94-100% for patients with early-stage TGCT regardless of tumor histology and initial management strategy. For men with seminoma, median cancer-specific survival was 99.7% (range 97-100%), 99.5% (96.8-100%), and 100% (100-100%) among those managed by surveillance, radiotherapy, and chemotherapy, respectively. Median cancer-specific survival for men with nonseminomatous TGCT was 100% (98.6-100%), 100% (96.9-100%), and 100% (94-100%) when managed by surveillance, RPLND, and chemotherapy, respectively. Recurrence rates and toxicities varied by management strategy. For men with seminoma, surveillance, chemotherapy, and radiotherapy were associated with median recurrence rates of 15%, 2%, and 3.7%, respectively. For men with nonseminomatous TGCT, median recurrence rates were 20.5%, 3.3%, and 11.1% for surveillance, chemotherapy, and RPLND, respectively. Surveillance was associated with minimal toxicities compared to other approaches. Primary chemotherapy had the highest rate of short-term toxicities and was associated with long-term risks of metabolic syndrome, hypogonadism, renal impairment, neuropathy, infertility, and secondary malignancies. Toxicities with radiotherapy included acute dermatitis and long-term gastrointestinal complications, infertility, and high rates of secondary malignancies (2-3%). Patients undergoing RPLND had significant risk of toxicity perioperatively and long-term infertility in men with anejaculation. Transient detriments in patient-reported outcomes and quality of life were noted with all management options.

Men with early-stage TGCT experience excellent cancer-specific survival regardless of management strategy. Management options, however, differ in terms of associated recurrence rates, short- and long-term toxicities, and patient-reported outcomes. The profile for each approach should be clearly communicated to patients and matched with patient preferences to offer the best individual outcome.

The Journal of urology. 2020 Sep 11 [Epub ahead of print]

Phillip M Pierorazio, Joseph G Cheaib, Hiten D Patel, Mohit Gupta, Ritu Sharma, Allen Zhang, Giorgia Tema, Eric B Bass

Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland., Department of Urology, New York University School of Medicine, New York City, New York., The Johns Hopkins Evidence-Based Practice Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland., Department of Urology, Sant'Andrea Hospital -"La Sapienza" University of Rome, Rome, Italy.

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