Stage I non-seminomatous germ-cell tumours of the testis: identification of a subgroup of patients with a very low risk of relapse

Testicular Cancer: Contemporary Updates in Staging

Testicular tumors are the most common solid tumors in young men, the vast majority of which are of germ cell origin. The staging of human cancers is paramount to correct patient management. Staging systems have passed through several developments leading to the release of the most recent 8th edition of the American Joint Committee for Cancer (AJCC) staging manual, which is based on the current understanding of tumor behavior and spread. In this review, the authors summarize the current AJCC staging of the germ cell tumors, highlight essential concepts, and provide insight into the most important parameters of testicular tumors.

Pathological predictors of metastatic disease in testicular non-seminomatous germ cell tumors: which tumor-node-metastasis staging system?

Pathological risk factors for metastatic disease in patients with testicular non-seminomatous germ cell tumors are debated. The tumor-node-metastasis (TNM) classification eighth edition for testicular cancers includes divergent versions, by the International Union Against Cancer (UICC) and by the American Joint Committee for cancer (AJCC). We investigated pathological predictors of metastatic disease at presentation in 219 non-seminomatous germ cell tumors with reference to both classifications. Age, tumor size, percentage of embryonal carcinoma, lymphovascular invasion, invasion of stromal rete testis, hilar soft tissue, epididymis, spermatic cord, and tunica vaginalis, as well as tumor at spermatic cord margin, were assessed and correlated with clinical stage at presentation. Of the 219 NSGCT cases, 151 (69%) were clinical stage I, 68 (31%) were clinical stage II/III. On univariate analysis, tumor size (P = 0.028), percentage of embryonal carcinoma (P = 0.004), lymphovascular invasion (P = 0.001), stromal rete testis invasion (P = 0.001), hilar soft tissue invasion (P = 0.010), epididymis invasion (P = 0.010), direct spermatic cord invasion (P = 0.001), and tumor at spermatic cord margin ((P = 0.009) were associated with higher clinical stage. On multivariate analysis, lymphovascular invasion (P = 0.003), tumor size (P = 0.005), percentage of embryonal carcinoma (P = 0.005), stromal rete testis invasion (P = 0.008) remained significant. A tumor size of 6 cm and an embryonal carcinoma percentage of 70% were the significant cut-off values. We conclude that in addition to lymphovascular invasion, stromal rete testis invasion, tumor size, and embryonal carcinoma percentage are strong predictors of metastatic disease at presentation and their inclusion should be considered in any future TNM revision. Further, our results support the changes in the AJCC TNM eighth edition as invasion of the epididymis and hilar soft tissue were both univariately significant.

Testicular Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Testicular cancer is relatively uncommon and accounts for <1% of all male tumors. However, it is the most common solid tumor in men between the ages of 20 and 34 years, and the global incidence has been steadily rising over the past several decades. Several risk factors for testicular cancer have been identified, including personal or family history of testicular cancer and cryptorchidism. Testicular germ cell tumors (GCTs) comprise 95% of malignant tumors arising in the testes and are categorized into 2 main histologic subtypes: seminoma and nonseminoma. Although nonseminoma is the more clinically aggressive tumor subtype, 5-year survival rates exceed 70% with current treatment options, even in patients with advanced or metastatic disease. Radical inguinal orchiectomy is the primary treatment for most patients with testicular GCTs. Postorchiectomy management is dictated by stage, histology, and risk classification; treatment options for nonseminoma include surveillance, systemic therapy, and nerve-sparing retroperitoneal lymph node dissection. Although rarely occurring, prognosis for patients with brain metastases remains poor, with >50% of patients dying within 1 year of diagnosis. This selection from the NCCN Guidelines for Testicular Cancer focuses on recommendations for the management of adult patients with nonseminomatous GCTs.

Lymphovascular invasion and presence of embryonal carcinoma as risk factors for occult metastatic disease in clinical stage I nonseminomatous germ cell tumour: a systematic review and meta-analysis

Objective

To systematically review the literature on the prognostic value of lymphovascular invasion (LVI) and embryonal carcinoma (EC) for occult metastatic disease in clinical stage I nonseminomatous germ cell tumour (CS I NSGCT).

Materials and methods

The PubMed, Embase (OVID) and SCOPUS databases were searched up to March 2019. Studies reporting on the association between LVI and/or EC and occult metastatic disease were considered for inclusion. The quality and risk of bias were evaluated by the Quality in Prognosis Studies tool.

Results

We screened 5287 abstracts and 207 full‐text articles. We included 35 studies in the narrative synthesis and 24 studies in a meta‐analysis. LVI showed the strongest effect. Pooled rates of occult metastasis were 47.5% and 16.9% for LVI‐positive and LVI‐negative patients, respectively (odds ratio [OR] 4.33, 95% confidence interval [CI] 3.55–5.30; P < 0.001). Pooled rates of occult metastasis were 33.2% for EC presence and 16.2% for EC absence (OR 2.49, 95% CI 1.64–3.77; P < 0.001). Pooled rates of occult metastasis were 40.0% for EC >50% and 20.0% for EC <50% (OR 2.62, 95% CI 1.93–3.56; P < 0.001).

