Management of patients with clinical stage I nonseminomatous testicular germ cell tumours: Active surveillance versus primary chemotherapy versus nerve sparing retroperitoneal lymphadenectomy - Abstract

Clinical stage I testicular nonseminomatous germ cell tumours (NSGCT) are highly curable. Following orchidectomy a risk-adapted approach using active surveillance (AS), nerve sparing retroperitoneal lymph node dissection (nsRPLND) and primary chemotherapy is recommended by the current guidelines. CS I is defined negative or declining tumour markers to their half-life following orchidectomy and negative imaging studies of the chest, abdomen and retroperitoneum. Low risk CS I NSGCT are defined by the absence of vascular invasion, low percentage of embryonal carcinoma (ECA) and low proliferating Ki-67 index. High risk CS I NSGCT are defined by the presence of VI, high percentage of ECA and a high Ki-67 index. According to the current guidelines, active surveillance, primary chemotherapy and nerve sparing RPLND represent 3 treatment options with the same high cure rate of about 100% but significantly different long-term complications. As demonstrated, active surveillance can be performed in low risk and in high risk NSGCT with an anticipated relapse rate of about 15% and 50%. The majority of patients will relapse with good and intermediate prognosis tumours which have to be treated with 3 to 4 cycles chemotherapy. About 25% to 30% of these patients will have to undergo postchemotherapy RPLND for residual masses. Primary chemotherapy with 1 -2 cycles PEB is a therapeutic option for high risk clinical stage I NSGCT associated with a recurrence rate of only 2-3% and a minimal acute and long-term toxicity rate. Nerve sparing RPLND, if performed properly, will cure about 85% of all high risk patients with clinical stage I NSGCT without the need for chemotherapy. Although armchair calculations of the odds of cure and toxicity associated with the various treatment options can be performed, recommendations about the most optimal therapy in clinical stage I NSGCT remain controversial. There seems to be a consensus that active surveillance is the treatment strategy of choice for CS I low risk patients. However, there is no clear cut recommendation in high risk patients. Each treatment has its own advantages and disadvantages which have to be discussed thoroughly with the patient. If, however, the positive results of 1 cycle of PEB can be validated, it will become the standard cytotoxic approach for clinical stage I NSGCT.

Written by:
Heidenreich A, Pfister D.   Are you the author?
Department of Urology, Urologic Oncology, Pediatric Urology and Renal Transplantation, RWTH University Aachen, Germany.

Reference: Arch Esp Urol. 2012 Mar;65(2):215-26

PubMed Abstract
PMID: 22414450

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