No adjuvant chemotherapy in selected patients with pathologic stage II nonseminomatous germ cell tumors of the testis

IGG* Practice Guidelines on Germ Cell Tumor in Adult Male Patients

Germ cell tumors are rare neoplasms that affect young males. Nearly 99% of patients with localized stage I disease and nearly 80% of patients with metastatic disease can be cured. Even patients who relapse following chemotherapy can achieve a long-term survival in approximately 30–40% of cases. The main objective in early stages and in good prognosis patients has changed in recent years, and it has become of major importance to reduce treatment-related morbidity without compromising the excellent long-term survival rate. In poor prognosis patients, there is a correlation between the experience of the treating institution and the long-term clinical outcome of the patients, particularly when the most sophisticated therapies are needed. So far, of utmost importance is the information from updated practice guidelines for the diagnosis and treatment of germ cell tumors. The Italian Germ cell cancer Group (IGG) has developed the following clinical recommendations, which identify the current standards in diagnosis and treatment of germ cell tumors in adult males.

Risk stratification of pubertal children and postpubertal adolescents with clinical stage I testicular nonseminomatous germ cell tumors

PURPOSE

The COG (Children's Oncology Group) currently recommends surveillance for all children and adolescents with clinical stage I testicular germ cell tumors. However, up to 30% of adults with clinical stage I testicular germ cell tumors harbor occult metastatic disease. In adults with clinical stage I nonseminoma some groups advocate a risk stratified approach. Occult metastases were noted in 50% of patients with features such as lymphovascular invasion or embryonal carcinoma predominance in the orchiectomy. However, to our knowledge there are no data on the impact of high risk features in such pubertal children and postpubertal adolescents.

MATERIALS AND METHODS

We reviewed an institutional testis cancer database for pubertal children and postpubertal adolescents younger than 21 years. We tested the hypothesis that lymphovascular invasion, or 40% or greater embryonal carcinoma in the orchiectomy specimen, would increase the risk of occult metastases, ie relapse during surveillance or positive nodes on retroperitoneal lymph node dissection.

RESULTS

We identified 23 patients with a median age of 18.6 years (range 7.1 to 20.9) at diagnosis. Of these patients 14 (60.9%) were on surveillance, 9 (39.1%) underwent primary retroperitoneal lymph node dissection and none received initial chemotherapy. Seven patients (30.4%) had occult metastatic disease. High risk pathological features were found in the orchiectomy specimen in 12 patients (52.2%), including all 12 (52.2%) with 40% or greater embryonal carcinoma and 3 (13.0%) with lymphovascular invasion. Seven patients (58.3%) with high risk features had occult metastatic disease vs none (0%) without high risk features (log rank p = 0.031).

CONCLUSIONS

Approximately half of pubertal children and postpubertal adolescents with high risk clinical stage I testicular germ cell tumors harbor occult metastatic disease. These results may be useful when discussing prognosis and treatment with patients and families.

Laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ cell tumors: long-term oncologic outcomes

PURPOSE OF REVIEW

Laparoscopic retroperitoneal lymph node dissection was first described in 1992, and has become more commonly practiced at certain centers. Laparoscopic retroperitoneal lymph node dissection may be less morbid than open retroperitoneal lymph node dissection, but more costly. Controversy exists, however, regarding the oncologic adequacy of the procedure. The published literature regarding the oncologic outcomes of laparoscopic retroperitoneal lymph node dissection is reviewed herein.

RECENT FINDINGS

Laparoscopic retroperitoneal lymph node dissection has not been as widely adopted as other laparoscopic procedures for genitourinary malignancy. There have only been seven publications in the last 3 years, often coming from the same centers. Recently there has been a change in practice with a greater effort to perform therapeutic laparoscopic retroperitoneal lymph node dissection and not simply a staging procedure. Adjuvant chemotherapy is no longer routinely offered to all patients with positive nodes.

SUMMARY

The impressive cure rate and decreasing morbidity associated with conventional open retroperitoneal lymph node dissection are difficult to improve upon. While on par with open retroperitoneal lymph node dissection series, the current oncologic outcomes are difficult to attribute to successful laparoscopic retroperitoneal lymph node dissection alone. Most patients with viable tumor in the retroperitoneal lymph node dissection specimen received chemotherapy. Thus, we must await follow-up of the patients who declined adjuvant chemotherapy after laparoscopic retroperitoneal lymph node dissection or the results of more recent initiatives with laparoscopic retroperitoneal lymph node dissection alone.

Laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ-cell tumors: current status

We review the published literature regarding the technical feasibility, oncologic outcomes, morbidity, and cost-effectiveness of laparoscopic retroperitoneal lymph node dissection (LRPLND). With proof that it is feasible, several centers have become expert in LRPLND and morbidity appears to be less than that of open RPLND. As the technique improves, it is likely that LRPLND will become equally if not more cost-effective than conventional RPLND. However, the oncologic outcomes, while on par with open RPLND series, are difficult to attribute to successful LRPLND alone when nearly all patients with positive lymph nodes received chemotherapy postoperatively. Although uncertainties exist, LRPLND holds much future promise.

Adjuvant Chemotherapy for Stage II Nonseminomatous Germ Cell Tumors

Management options for patients who have stage II nonseminomatous germ cell cancer, completely resected at retroperitoneal lymph node dissection (RPLND), include two cycles of adjuvant cisplatin-based chemotherapy or close surveillance, with chemotherapy reserved for patients who relapse. Both options are associated with cure in an equally high percentage of patients. The choice of options is influenced by the extent of the tumor resected and patient compliance. Surveillance is a strong consideration for patients who have low-volume nodal disease at RPLND because the relapse proportion is 30% or less. In contrast, patients who have high-volume nodal involvement at RPLND have a relapse rate of 50% to 90% with surveillance alone, and adjuvant chemotherapy is the preferable option in this group.

Does the Presence of Extranodal Extension in Pathological Stage B1 Nonseminomatous Germ Cell Tumor Necessitate Adjuvant Chemotherapy?

PURPOSE

The presence of extranodal extension identified at primary retroperitoneal lymph node dissection has been associated with an increased risk of disease recurrence, and as such these patients are sometimes treated with adjuvant chemotherapy. We decided to evaluate the significance of extranodal extension on disease-free survival in patients with pathological stage B nonseminomatous germ cell tumor who did not receive adjuvant chemotherapy.

MATERIALS AND METHODS

A retrospective review of our testicular cancer database was performed to identify all patients with clinical stage A nonseminomatous germ cell tumor who underwent primary retroperitoneal lymph node dissection and were found to have retroperitoneal metastasis with 5 or fewer involved nodes and no metastatic node larger than 2 cm. No patient received adjuvant chemotherapy, and all had a minimum followup of 24 months. A single pathologist (LC), who was blinded to clinical outcome, reviewed the retroperitoneal nodal package to identify the presence or absence of extranodal extension, defined as cancer perforating through the lymph node capsule into perinodal tissue.

RESULTS

A total of 80 patients were identified with a median followup 48 months, and a 2 and 5-year disease-free survival of 75%. Extranodal extension was present in 23 patients and absent in 57 patients with a median followup of 54 and 44 months, respectively. The 5-year disease-free survival for patients with and without extranodal extension was 74% and 75%, respectively (p=0.67).

CONCLUSIONS

We were unable to detect any prognostic significance of extranodal extension in patients found to have retroperitoneal metastasis at primary retroperitoneal lymph node dissection.

Advances in the treatment of testicular cancer

Testicular cancer is the most common solid tumour in young men, and the treatment of testicular germ cell tumours (TGCT) has been called a success story of medical oncology, germ cell cancer being regarded as the "model of a curable neoplasm". Even with metastatic disease, high cure rates can be achieved: the overall 5-year survival for all stages of TGCT is approximately 80%. Today, elaborate systems for prognostic evaluation for gonadal and extragonadal germ cell tumours facilitate the choice of the most appropriate therapy for individual patients. In doing so, the ultimate goal of treatment is tumour-free survival for any patient with TGCT. This goal has already been reached for >99% of the patients with early-stage tumours, as well as for the majority of patients with advanced disease (56% of patients with metastases are considered to have a good prognosis at the time of diagnosis; the 5-year survival rate for this group is 90%). However, patients with 'intermediate' or 'poor' prognosis at the time of diagnosis, as well as patients with relapsed disease after cisplatin-containing therapy, still have an unsatisfactorily low 5-year survival rate after standard therapy with PEB (cisplatin, etoposide, bleomycin) of only 80%, 45-55% and 20-25%, respectively.Therefore, our goals must be (i) to limit acute and chronic toxicity by avoiding overtreatment for patients with localised disease and/or good prognosis with advanced disease; and (ii) to identify patients with poor prognosis and treat them in specialised centres, where not only is optimal interdisciplinary care available but new treatment strategies are being applied. For example, tandem high-dose chemotherapy regimens might be effective in achieving higher cure rates in these patients.

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.

IMPACT OF THE NUMBER OF POSITIVE LYMPH NODES ON DISEASE-FREE SURVIVAL IN PATIENTS WITH PATHOLOGICAL STAGE B1 NONSEMINOMATOUS GERM CELL TUMOR

PURPOSE

The prognostic significance of the number of metastatic lymph nodes detected at surgery on survival is well documented for breast and colon cancer, and it has recently been reported in bladder cancer. We tested this hypothesis in patients with pathological stage B1 nonseminomatous germ cell tumor (NSGCT).