Conclusions

LVI is the strongest risk factor for relapse. The prognostic value of EC is high, but there is no common agreement on how to define this risk factor. Both EC presence and EC >50% have similar ORs for occult metastasis. This shows that the assessment of EC presence is sufficient for the classification of EC.

Prognostic factors for relapse in patients with clinical stage I testicular cancer: protocol for a Danish nationwide cohort study

INTRODUCTION

Approximately one-fourth of patients with clinical stage I testicular germ cell cancer will relapse within 5 years of follow-up. Certain histopathological features in the primary tumour have been associated with an increased risk of relapse. The available evidence on the prognostic value of the risk factors, however, is hampered by heterogeneity of the study populations included and variable reporting of the histopathological features. The aim of this study is to identify pathological risk factors for relapse in an unselected large nationwide cohort of patients with stage I disease.

METHODS AND ANALYSIS

All incident cases of stage I testicular germ cell cancer diagnosed in Denmark between 2013 and 2018 will be identified using the nationwide prospective Danish Testicular Cancer (DaTeCa) database. Archived microscopic slides from the orchiectomy specimens will be retrieved through linkage to the Danish Pathology Data Bank and reviewed blinded to the clinical outcome. The DaTeCa database includes 960 stage I seminoma patients with expected 185 relapses and 480 patients with stage I non-seminoma with expected 150 relapses. A minimum follow-up period of 3 years of all patients will be ensured. Predefined prognostic variables will be investigated with regard to relapse in univariable and multivariable analysis using the Cox proportional hazards model.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Regional Ethics Committee (Region Zealand, Denmark) and the Danish Data Protection Agency. All data will be managed confidentially according to legislation. Study results will be presented at international conferences and published in peer-review journals.

[Stage 1 germ-cell tumour]

Stage I germ-cell tumors are rare and highly curable diseases. As such, management of these tumours should carefully follow guidelines. Initial management is based on orchiectomy and several options as adjuvant therapy. Pro's and con's should be discussed with the patient for a personalized management. Patients with stage 1 germ-cell tumours should be addressed to expert centers.

Datasets for the reporting of neoplasia of the testis: recommendations from the International Collaboration on Cancer Reporting

We here describe the development of an evidence-based cancer dataset by an International Collaboration on Cancer Reporting expert panel for the reporting of primary testicular neoplasia, and present the 'required' and 'recommended' elements to be included in the pathology report, as well as a commentary. This dataset encompasses the updated 2016 World Health Organisation classification of urological tumours, the results of an International Society of Urological Pathology consultation, and also staging with our preferred method: the American Joint Committee on Cancer version 8. Implementation of this dataset will facilitate consistent and accurate data collection between different cohorts, facilitate research, and hopefully result in improved patient management.

Updates in Staging and Reporting of Testicular Cancer

The American Joint Committee for Cancer eighth edition staging manual incorporated several critical changes regarding staging of testis germ cell tumors, and these changes are summarized and discussed in this article. Further challenges, however, remain, and these are also highlighted.

Dissecting the Evolving Risk of Relapse over Time in Surveillance for Testicular Cancer

Testicular cancer is the most common malignancy in young men, and the incidence is increasing in most countries worldwide. The vast majority of patients present with clinical stage I disease, and surveillance is being increasingly adopted as the preferred management strategy. At the time of diagnosis, patients on surveillance are often counselled about their risk of relapse based on risk factors present at diagnosis, but this risk estimate becomes less informative in patients that have survived a period of time without experiencing relapse. Conditional survival estimates, on the other hand, provide information on a patient's evolving risk of relapse over time. In this review, we describe the concept of conditional survival and its applications for surveillance of clinical stage I seminoma and nonseminoma germ cell tumours. These estimates can be used to tailor surveillance protocols based on future risk of relapse within risk subgroups of seminoma and nonseminoma, which may reduce the burden of follow-up for some patients, physicians, and the health care system. Furthermore, conditional survival estimates provide patients with a meaningful, evolving risk estimate and may be helpful to reassure patients and reduce potential anxiety of being on surveillance.

Current Concepts in Management of Stage I NSGCT

While about 50% of non- seminomatous germ cell tumors of the testes present as clinical stage I (CSI), further management of these patients continues to be mired in controversy. Active surveillance is a frontline option for low- risk CS I patients and according to some, even the high- risk ones with high embryonal carcinoma (ECA) component and vascular invasion (VI). However, it carries the disadvantage of long- term surveillance, the need for prolonged chemotherapy in case of recurrence and the possibility of secondary malignancies due to radiation exposure from frequent CT scans. One or two cycles of BEP chemotherapy is a popular alternative to active surveillance which carries a very low relapse rate, but valid concerns about overtreatment of a majority of patients, with the attendant chemotherapy- related toxicity exist. Retroperitoneal lymph node dissection has been used as a means of avoiding chemotherapy, especially in high- risk patients, but carries the disadvantage of a high surgical morbidity and complications. As with any major surgical procedure, the best results are dependent on the experience and skill of the individual surgeon.

Do Histopathologic Variables Affect the Reporting of Lymphovascular Invasion in Testicular Germ Cell Tumors?

OBJECTIVES

Identification of lymphovascular invasion (LVI) in testicular germ cell tumors (GCTs) is a challenging yet important aspect of cancer staging that can alter therapeutic management. Our study aimed to identify pathologic features that affect the reporting of LVI.

