Surgery versus surveillance in stage I non-seminoma testicular cancer

Prediction of relapse in stage I testicular germ cell tumor patients on surveillance: investigation of biomarkers

Background

Better biomarkers for assessing risk of relapse in stage I testicular germ cell tumor patients are needed, to complement classical histopathological variables. We aimed to assess the prognostic value of previously suggested biomarkers, related to proliferation (MIB-1 and TEX19) and to immune microenvironment (CXCL12, CXCR4, beta-catenin and MECA-79) in a surveillance cohort of stage I testicular germ cell tumor patients.

Methods

A total of 70 patients were included. Survival analyses were performed, including Cox regression models.

Results

Patients with vascular invasion and elevated human chorionic gonadotropin levels showed significantly poorer relapse-free survival in multivariable analysis (hazard ratio = 2.820, 95% confidence interval 1.257–6.328; hazard ratio = 3.025, 95% confidence interval 1.345–6.808). Patients with no vascular invasion but with MIB-1 staining in > 50% tumor cells showed significantly shorter relapse-free survival (p = 0.042). TEX19 nuclear immunoexpression was confirmed in spermatogonial cells, and weak cytoplasmic immunoexpression was depicted in 15/70 tumors, not significantly impacting survival. CXCL12 immunoexpression in tumor cells did not associate with relapse, but non-seminoma patients exhibiting vascular invasion and CXCL12-positive stromal/inflammatory cells showed significantly improved relapse-free survival (p = 0.015). Exclusively nuclear immunoexpression of CXCR4 associated with better relapse-free survival (p = 0.032), but not after adjusting for vascular invasion. Patients with higher beta-catenin scores showed a tendency for poorer relapse-free survival (p = 0.056). MECA-79 immunoexpression was absent.

Conclusions

The informative protein biomarkers (i.e., MIB-1, CXCL12, beta-catenin, and possibly CXCR4) may prove useful for risk-stratifying patients if validated in larger, multicentric and well-defined studies. Currently, classical histopathological features of testicular germ cell tumors remain key for relapse prediction.

Interobserver Agreement in Vascular Invasion Scoring and the Added Value of Immunohistochemistry for Vascular Markers to Predict Disease Relapse in Stage I Testicular Nonseminomas

Vascular invasion has been identified as an informative risk factor for relapse in stage I testicular nonseminomas, used to tailor treatment. We investigated interobserver agreement in vascular invasion reporting and studied the potential additional value of immunohistochemistry for vascular markers for predicting relapse. Patients (n=52) with stage I testicular nonseminomas undergoing surveillance (1993-2006) were included (median follow-up of 66 mo). Two formalin-fixed paraffin-embedded blocks with >1 cm tissue and tumor/normal parenchyma interface were stained with hematoxylin and eosin and CD31, FVIII, and D2-40. Slides were assessed by 3 independent testicular germ cell tumor-dedicated pathologists, and agreement was assessed using Cohen κ statistic. Sensitivity, specificity, and accuracy of vascular invasion scoring in predicting relapse were calculated. Agreement among testicular germ cell tumor-dedicated pathologists was moderate (κ=0.49 to 0.54), as was performance in predicting disease relapse (particularly, specificity of 86%). Immunohistochemistry increased overall sensitivity (71%), but decreased specificity (71%) in predicting relapse. All patients (n=8) with both blood and lymphatic vascular invasion developed a relapse. In multivariable analysis (including age, tumor size, rete testis invasion, and serum tumor markers), only vascular invasion had an independent impact in predicting relapse. Assessment of vascular invasion by testicular germ cell tumor-dedicated pathologists is good and is clinically meaningful, predicting disease relapse. Immunohistochemistry for vascular markers improves sensitivity of detecting disease relapse and allows for the identification of high-risk patients with both blood and lymphatic vascular invasion simultaneously, potentially of interest for tailored chemotherapy.