MATERIAL AND METHODS

This series included 118 patients with pathological stage B1 NSGCT (5 or fewer positive lymph nodes) at primary retroperitoneal lymph node dissection who did not receive adjuvant chemotherapy at a followup of greater than 24 months.

RESULTS

Five-year disease-free survival (DFS) was 68% at a median followup of 43 months. Median followup in patients without recurrence was 67.4 months and median time to recurrence was 5.0 months. The mean and median number of positive lymph nodes was 2.0. Five-year DFS for 1 or 2 and 3 to 5 positive lymph nodes was 72% and 59%, respectively (p = 0.0847). Five-year DFS for lymph node density less or greater than 0.05 was 75% and 66%, respectively (p = 0.261). Neither the number of positive lymph nodes (continuous and categorical p = 0.201 and 0.271) or the ratio of the number of positive lymph nodes to the total number resected (continuous and categorical p = 0.415 and 0.998, respectively) predicted recurrence.

CONCLUSIONS

Primary retroperitoneal lymph node dissection is curative in patients with pathological stage B1 NSGCT and DFS does not seem to be influenced by the number or the ratio of positive lymph nodes resected. This information may be helpful in limiting adjuvant chemotherapy in patients otherwise cured by surgery.

[Lymphadenectomy for testicular cancer. Diagnostic and prognostic significance as well as therapeutic benefit]

The rationale to perform retroperitoneal lymph node dissection (RPLND) in testicular cancer depends on the clinical stage and previous therapy. Thus, it can be performed either with diagnostic, prognostic, or therapeutic intention. In verified clinical stage I nonseminoma, RPLND provides one of three adjuvant options. To verify the clinical stage pathologically, surgery is done for diagnostic reasons, since CT scanning provides a false-negative staging in up to 30%. In higher stage lesions RPLND is a therapeutic procedure. The importance, however, of RPLND in clinical stage I nonseminoma is decreasing, since prognostic factors are available to stratify patients with either low or high risk for recurrence. Thus, these patients are selected for surveillance (low risk) or adjuvant chemotherapy (high risk). RPLND after chemotherapy is done for resection of residual tumor with a therapeutic intention. The histology of the residual mass is of prognostic importance and may help define further therapy. Resection of retroperitoneal metastases in patients with chemorefractory tumors is curative in about 25%.

Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: impact of patient selection factors on outcome

PURPOSE

To investigate the impact of patient selection criteria on the outcome of patients with nonseminomatous germ cell testicular cancer (NSGCT) treated by primary retroperitoneal lymph node dissection (RPLND). Since 1999, our criteria have excluded patients with persistent postorchiectomy elevation of serum tumor markers (STM) or clinical stage (CS) IIB disease from RPLND.

PATIENTS AND METHODS

Between 1989 and 2002, 453 patients underwent primary RPLND at our institution for CS I to IIB NSGCT. Patient information was obtained from a prospective database. Retroperitoneal pathology and relapse rates were compared for patients treated before and after application of the current selection criteria in 1999.

RESULTS

By excluding patients with elevated STM or CS IIB disease after 1999, the proportion of pathologic stage II patients with low-volume (pN1) retroperitoneal disease increased significantly (40% before 1999 v 64% after 1999; P = .01), without significantly affecting the rate of retroperitoneal teratoma (21% v 22%, respectively; P = .89) or pathologic stage I disease (56% v 67%, respectively; P = .06). For patients who did not receive adjuvant chemotherapy, the 4-year progression-free probability improved significantly from 83% before 1999 (95% CI, 79% to 88%) to 96% after 1999 (95% CI, 91% to 100%; P = .005). Elevated postorchiectomy STM (P < .0001), clinical stage (P = .0002), and pre-1999 RPLND (P = .05) were independent pretreatment predictors of progression.

CONCLUSION

Excluding patients with CS IIB disease or elevated postorchiectomy STM from primary RPLND has had a favorable impact on the extent of retroperitoneal disease and has significantly reduced the risk of relapse after RPLND. For patients with normal STM and CS I to IIA disease, the low rate of systemic progression and 22% incidence of retroperitoneal teratoma supports RPLND as the preferred primary intervention.

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

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.

Relapse-Free and Overall Survival in Patients With Pathologic Stage II Nonseminomatous Germ Cell Cancer Treated With Etoposide and Cisplatin Adjuvant Chemotherapy

Purpose

To assess the long-term relapse-free survival and overall survival of patients with stage II nonseminomatous germ cell tumor (NSGCT) who received two cycles of adjuvant etoposide and cisplatin (EP) after primary retroperitoneal lymph node dissection.