METHODS

Pathology report and slide review of orchiectomies performed at our institution between 2007 and 2013 for testicular GCTs were performed.

RESULTS

Seminomas grossed by residents had a higher rate of reported LVI compared with specimens grossed by pathology assistants (46% vs 15%). Tumor displacement artifact was more frequent in seminomas vs mixed GCTs (60% vs 38%). LVI concordance was high upon review (κ = 0.77), with displacement artifact present in all discrepancies. Tumor emboli from cases reported to have LVI had a higher frequency of tumor cohesiveness, smooth contours, and adherence to vessel walls compared with tumor emboli that were considered pseudo-LVI. Presence of fibrin and RBCs were features found at a similar frequency in emboli that were reported as LVI compared with those deemed artifactual.

CONCLUSIONS

Grosser type, tumor subtype, tumor displacement artifact, and characteristics of tumor emboli are pathologic features that affect the interpretation of LVI in testicular GCTs. Pathologists should be aware of these variables to more accurately diagnose LVI.

Management of Stage I Nonseminomatous Germ Cell Tumors

Testis cancer represents the model for a curable malignancy. Although there is consensus about the appropriate management of metastatic (clinical stage [CS] IIC-III) nonseminomatous germ cell tumor (NSGCT) in terms of the chemotherapy regimens, number of cycles, and the surgical resection of postchemotherapy residual masses, there remains controversy regarding the appropriate management of low-stage NSGCT (CSI-IIB). In this article, the benefits and drawbacks of each treatment option are reviewed; an evidence-based approach when confronted with such a patient and how to best select a treatment avenue based on the patient's clinical and pathologic features are also discussed.

Prostatic relapse of an undifferentiated teratoma 24 years after orchidectomy

BACKGROUND

Non-seminomatous germ cell tumours make up about 40 % of all germ cell tumours, which in turn are the most common tumours in men aged 15-44 years. Low risk stage I non-seminomatous germ cell tumours, which are confined to the testes, are commonly treated by orchiectomy and surveillance. Up to 20 % of patients with this diagnosis relapse, usually within 1-2 years of follow up, but very rarely after more than 5 years. The most common sites of relapse are the retroperitoneal lymph nodes, the mediastinum, and the lungs. We describe a case of relapse in the prostate over 20 years after initial diagnosis, which has not been described in the literature so far.

CASE PRESENTATION

This report presents a 49-year-old white British man with relapsed testicular non-seminomatous germ cell tumour 22 years after initial treatment with orchidectomy only. He relapsed with a prostatic mass, haematospermia and back pain. His prostate specific antigen levels were within normal range. Alpha feto-protein and lactate dehydrogenase levels were elevated, and his human chorionic gonadotrophin levels were normal. A biopsy confirmed undifferentiated malignant tumour, shown immunohistochemically to be a yolk sac tumour. The patient was initially treated with bleomycin, etoposide and cisplatin chemotherapy, but developed bleomycin-related pulmonary side effects after two cycles. His treatment was changed and he completed four cycles of chemotherapy by receiving two cycles of etoposide, ifosfamide, and cisplatin. Post treatment blood tumour markers were normal, but a follow up computed tomography showed a mass in the base of the prostate, the trigone and the left distal ureter which was surgically resected. The histology from the surgical resection was of necrotic tissue. The patient is now in follow up at 3 years after treatment with no evidence of residual disease on computed tomography. His Alpha feto-protein, beta human chorionic gonadotrophin and lactate dehydrogenase levels are normal.

CONCLUSIONS

Very late relapse in stage I non-seminomatous germ cell tumours is extremely rare and the prostate is a highly unusual site of relapsed disease. For diagnosis of late relapse, this case confirms the value of serum biomarkers in germ cell tumours, in particular non-seminomatous germ cell tumours.

A refined risk stratification scheme for clinical stage 1 NSGCT based on evaluation of both embryonal predominance and lymphovascular invasion

BACKGROUND

Active surveillance is an increasingly accepted approach for managing patients with germ-cell tumors (GCTs) after an orchiectomy. Here we investigate a time-to-relapse stratification scheme for clinical stage 1 (CS1) nonseminoma GCT (NSGCT) patients according to factors associated with relapse and identify a group of patients with a lower frequency and longer time-to-relapse who may require an alternative surveillance strategy.

PATIENTS AND METHODS

We analyzed 266 CS1 GCT patients from the IRB-approved DFCI GCT database that exclusively underwent surveillance following orchiectomy from 1997 to 2013. We stratified NSGCT patients according to predominance of embryonal carcinoma (EmbP) and lymphovascular invasion (LVI), using a 0, 1, and 2 scoring system. Cox regression and conditional risk analysis were used to compare each NSGCT group to patients in the seminomatous germ-cell tumor (SGCT) category. Median time-to-relapse values were then calculated among those patients who underwent relapse. Relapse-free survival curves were generated using the Kaplan-Meier method.

RESULTS

Fifty (37%) NSGCT and 20 (15%) SGCT patients relapsed. The median time-to-relapse was 11.5 versus 6.3 months for the SGCT and NSGCT groups, respectively. For NSGCT patients, relapse rates were higher and median time-to-relapse faster with increasing number of risk factors (RFs). Relapse rates (%) and median time-to-relapse (months) were 25%/8.5 months, 41%/6.8 months and 78%/3.8 months for RF0, RF1 and RF2, respectively. We found a statistically significant difference between SGCT and patients with one or two RFs (P < 0.001) but not between SGCT and NSGCT RF0 (P = 0.108).