Risk factors for relapse in patients with clinical stage I testicular nonseminomatous germ cell tumors

Prediction of oncological outcomes facilitates individualized risk-adapted management for clinical stage I testicular nonseminomatous germ cell tumors (CS I NSGCTs). We investigated risk factors for relapse following orchidectomy, with particular focus on patients with active surveillance. Patients with CS I NSGCTs treated by retroperitoneal lymph node dissection (RPLND), chemotherapy, or surveillance between January 1997 and December 2009 were identified. Demographic and post-operative records were collected. Disease-specific survival and progression-free survival (PFS) rates were estimated using Kaplan-Meier analysis. Cox regression analysis was used to confirm variables that influenced disease relapse. A median follow-up period of 82 months was achieved in 89 patients, of whom 9 (8 in surveillance and 1 in chemotherapy group) had relapses. Cumulative 5-year PFS rates were 74.1, 92.3, and 100 % for the surveillance, chemotherapy, and RPLND groups, respectively (p = 0.01). The relapse rate was significantly higher in patients presented with lymphatic/vascular invasion (LVI) than in those without LVI (26.6 vs. 6.8 %, p = 0.02). In the surveillance group, a higher relapse rate was associated with history of cryptorchidism (50 vs. 13.3 %, p = 0.02) and an age older than 13 years (33.3 vs. 5.9 %, p = 0.04). On multivariate analysis, patient age (OR 1.16; p = 0.05), history of cryptorchidism (OR 0.09; p = 0.01), and LVI (OR 12.10; p = 0.01) were significantly associated with relapse during surveillance. The disease-free period is short in the patients with surveillance. LVI, patient age, and history of cryptorchidism may be used as predictors for relapse during surveillance.

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.

Efficacy of routine follow-up after first-line treatment for testicular cancer

To define guidelines for the follow-up management of patients treated for testicular germ cell tumor this study assessed characteristics of patients with recurrent disease. The charts of 505 patients with testicular cancer treated and followed-up at the University Medical Centre Nijmegen between 1982-2000 were reviewed retrospectively. In 42 patients disease recurrence was found during routine follow-up. In a subset of patients no recurrences were seen after first-line treatment: (a) pathological stage IIa nonseminoma patients who were adjuvantly treated with chemotherapy and (b) histologically confirmed complete responders after primary chemotherapy. Furthermore, in low-stage disease no intra-abdominal recurrences were seen in (a) pathological stage I nonseminoma patients and (b) low-stage seminoma patients who received radiotherapy. The risk of recurrent testicular cancer depends on primary therapy and efficacy of it; these results indicate a limited role for follow-up in pathological stage II nonseminoma patients adjuvantly treated with chemotherapy and in histologically confirmed complete responders after chemotherapy. Abdominal computed tomography does not appear necessary in routine follow-up of patients treated for low-stage testicular cancer.

Randomized comparison of combination chemotherapy with etoposide, bleomycin, and either high-dose or standard-dose cisplatin in children and adolescents with high-risk malignant germ cell tumors: a pediatric intergroup study--Pediatric Oncology Group 9049 and Children's Cancer Group 8882

PURPOSE

To determine in a randomized comparison whether combination chemotherapy with high-dose cisplatin (HDPEB) improves the event-free (EFS) and overall (OS) survival of children and adolescents with high-risk malignant germ cell tumors (MGCT) as compared with standard-dose cisplatin (PEB) and to compare the regimens' toxicity.

PATIENTS AND METHODS

Between March 1990 and February 1996, 299 eligible patients with stage III and IV gonadal and extragonadal (all stages) MGCT were enrolled onto this Pediatric Oncology Group and Children's Cancer Group study. Chemotherapy included bleomycin 15 units/m(2) on day 1, etoposide 100 mg/m(2) on days 1 through 5, and either high-dose cisplatin 40 mg/m(2) on days 1 through 5 (HDPEB; n = 149) or standard-dose cisplatin 20 mg/m(2) on days 1 through 5 (PEB; n = 150). Patients were evaluated after four cycles of therapy, and those with residual disease underwent surgery. Those with malignant disease in resected specimen received two additional cycles of their assigned regimen.

RESULTS

One hundred thirty-four eligible patients with advanced testicular (n = 60) or ovarian (n = 74) tumors and 165 with stage I to IV extragonadal tumors were enrolled. HDPEB treatment resulted in significantly improved 6-year EFS rate +/- SE (89.6% +/- 3.6% v 80.5% +/- 4.8% for PEB; P =.0284). There was no significant difference in OS (HDPEB 91.7% +/- 3.3% v PEB 86.0% +/- 4.1%). Tumor-related deaths were more common after PEB (14 deaths v two deaths). Toxic deaths were more common with HDPEB (six deaths v one death). Other treatment-related toxicities were more common with HDPEB.

CONCLUSION

Combination chemotherapy with HDPEB significantly improves EFS for children with high-risk MGCT. The OS is similar in both regimens, and the significant toxicity associated with HDPEB limits its use.