Patients and Methods

Eighty-seven patients with completely resected pathologic stage II NSGCT were treated with adjuvant EP chemotherapy. Adjuvant EP consisted of two cycles of etoposide (100 mg/m2) plus cisplatin (20 mg/m2) per day, administered days 1 to 5 at a 21-day interval.

Results

Ten patients (11%) had pN1 disease, 73 (84%) had pN2 disease, and four (5%) had pN3 disease. Eighty-six patients received two cycles of EP, and one patient received an additional two cycles of EP after a transient marker increase after his first cycle. Eighty-seven patients are alive, and 86 patients (99%) remain relapse-free at a median follow-up of 8 years (range, 0.9 to 13.5 years).

Conclusion

Two cycles of adjuvant EP is highly effective in preventing relapse in patients with pathologic stage II pN1 and pN2 NSGCT. An alternative treatment strategy is surveillance with full-course chemotherapy at relapse. Because there is a higher risk of relapse for patients with pN2 disease, these patients are offered adjuvant chemotherapy.

Low-volume nodal metastases detected at retroperitoneal lymphadenectomy for testicular cancer: pattern and prognostic factors for relapse

PURPOSE

To determine the incidence, pattern, and predictive factors for relapse in patients with low-volume nodal metastases (stage pN1) at retroperitoneal lymphadenectomy (RPLND) and identify who may benefit from chemotherapy in the adjuvant or primary setting.

PATIENTS AND METHODS

Fifty-four patients with testicular nonseminomatous germ cell tumor had low-volume retroperitoneal metastases (pathologic stage pN1, 1997 tumor-node-metastasis classification) resected at RPLND, 50 of whom were managed expectantly without adjuvant chemotherapy. The dissection was bilateral in 12 and was a modified template in 38 patients. Retroperitoneal metastases were limited to microscopic nodal involvement in 14 patients. Follow-up ranged from 1 to 106 months (median, 31.4 months).

RESULTS

Eleven patients (22%) suffered a relapse at a median follow-up of 1.8 months (range, 0.6 to 28 months). The most frequent form of recurrence was marker elevation in nine (18%) patients. Persistent marker elevation after orchiectomy and before retroperitoneal lymphadenectomy was a significant independent predictor of relapse (relative risk, 8.0; 95% confidence interval, 2.3 to 27.8; P =.001). Four of five (80%) patients with elevated markers (alpha-fetoprotein alone in three, alpha-fetoprotein and beta human chorionic gonadotropin in one) suffered a relapse, compared with seven of 45 (15.6%) patients with normal markers.

CONCLUSION

Clinical stage I and IIA patients with normal markers who have low-volume nodal metastases have a low incidence of relapse and can be managed by observation only if compliance can be assured. In contrast, patients with elevated markers before retroperitoneal lymphadenectomy have a high rate of relapse and should be considered for primary chemotherapy.

A rational approach to managing stage I nonseminomatous germ cell cancer

Regardless of the treatment option selected for management of low-stage germ cell cancer, ultimate survival is nearly identical. Treatment-related morbidity is very low regardless of management modality and the individual patient can expect similar physical limitations owing to therapy. The overall difference in loss of productivity between treatment programs varies by little more than 1 week. The cost of treatment is similar for all methods, although there is a definite financial advantage to surveillance, less so for selective surveillance, when compared with other forms of management. Socioeconomic factors are of importance when managing limited resources for a large population, but are of less concern to an individual, especially when the mean differences in per patient costs vary by only $5000. Because of these close similarities in efficacy, morbidity, and costs treatment decisions should be individualized. A responsible and reliable patient can be managed safely by selective surveillance. Those individuals considered to be less self-motivated to pursue intensive care should be managed by primary therapy. Without more information regarding the long-term outcomes associated with primary adjuvant chemotherapy, primary adjuvant RPLND, where experienced surgical support is available, is the preferred management for low-stage germ cell cancer in patients selected for, or electing, active treatment rather than surveillance. Active investigations examining the role of medical management in this population should be continued. Our preferred choice of initial management is to offer selective surveillance to appropriate patients and modified RPLND to the remainder.

Stage II nonseminomatous testis cancer: the roles of primary and adjuvant chemotherapy

Historically, a retroperitoneal lymph node dissection (RPLND) has been the primary treatment of stage II nonseminomatous germ cell tumor (NSGCT) patients, whereas chemotherapy has been used in the adjuvant setting. Increasing evidence of the efficacy of chemotherapy has led to additional treatment possibilities for stage II patients. Both chemotherapy and RPLND have a role in the primary therapy of stage II NSGCT, and both modalities can be used as secondary adjunctive therapy. Management of these patients now requires a renewed emphasis on risk stratification and on the integration of patient preferences into the management algorithm.