CONCLUSION

NSGCT patients grouped by a risk score system based on EmbP and LVI yielded three groups with distinct relapse patterns -and patients with neither EmbP nor LVI appear to behave similar to SGCT.

Handling and reporting of orchidectomy specimens with testicular cancer: areas of consensus and variation among 25 experts and 225 European pathologists

AIMS

The handling and reporting of testicular tumours is difficult due to their rarity.

METHODS AND RESULTS

A survey developed by the European Network of Uro-Pathology (ENUP) and sent to its members and experts to assess the evaluation of testicular germ cell tumours. Twenty-five experts and 225 ENUP members replied. Areas of disagreement included immaturity in teratomas, reported by 32% of experts but 68% of ENUP. Although the presence of rete testis invasion was reported widely, the distinction between pagetoid and stromal invasion was made by 96% of experts but only 63% of ENUP. Immunohistochemistry was used in more than 50% of cases by 68% of ENUP and 12% of experts. Staging revealed the greatest areas of disagreement. Invasion of the tunica vaginalis without vascular invasion was interpreted as T1 by 52% of experts and 67% of ENUP, but T2 by the remainder. Tumour invading the hilar adipose tissue adjacent to the epididymis without vascular invasion was interpreted as T1: 40% of experts, 43% of ENUP; T2: 36% of experts, 30% of ENUP; and T3: 24% of experts, 27% of ENUP.

CONCLUSIONS

There is remarkable consensus in many areas of testicular pathology. Significant areas of disagreement included staging and reporting of histological types, both of which have the potential to impact on therapy.

Surveillance for patients with clinical stage I nonseminomatous testicular germ cell tumors

PURPOSE

To assess the prognostic value of histological parameters in patients with clinical stage I nonseminomatous germ cell tumors (NSGCTs) undergoing active surveillance post-orchiectomy.

METHODS

Prognoses and recurrence patterns were investigated in 78 patients with CSI NSGCT who underwent orchiectomy. Immediately following orchiectomy, patients participated in active surveillance between 1999 and 2013 at Sun Yat-sen University Cancer Center, Guangzhou, China.

RESULTS

23.1 % of the 78 investigated patients with CSI NSGCT relapsed, within a median time of 5.6 months It was determined using multivariate analysis that lymph vascular invasion (LVI) (OR 6.521; 95 % CI 1.872-22.721; p = 0.003) and the predominant presence of yolk sac tumor (greater than 50 %) (OR 3.537; 95 % CI 1.076-11.628; p = 0.038) independently correlated with relapse-free survival (RFS). Patients were categorized accordingly into three risk groups: low risk [<50 % presence of yolk sac tumor and LVI (-); n = 41], intermediate risk [50 % or greater presence of yolk sac tumor and LVI (+); n = 29], and high risk [50 % or greater presence of yolk sac tumor and LVI (+); n = 8]. Relapse rates of the low-risk, intermediate-risk, and high-risk groups were 7.3, 31.0, and 75.0 %, respectively.

CONCLUSIONS

LVI and a predominant presence of yolk sac tumor are crucial risk factors for relapse of CSI NSGCT. For patients without either of these risk factors, active surveillance post-orchiectomy is a safe and effective approach for the initial management of CSI NSGCT.

Management of clinical stage I nonseminomatous germ cell tumors

Therapeutic options for clinical stage I nonseminomatous germ cell tumor include active surveillance, adjuvant chemotherapy and retroperitoneal lymph node dissection (RPLND). Lymphovascular invasion (LVI) determines risk of recurrence, as those without LVI have 15% risk of relapse on surveillance while those with LVI have a 50% risk. This stratifies patients into high risk(LVI+) and low risk(LVI-) groups which direct treatment recommendations. Surveillance is preferred for those with low risk disease, and is an option for those with high risk disease, as at least half are over-treated with other options. Adjuvant chemotherapy is an option for all patients as it can eradicate micrometastatic disease and reduce recurrence by at least 90%. RPLND benefits patients with low volume retroperitoneal disease with a cure rate of RPLND alone at approximately 70%. All three treatment modalities have similar survival rates approaching 100% but differing potential morbidities, which, along with patient preferences and compliance, should guide treatment decisions.

[Treatment of testicular cancer]

Germ-cell tumours (GCTs) are the most common type of cancer in young men. Since the late 1970s, disseminated GCT have been a paradigm for curable metastatic cancer and metastatic GCTs are highly curable with cisplatin-based chemotherapy followed by surgical resection of residual masses. Patients' prognosis is currently assessed using the International Germ-Cell Consensus Classification (IGCCC) and used to adapt the burden of chemotherapy. Approximately 20% of patients still do not achieve cure after first-line cisplatin-based chemotherapy, and need salvage chemotherapy (high dose or standard dose chemotherapy). Clinical stage I testicular cancer is the most common presentation and different strategies are proposed: adjuvant therapies, surgery or surveillance. During the last three decades, clinical trials and strong international collaborations lead to the development of a consensus in the management of GCTs.

Oncological outcomes in patients with stage I testicular seminoma and nonseminoma: pathological risk factors for relapse and feasibility of surveillance after orchiectomy

Background

Surveillance after orchiectomy has recently been a management option in patients with stage I seminoma, while it remains controversial in those with stage I nonseminoma, and the risk factor associated with relapse is still a matter of concern in both entities. This study was performed to explore pathological risk factors for post-orchiectomy relapse in patients with stage I seminoma and nonseminoma, and to assess oncological outcomes in those managed with surveillance.

Methods

In this single institution study, 118 and 40 consecutive patients with stage I seminoma and nonseminoma were reviewed, respectively. Of the 118 patients with stage I seminoma, 56 and one received adjuvant radiotherapy and chemotherapy, respectively, and 61 were managed with surveillance. Of the 40 men with stage I nonseminoma, 4 underwent adjuvant chemotherapy and 36 were managed with surveillance.

Results

No patient had cause-specific death during the mean observation period of 104 and 99 months in men with seminoma and nonseminoma, respectively. In men with stage I seminoma, 1 (1.7%) receiving radiotherapy and 4 (6.6%) men managed with surveillance had disease relapse; the 10-year relapse-free survival (RFS) rate was 93.4% in men managed with surveillance, and their RFS was not different from that in patients receiving adjuvant radiotherapy (logrank P=0.15). Patients with tunica albuginea involvement showed a poorer RFS than those without (10-year RFS rate 80.0% vs. 94.1%), although the difference was of borderline significance (P=0.09). In men with stage I nonseminoma, 9 (22.5%) patients experienced relapse. Patients with lymphovascular invasion seemingly had a poorer RFS than those without; 40.0% and 18.7% of the patients with and without lymphovascular invasion had disease relapse, respectively, although the difference was not significant (logrank P=0.17).

Conclusion

In both men with stage I seminoma and nonseminoma, surveillance after orchiectomy is a feasible option. However, disease extension through tunica albuginea might be a factor associated with disease relapse in patients with organ-confined seminoma, and those with stage I nonseminoma showing lymphovascular invasion may possibly be at high risk for disease relapse.

Testicular hilum and vascular invasion predict advanced clinical stage in nonseminomatous germ cell tumors

Clinical staging is a critical step in the management of testicular germ cell tumors. Up to one-third of nonseminomatous germ cell tumors of the testis present with metastatic disease (clinical stages II and III). We investigated the predictors of metastatic disease at presentation in a cohort of 148 consecutive nonseminomatous germ cell tumors of the testis, over a 10-year period. The following clinical and pathologic features were evaluated: age, tumor size, dominant tumor histology, coagulative necrosis, vascular invasion, rete testis invasion and tumor extension into tunica vaginalis, hilar soft tissue, epididymis, or spermatic cord. Studied parameters were correlated with the clinical stage at presentation. Of the 148 patients with nonseminomatous germ cell tumors of the testis, 94 (63%) were clinical stage I, 26 (18%) were stage II, and 28 (19%) were stage III at presentation. Mean patient age was 31 years (range, 17-83). Mean tumor size was 4.1 cm (range, 0.6-19). On univariate analysis, the following parameters showed statistically significant association with the advanced clinical stage at presentation: vascular invasion (P<0.001), rete testis invasion (P<0.001), hilar soft tissue invasion (P<0.001), epididymis invasion (P=0.005), spermatic cord invasion (P=0.005), and coagulative necrosis (P=0.062). On multivariate analysis, only vascular invasion (P=0.011) and invasion into the rete testis and the hilar soft tissues (P=0.007 and P=0.017, respectively) demonstrated significant association with advanced clinical stage at presentation. We conclude that in addition to vascular invasion, tumor invasion into the hilum (rete testis or hilar soft tissue) is also strongly associated with metastatic disease at presentation and should be part of the routine pathology reporting.

Prognostic features and markers for testicular cancer management

Testicular neoplasm accounts for about 1% of all cancers in men. Over the last 40 years, the incidence of testicular cancer has increased in northern European male populations for unknown reasons. When diagnosed at early stage, testicular cancer is usually curable with a high survival rate. In the past three decades, successful multidisciplinary approaches for the management of testicular cancer have significantly increased patient survival rates. Utilization of tumor markers and accurate prognostic classification has also contributed to successful therapy. In this article, we highlight the most commonly used tumor markers and several potential "novel" markers for testicular cancer as part of the ongoing effort in biomarker research and discovery. In addition, this article also identifies several key prognostic features that have been demonstrated to play a role in predicting relapse. These features include tumor size, rete testis invasion, lymphovascular invasion, and tumor histology. Together with tumor markers, these prognostic factors should be taken into account for risk-adapted management of testicular cancer.