Treatment of clinical stage I testicular cancer and a possible role for new biological prognostic parameters

Three different treatment strategies for patients with stage I non-seminomatous testicular cancer are available that will all result in long-term survival in more than 98% of the patients: a "wait and see" strategy with follow-up and chemotherapy in cases of tumour progression, retroperitoneal lymphadenectomy, with or without application of systemic chemotherapy, in cases of retroperitoneal metastases (pathological stage II disease) or primary adjuvant chemotherapy following inguinal orchiectomy. Each treatment strategy is associated with specific side-effects. In several studies histological characteristics of the primary tumour, particularly the presence of vascular invasion and of embryonal carcinoma cells, have been demonstrated to be significant prognostic factors for the risk of occult retroperitoneal metastases in patients with stage I disease. In addition, new biological prognostic factors determined by flow cytometry, cytogenetic analysis or molecular-biological DNA or RNA analysis have been investigated, among which alterations of the p53 tumour-suppressor gene may represent a promising new prognostic factor. Although alterations of p53 gene expression seem to be associated with advanced tumour stage and may predict retroperitoneal metastatic disease, the independent role of these molecular genetic alterations needs to be prospectively studied. Currently a risk-adapted treatment strategy based on the histological criteria of vascular invasion and the presence of embryonal carcinoma can be used to stratify patients into a "high-" and "low-risk" group with respect to tumour progression. While primary-nerve-sparing retroperitoneal lymphadenectomy or adjuvant chemotherapy with two cycles of platinum, etoposide and bleomycin may be appropriate for patients with a high risk (above 40%) for tumour progression, a "wait-and-see" strategy can be used for "low-risk" (less than 15% risk of progression) patients. Molecular investigations of prognostic factors may be able to improve further the stratification of patients into these different risk categories.

Primary treatment in stage II non-seminomatous germ cell tumours of the testis: a matter of scalpel or drug infusion?

The optimal primary treatment of patients with low volume (< or = 5 cm) retroperitoneal metastases remains a matter of debate. Retroperitoneal lymph node dissection (RPLND) is a common practice in North America whereas chemotherapy is a prevailing approach in Europe. In patients with normal serum tumour markers after orchiectomy, primary RPLND appears to be the most appropriate way of staging. In other patients, neither surgery nor chemotherapy are entirely sufficient as monotherapy since approximately one-third of cases for each approach will need the other for achieving optimal results. Treatment decisions are based on cost/benefit and risk/benefit considerations, including relative toxicity and individual patient preference. The treatment of low volume stage II non-seminomatous germ cell tumours (NSGCT) clearly is a matter of scalpel and drug infusion.

Cisplatin-based chemotherapy after retroperitoneal lymph node dissection in patients with pathological stage II nonseminomatous germ cell tumors

In order to assess the results of cisplatin-based chemotherapy after primary lymph node dissection in patients with pathological stage II nonseminomatous germ cell tumors of the testis, we retrospectively reviewed the long-term outcome of 44 patients who received adjuvant chemotherapy at Institut Gustave Roussy over a 7-year period. Two chemotherapy regimens were sequentially delivered. Twenty-three patients were treated with vinblastine, cyclophosphamide, bleomycin, actinomycin D, and cisplatin (mVAB-6, four cycles), while 21 patients received a combination of etoposide and cisplatin (EP, four cycles). After a median follow-up of 6 years, all patients remain free from progression. The long-term toxicity included retrograde ejaculation in eight patients and severe ototoxicity in two patients. We conclude that four cycles of cisplatin-based chemotherapy for pathological stage II testicular cancer resulted in a 100% cure rate with minimal toxicity.

Primary chemotherapy for clinical stage II nonseminomatous germ cell testicular tumors: selection criteria and long-term results

OBJECTIVE

To determine the treatment option for patients with low-volume stage II nonseminomatous germ cell testicular tumors (NSGCTT) that yields the best survival, is associated with the least morbidity, and avoids "double therapy"--that is, chemotherapy and retroperitoneal lymph node dissection (RPLND).

DESIGN

We reviewed our institutional experience with 28 patients with stage II NSGCTT who received primary chemotherapy between August 1983 and October 1992.

MATERIAL AND METHODS

The 28 study patients (mean age, 28 years; range, 20 to 52) with low-volume stage II NSGCTT were treated with bleomycin, etoposide, and cisplatin. The correlation of response rates with volume of disease and predominant histologic cell type was determined. The duration of survival was measured from the initiation of chemotherapy to the appearance of progressive disease or death or the date of last follow-up visit.

RESULTS

Of the 28 patients treated, 27 (96%) achieved a complete response--20 (71%) with only chemotherapy and an additional 7 (25%) with chemotherapy plus surgical treatment. Twenty-seven patients (96%) remained free of disease after a median follow-up of 72 months. The most frequent complication was cisplatin-associated paresthesias or tinnitus which was noted in 13 patients (46%). In 11 of 15 patients (73%), attempts to have children have been successful.

CONCLUSION

Excellent long-term survival rates in patients with stage II NSGCTT can be achieved with primary chemotherapy. In this series, 71% of patients were spared RPLND. The need for postchemotherapy RPLND seemed to be related to the initial metastatic tumor volume and possibly the histologic features of the primary tumor. Continued refinement in surgical techniques and chemotherapeutic regimens will necessitate the comparison of these two treatment approaches in a randomized prospective trial.

Cost and risk benefit in the management of clinical stage II nonseminomatous testicular tumors

BACKGROUND

Two similarly effective treatment options exist for managing clinical low volume Stage II nonseminomatous germ cell testis tumors (NSGCT). Primary retroperitoneal lymph node dissection (RPLND) (with immediate adjuvant chemotherapy or chemotherapy at relapse) and primary chemotherapy have resulted in similar survival rates in large series. Because the chance for cure is similar with either approach, the cost and morbidity of therapy should be considered important discriminating factors in deciding which option to pursue for an individual patient. The purpose of this study was to undertake a cost/benefit and risk/benefit analysis of these two options using data and costs from the Indiana University experience.

METHODS

The overall direct costs for 100 patients undergoing primary RPLND were compared with the total direct costs of 100 patients receiving primary chemotherapy for low volume Stage II disease, including the costs of adjuvant chemotherapy, salvage chemotherapy in relapsing patients, and routine follow-up for a 5-year period. In addition, the two treatment options were analyzed relative to survival, late relapse, acute and chronic toxicity, (including fertility), and perioperative morbidity.

RESULTS

In this analysis, the overall 5-year costs of RPLND were significantly less than the costs of primary chemotherapy. The two options did not differ significantly in terms of survival or quality of life. Patients receiving RPLND were found to have an advantage also in terms of fertility, toxicity, and late relapse.

CONCLUSIONS

Treatment decisions for patients with clinical low volume Stage II NSGCT may be based on cost/benefit and risk/benefit considerations, including relative toxicity, long term cure rate, and individual patient preference. Patient compliance with follow-up, the specific expertise of the physicians, and the availability of specialized therapeutic care ultimately may influence such decisions.

Testicular neoplasms and tumoral markers

The use of tumoral markers and especially of BHCG and AFP in the diagnosis, staging and follow-up of patients affected by testicle germinai neoplasms is now widespread. Nevertheless, controversies stili exist in each one of these fields. Especially for clinical staging, high percentages of understaging of stage I tumours are reported in literature with considerable effects on therapeutical indications and prognosis. The Authors attempt a criticai review on the use of markers for diagnosis and staging of testicular neoplasms based upon their own experience of 79 cases over a 14-year period.

Adjuvant chemotherapy for stage II nonseminomatous germ cell cancer of the testis

BACKGROUND

The success of chemotherapy for Stage III testicular carcinoma warranted its use as an adjuvant therapy for Stage II cancer. The current report reflects the adjuvant program begun at the University of Minnesota using four courses of vinblastine, bleomycin, and cisplatin (VBP) before the onset of the Testicular Cancer Intergroup Study using two courses of chemotherapies.

METHODS

A review of 78 patients with Stage II nonseminomatous germ cell tumors treated between 1972 and 1986 defined three groups: 19 patients treated between 1972 and 1979 with various adjuvant chemotherapies (termed "other"), 37 patients treated from 1975 to 1986 with VBP adjuvant chemotherapy, and 21 patients who received no therapy during the same era of VBP. The latter group was not offered adjuvant chemotherapy at other institutions or declined therapy.

RESULTS

Nineteen patients received adjuvant chemotherapy before the cisplatin era. Their survival rate was 42%, including two patients treated with cisplatin-based chemotherapy for recurrence. In the group of 21 patients who did not receive adjuvant therapy, 14 (66.7%) survived. Of these, five had no recurrence and nine were treated for recurrence. In a third group, adjuvant VBP therapy was given to 37 patients, 32 of whom received four full courses. There have been no recurrences, and 36 (97.3%) remain alive; one obese patient with hypertension died of a ruptured aortic aneurysm 12.9 years after the retroperitoneal lymph node dissection. Nodal involvement was more extensive in the VBP group.

CONCLUSION

Four courses of VBP adjuvant chemotherapy for pathologic Stage II testicular cancer resulted in a 100% cure rate, all patients having been followed up for more than 6 years. Whether two courses are as adequate remains to be determined when long-term follow-up is reported.