Surgical management of low-stage nonseminomatous germ cell testicular cancer

The optimal treatment of low-stage nonseminomatous germ cell testicular cancer (NSGCT) is controversial. For clinical stage (CS) I NSGCT, retroperitoneal lymph node dissection (RPLND), two cycles of chemotherapy and surveillance are all accepted treatment options. For CS IIA-B, standard treatments include RPLND (+/- adjuvant chemotherapy) and induction chemotherapy (+/- RPLND). The long-term survival rate is >97% for CS I and 95% for CS IIA-B NSGCT, regardless of the treatment received. The risk of retroperitoneal metastasis varies by clinical stage (25-35% for CS I, 65-85% for CS IIA-B), and the presence of lymphovascular invasion and percentage of embryonal carcinoma in the primary tumour. Patients with elevated serum tumour markers (STMs) and adenopathy of >3 cm are at high risk of having occult systemic disease. Compared with chemotherapy, RPLND is associated with a considerably more favourable long-term morbidity profile and is the most effective method for controlling the retroperitoneum. Surveillance is associated with the lowest risk of long-term complications. As such, we favour surveillance for low-risk CS I, induction chemotherapy for those at high risk of systemic disease (elevated STM, adenopathy >3 cm), and RPLND for all others. Modified template dissections reduce the risk of ejaculatory dysfunction, but might increase the risk of local recurrence. Therefore, we favour a full-bilateral template dissection with nerve-sparing in patients with low-stage NSGCT. The therapeutic efficacy of laparoscopic RPLND is not proven and currently should be considered a staging procedure only. Adjuvant chemotherapy after RPLND is typically restricted to patients with pathological stage N2-3 disease.

Quality of surveillance for stage I testis cancer in the community

PURPOSE

Patients with clinical stage I testicular germ cell tumors have been managed with adjuvant radiotherapy, chemotherapy, or retroperitoneal lymph node dissection (RPLND). The use of surveillance-only strategies at referral centers has yielded survival outcomes comparable to those achieved with adjuvant therapy. We evaluated compliance with follow-up protocols developed at referral centers within the community.

METHODS

We identified patients with stage I testis cancer within a large private insurance claims database and calculated compliance of follow-up test use with guidelines from the National Comprehensive Cancer Network.

RESULTS

Surveillance was widely used in the community. Compliance with surveillance and postadjuvant therapy follow-up testing was poor and degraded with increasing time from diagnosis. Nearly 30% of all surveillance patients received no abdominal imaging, chest imaging, or tumor marker tests within the first year of diagnosis. Patients who elected RPLND were most compliant with recommended follow-up testing within the first year. Recurrence rates were consistent with previously reported literature, despite poor compliance.

CONCLUSION

Surveillance is a widely accepted strategy in clinical stage I testicular cancer treatment in the community. However, follow-up care recommendations developed at referral centers are not being adhered to in the community. Although recurrence rates are similar to those of reported literature, the clinical impact of noncompliance on recurrence severity and mortality are not known. Further prospective work needs to be done to evaluate this apparent quality of care problem in the community.

Risk-Adapted Treatment in Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer: The SWENOTECA Management Program

Purpose

To offer minimized risk-adapted adjuvant treatment on a nationwide basis for patients with clinical stage 1 (CS1) nonseminomatous germ-cell testicular cancer (NSGCT). The aim was to reduce the risk of relapse and thereby reducing the need of later salvage chemotherapy while maintaining a high cure rate.

Patients and Methods

From 1998 to 2005, 745 Norwegian and Swedish patients were included into a prospective, community-based multicenter Swedish and Norwegian Testicular Cancer Project (SWENOTECA) management program. Treatment strategy depended on the presence or absence of vascular tumor invasion (VASC). VASC-positive patients were recommended brief adjuvant chemotherapy (ACT) with bleomycin, etoposide, and cisplatin (BEP), whereas VASC-negative patients could choose between ACT and surveillance.

Results

At a median follow-up of 4.7 years, there have been 51 relapses. On surveillance, 41.7% of VASC+ patients relapsed, compared with 13.2% of VASC− patients. After one course of BEP, 3.2% of VASC+ and 1.3% of VASC− patients relapsed. The toxicity of adjuvant BEP was low. Eight patients have died, none died from progressive disease.

Conclusion

One course of adjuvant BEP reduces the risk of relapse by approximately 90% in both VASC+ and VASC− CS1 NSGCT, and may be a new option as initial treatment for all CS1 NSGCT. One course of adjuvant BEP for VASC+ CS1 reduces the total burden of chemotherapy compared with surveillance or two courses of BEP. SWENOTECA currently recommends one course of BEP as standard treatment of VASC+ CS1 NSGCT, whereas both surveillance and one course of BEP are options for VASC− CS1 NSGCT.

Risk-adapted management for patients with clinical stage I non-seminomatous germ cell tumour of the testis

Testis cancer is the most common cancer in young men and its incidence continues to rise. Even if prognosis is considered as good, a group with bad prognosis still remains. We aimed to evaluate whether two courses of chemotherapy after orchiectomy in patients with clinical stage I, non-seminomatous germ cell testicular tumour at high risk of relapse, will spare patients additional chemotherapy or surgery. High-risk patients had one or more of the following: preorchiectomy alpha-fetoprotein level of 80 ng/dl, 80% embryonal cell carcinoma or greater, vessel invasion in the primary tumour and tumour stage pT2 or greater. Low-risk patients had none of these factors or had 50% teratoma or more without vessel invasion. High-risk patients were offered two 21-day courses of outpatient chemotherapy consisting cisplatin, etoposide and bleomycin (BEP). Low-risk patients were observed. Of the 108 patients, we classified 71 as high risk and 37 as low risk of relapse. All of the high-risk patients received two courses of BEP chemotherapy. Low-risk patients were kept on close-up. The median follow-up was 26 months (range 10-60). Of the 71 patients in high-risk group, 3 relapsed with viable cancer and required additional chemotherapy and 1 patient with normal biomarkers and a late-appearing mass underwent retroperitoneal lympadenectomy for mature teratoma. All 4 relapsed patients were in high-risk group and presently they are free of disease. None of the 37 patients at low risk of recurrences developed relapse. We recommend two courses of adjuvant chemotherapy after postorchiectomy for high-risk patients with stage I non-seminomatous germ cell tumour of the testis. Adjuvant chemotherapy for these patients results in a low relapse and morbidity, wich compares favourably with the results of surveillance or RPLND. This well-tolerated approach may spare patients additional surgery or protracted chemotherapy, reduce the cost and eliminate the compliance problems associated with intensive follow up of high-risk patients.

Current management of stage I testicular non-seminomatous germ cell tumours

Testicular germ cell tumors represent the most common malignancies in young males between the ages of 15 and 35; 50% of those with non-seminomatous germ cell tumors (NSGCT) have clinical stage I at diagnosis. Predictors for relapse include lymphovascular invasion, percentage of embryonal-cell carcinoma component, absence of yolk-sack histology and MIB1 proliferation rate. Therapeutic options following orchidectomy in stage I NSGCT comprise nerve-sparing retroperitoneal lymph node dissection (RPLND), surveillance or adjuvant cisplatin-based chemotherapy. Using a risk adapted approach, in about 50% of patients with clinical stage I NSGCT surveillance is favored in patients with good compliance. Adjuvant chemotherapy is recommended for patients at high risk for developing metastatic disease. Non-seminomatous germ cell testicular cancer is a curable neoplasia. All available treatment modalities produce excellent results, with a long-term survival of almost 100%. Consequently, therapy-induced toxicity is an important concern in the management of these patients. An individually tailored approach that takes into account the prognostic factor profile, as well as the patients' preferences and their ability to comply with treatment, is the key for the successful management of stage I testicular cancer.

[Testicular tumors. Predictive factors]

Patients with germ cell tumors of the testis can be given adjuvant treatment immediately after orchidectomy or put under surveillance with definitive treatment deferred until relapse. Both therapies are equally successful (success rate 98-99%), with surveillance alone, however, only approximately 50% of cases need toxic chemotherapy. The surveillance strategy is especially successful in patients with tumors which do not have morphological predictors of metastases. In seminomas the strongest predictor of metastases is tumor invasion of the rete testis followed by the size (Ø > or =4 cm) of the tumor. Vascular invasion, the most important predictor in non-seminomatous germ cell tumors, is less important in seminomas. The second most important predictor in mixed tumors is the presence or absence and the amount of embryonal carcinoma. The presence of teratomas and yolk sac tumors are considered to be predictors of a favorable course of the disease. The statistical impact of these markers is, however, not very strong. The only reliable predictor of malignancy of the gonadal stromal tumors is the size and tumors with a diameter > or =5 cm are always malignant.

A comprehensive systematic review of testicular germ cell tumor surveillance

BACKGROUND

Testicular cancer is the most common malignancy in men aged 15-34, and its incidence has been increasing over the past half-century. Survival for stage I testis cancer approaches 100% regardless of management strategy which is often dictated by other factors such as perceived morbidity. Advances in treatment have attempted to decrease morbidity and surveillance is thought to achieve this goal.

METHODS

An English language literature search of MEDLINE from 1966 to December 2005 and CINAHL from 1982 to December 2005 was conducted using a broad search strategy. Comparative and descriptive original articles on outcomes of seminoma or NSGCT surveillance would be deemed eligible and review articles containing no original data were omitted. One hundred and thirty-eight articles were selected for formal review, during which a database was compiled that documented the first author, publication year, tumor histologic type, study purpose or topic(s), methodology, sample size, median follow-up, and relevant results.

RESULTS

Most evidence for the efficacy of surveillance is from descriptive series or non-experimental comparative studies. Relapse occurs in approximately 28% and 17% of surveillance patients in NSGCT and seminoma, respectively, and cause-specific survival is approximately 98% and 100%, respectively. Compliance with surveillance ranges from poor to adequate, however there is no evidence that compliance impacts clinical outcome. Cost analyses have yielded inconsistent results when comparing treatment modalities. There is scant literature on quality of life and psychosocial issues and results are inconsistent. Active surveillance appears to be appropriate and perhaps optimal first line management of clinical stage I seminoma and non-seminomatous germ cell tumors. Further quantitative and qualitative research is warranted to deepen understanding of these issues that may impact treatment decision-making.

Adjuvant treatment in the management of testis-confined germ cell tumours after orchidectomy

Germ cell tumours are highly curable, especially when still at the localized stage, which is the case for most testicular tumours. Various options are available for organ-confined disease; depending on the histological review, patients with clinical stage I seminomas can be offered radiotherapy, surveillance or chemotherapy, whereas those with clinical stage I nonseminomas can be offered retroperitoneal lymph node dissection, surveillance or chemotherapy. As it is unlikely that any of these approaches will have a clear survival advantage, the most appropriate variables to be considered are acute and late side-effects, acceptability and quality of life. In recent years adjuvant chemotherapy has been extensively evaluated in patients with seminoma or nonseminoma. In this review we discuss the advantages and disadvantages of the different strategies for treating seminomas and nonseminomas, and their associated prognostic factors, and then consider future developments.