Primary chemotherapy in the management of low stage (IIA and IIB) non-seminomatous germ cell testicular tumours

In a prospective study a total of 65 patients in clinical stages IIA and IIB nonseminomatous testicular tumours were treated by primary chemotherapy followed by retroperitoneal lymphadenectomy in cases with residual disease. The patients were given a combination of cisplatin, vinblastine and bleomycin, or also etoposide. Sixty-two patients (95.4%) achieved complete response: 39 (60%) by chemotherapy alone and 23 (35.4%) following surgical removal of residual disease. Three patients died; there were two drug-related deaths during PVB chemotherapy, one patient had progression of disease following chemotherapy and died as a result of disease dissemination. Three patients relapsed from complete response following chemotherapy, two of them died within 19 and 29 months after the onset of therapy. The third patient received second-line chemotherapy and gained complete response again. Of the 65 patients, 60 (92.3%) survive with no evidence of disease. The follow-up period ranged from 6 to 79 months (mean 39.4 months, median 39 months).

Is routine primary retroperitoneal lymph node dissection still justified in patients with low stage non-seminomatous testicular cancer?

We present 8 years' experience of primary retroperitoneal lymph node dissection (RLND) in 190 patients with low stage non-seminoma; 154 patients had clinical stage I (CSI) and 36 had clinical stage IIa (CSIIa) disease. Of the 154 patients with CSI tumours, 33 had increased serum AFP and/or HCG before RLND (CSIM+) and 121 had normal tumour markers (CSIM-). Retroperitoneal lymph node metastases (pathological stage II) (PSII) were found in 38 of 121 patients with CSIM-, in 19 of 33 patients with CSIIM+ and in 26 of 36 patients with CSIIa. In a multivariate analysis, the presence of small vessel infiltration (demonstrated in histological sections of the primary tumour) and a prolonged tumour marker half-life were predictive factors for PSII. These 2 factors enabled a group of non-seminoma patients with CSI disease to be identified who had a 15% risk of retroperitoneal tumour growth (low risk group) as compared with a high risk group where 60 to 70% of patients had retroperitoneal lymph node metastases. Relapses occurred in 7 of 107 patients with PSI and in 6 of 83 patients with PSII disease; in the latter group, 5 relapses developed before the start of routine adjuvant chemotherapy; 6% of patients developed major post-operative complications. In addition, "dry ejaculation" was the principal side effect following RLND (unilateral RLND: 20/132 patients; bilateral RLND: 50/54 patients). The comparative cost to the health service during the first year of follow-up was estimated for low risk non-seminoma patients with CSI subjected to RLND and for those in whom a surveillance policy was adopted. The latter approach was preferable. It was concluded that a surveillance policy should be followed in low risk non-seminoma CSI patients provided that frequent follow-up is possible. A more active policy is recommended in high risk patients (e.g. adjuvant chemotherapy without RLND). Nerve-sparing RLND may be considered in patients with CSIIa disease and negative tumour markers.

Testicular cancer in young Norwegians

The clinical experience is reviewed in 597 Norwegian testicular cancer patients (age range: 15-45 years) treated from 1979 to 1986. During this period, computer tomography, determination of serum AFP/HCG, and cisplatin-based chemotherapy represented the modern diagnostic and therapeutic modalities. Before orchiectomy 67% of the patients had elevated AFP/HCG. An abnormal postorchiectomy serum tumour marker decrease and the presence of small vessel infiltration in the histological sections of the primary tumour significantly predicted microscopic retroperitoneal metastases in patients with clinical stage I (CSI) nonseminoma. One-third of these patients had a pathological stage II (PSII). After radiotherapy 99% of 90 seminoma patients (CSI/IIa) survived for 5 years. After cisplatin-based chemotherapy (+radiotherapy/surgery) the 5-year survival rate in 25 patients with advanced seminoma was 81%. The survival rate in 148 nonseminoma patients PSI/IIa was 100% and 87% in 94 patients with advanced nonseminoma (greater than or equal to CSIIb). Nausea, general exhaustion, myelosuppression, peripheral neuropathy, and Raynaud-like phenomena were the main acute treatment-related side effects. Slight gastrointestinal problems, slight peripheral neuropathy, Raynaud-like phenomena, and fertility disturbances were frequent late side effects. The sexual life in testicular cancer patients did not seem to be significantly impaired as compared to the normal population. Most of the patients reported no or only slight emotional problems during and after treatment. The need of thorough information at the time of diagnosis was stressed by most of them. Secondary cancer was diagnosed in 27 of 795 patients (1970-1982) (Testicular: 15; pulmonary: 4; sarcoma: 2; others: 6). Testicular cancer is today a curable malignancy. Future clinical research has to concentrate on the identification of high-risk and low-risk patients, the avoidance of overtreatment, and the reduction of toxicity (especially of long-term side effects).

Immediate adjuvant chemotherapy versus observation with treatment at relapse in pathological stage II testicular cancer

Between 1979 and 1984, 195 evaluable patients were entered in an international multicenter study comparing two regimens for patients with completely resected pathological Stage II testicular cancer (that is, with positive retroperitoneal lymph nodes). All patients had undergone orchiectomy and dissection of the retroperitoneal lymph nodes. They were randomly assigned to be treated with two cycles of immediate adjuvant cisplatin-based chemotherapy or to be observed monthly with treatment at relapse. The median follow-up period was four years. Of the 97 patients assigned to adjuvant chemotherapy, 6 (6 percent) had a recurrence; however, only 1 had received adjuvant chemotherapy before the recurrence. Three died (one of testicular cancer), and 94 of the 97 survived. Of the 98 patients who were observed, 48 (49 percent) had a relapse. However, almost all patients with relapses were effectively treated, and 93 of the 98 are alive and disease-free; 3 have died of testicular cancer. No identifiable factors were strongly associated with the risk of relapse. We conclude that two courses of cisplatin-based adjuvant chemotherapy will almost always prevent relapse in pathological Stage II testicular cancer treated with orchiectomy and retroperitoneal-lymph-node dissection. However, when surgery, follow-up, and chemotherapy are optimal, observation with chemotherapy only for relapse will lead to equivalent cure rates.

Fertility status of patients with clinical stage I testis tumors on a surveillance protocol

A potential benefit of a surveillance protocol for the management of patients with clinical stage I testis tumors is the avoidance of ejaculatory disturbances and infertility resulting from retroperitoneal lymph node dissection, the standard treatment for patients with this stage of disease. To address this issue we evaluated 22 patients with clinical stage I testis tumors on a surveillance protocol with history, physical examination and semen analysis. Previous fertility was unknown or it had not been tested in the majority of the patients (74 per cent). Ten patients (45 per cent) had abnormal spermatogenesis on the basis of a low sperm count or sperm motility. Of 6 patients with oligospermia or azoospermia 3 had recovered normal spermatogenesis when they were re-evaluated 4 to 19 months later. Although in this group of carefully staged cases the incidence of subfertile sperm counts seems to be similar to those with higher stage disease, some patients with abnormal counts clearly recover. The avoidance of retroperitoneal lymph node dissection seems to spare fertility in at least a small percentage of these patients.

Clinical stage II non-seminomatous germ cell testicular tumours. Results of management by primary chemotherapy

Between 1977 and 1984, 92 patients with clinical Stage II non-seminomatous germ-cell testicular tumours were treated by primary chemotherapy, with surgery reserved for the excision of persisting masses. Eighty patients (87%) are alive and disease-free: 96% for Stages IIA and IIB and 74% for Stage IIC. Of 43 Stage IIA, B and C patients treated with bleomycin, etoposide and cisplatin (BEP), 40 (93%) are disease-free. For the whole group there was a significant difference between the outcome of treatment in patients with retroperitoneal masses greater than 8 cm in transverse diameter compared with those in whom masses were less than 8 cm, the disease-free rates being 54 and 97% respectively. Primary histology did not influence the outcome of treatment. However, whereas 51% of patients with teratocarcinoma had masses resected after chemotherapy, only 26% of embryonal carcinoma patients came to surgery. The results obtained in this series are as good as those obtained when lymph node dissection is employed as the initial form of treatment. The avoidance of surgery with preservation of ejaculatory function in 78% of Stage IIA and IIB patients argues in favour, of an initially non-surgical approach to management.

Surveillance or lymph node dissection in clinical stage I non-seminomatous germinal testis cancer?

Surveillance following orchiectomy alone has gained popularity in the management of clinical stage I non-seminomatous germ cell tumours (NSGCT) of the testis. However, long-term follow-up of the retroperitoneal nodes can be difficult. We analysed the results of 71 consecutive patients followed for more than 1 year. Fifty men (70.5%) remain disease-free and 21 (29.5%) have relapsed. Relapses occurred 2 to 36 months after orchiectomy (median 6 months). Retroperitoneal nodes were involved in 12 cases (17%). In only one patient were retroperitoneal metastases diagnosed when smaller than 2 cm and in four they were diagnosed when larger than 5 cm. Furthermore, the late relapses occurred in the retroperitoneal nodes. After treatment of metastases, 69 patients (97%) are alive, disease-free and off therapy. As retroperitoneal relapses do not occur after a properly executed retroperitoneal lymph node dissection (RPLND) and ejaculation problems can be avoided with unilateral RPLND, it is suggested that RPLND can be used for clinical stage I NSGCT of the testis in experienced surgical centres, with the advantage of an easier follow-up.