Management of Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer

The optimal management of patients who have clinical stage I nonseminomatous germ cell tumors remains controversial. Surveillance, retroperitoneal lymph node dissection (RPLND), and chemotherapy with two cycles of bleomycin-etoposide-cisplatin are established treatment options and all are associated with long-term cancer control rates of 97% or greater. Studies have consistently identified the presence of lymphovascular invasion and a predominant component of embryonal carcinoma in the primary tumor as risk factors for occult metastatic disease in these patients. Patients who do not have these risk factors are optimally managed by active surveillance given the low risk for relapse. For patients at high risk for relapse and who are not candidates for surveillance, we believe the evidence supports RPLND over primary chemotherapy.

Controversies in the Management of Clinical Stage I Testis Cancer

During the last two decades, definitive primary treatments and surveillance with definitive treatment deferred until relapse have demonstrated 98% to 99% cure rates in patients with stage I testis cancer, and these options have obtained firm positions in standard management. The development of optimal management strategies in various countries were at least partly guided by available surgical expertise in retroperitoneal lymph node dissection in the United States, and easy access to reference hospitals in densely populated countries in Western Europe that facilitated close surveillance programs; hence, treatment preferences differ on the two sides of the Atlantic. The success of both approaches is highly dependent on the skills of the practitioner, particularly of surgery and of scrutinized surveillance. As a result, local expertise and familiarity with a chosen modality has strengthened over the years, and investigators have been reluctant to embark on randomized trials designed to compare one modality with another. Such expertise with one particular technique, with the other approach being less familiar territory, has created controversy, because both physicians and patients seek evidence-based data coming from randomized clinical trials on which to make management decisions. Moreover, the reduced risk of relapse resulting from the use of radiotherapy or carboplatin in stage I seminoma and of cisplatin-based chemotherapy in stage I nonseminoma must be balanced against the potential long-term adverse effects in this population of patients with a normal life expectancy. The purpose of this review is to present the currently available data and discuss the merits and the disadvantages of the various approaches, yielding to the possible conclusion that all options appear to be equal in terms of efficacy, but that modality-associated adverse effects differ.

Outcomes of Surveillance Protocol of Clinical Stage I Nonseminomatous Germ Cell Tumors—Is Shift to Risk Adapted Policy Justified?

PURPOSE

We evaluated the potential risk factors for disease relapse in patients with clinical stage I nonseminomatous germ cell tumors treated with surveillance and reevaluated our treatment of these patients.

MATERIALS AND METHODS

A total of 211 consecutive patients with clinical stage I nonseminomatous germ cell tumors treated with surveillance after orchiectomy between 1993 and 2005 were included in this retrospective study. Risk factors evaluated were presence of vascular invasion, proportion of embryonal carcinoma, age, tumor size, preoperatively increased serum alpha-fetoprotein and the absence of yolk sac component.

RESULTS

Of the 211 patients 66 (31.3%) had disease relapse. Recurrence ranged from 2 to 32 months after orchiectomy (median 6). A total of 52 (78.8%) cases of relapse were diagnosed in year 1 of followup, 11 (16.7%) during year 2 and only 3 cases were diagnosed thereafter. The first evidence of relapse was most commonly the increase in serum tumor markers alone (28.8%) or in combination with other modalities (66.7%, overall 95.5%). While 40.9% of patients with more than 50% embryonal carcinoma had disease relapse, the relapse rate was 20.8% in patients with less than 50% embryonal carcinoma (p = 0.002). Relapse rates in patients with and without vascular invasion were 75.5% and 17.9%, respectively (p = 0.000). The relapse rates were 6.1% and 75.7% in patients with no risk factors (no vascular invasion and less than 50% embryonal carcinoma) and 2 risk factors (vascular invasion and more than 50% embryonal carcinoma), respectively (p < 0.001). Multivariate analysis revealed that vascular invasion was the most powerful predictor of relapse (OR 16.350, 95% CI 5.582-47.893). Disease-free and disease specific survival rates were 97.6% at a median followup of 75 months.

CONCLUSIONS

In light of our results we suggest that all patients with vascular invasion should receive chemotherapy. However, patients with no risk factors and those with more than 50% embryonal carcinoma but without vascular invasion should be on surveillance after orchiectomy since the relapse rate is less than 30%. Although strict followup in the first year is justified, followup schemas may be reassessed for the frequency of radiological investigations.

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.

Germ cell tumours of the testis

Cancer of the testis is a relatively rare disease, accounting for about 1% of all cancers in men. Cryptorchidism is the only confirmed risk factor for testicular germ cell tumour. The majority of GCT are clinically detectable at initial presentation. Any nodular, hard, or fixed area discovered in the testis, must be considered neoplastic until proved otherwise. The appropriate surgical procedure to make the diagnosis is a radical orchidectomy through an inguinal incision. Many GCT produce tumoural markers (AFP, HCG, LDH), who are useful in the diagnosis and staging of disease; to monitor the therapeutic response and to detect tumour recurrence. In 1997 a prognostic factor-based classification for the metastatic germ cell tumours was developed by the IGCCCG: good, intermediate and poor prognosis, with 5-year survival of 91, 79 and 48%, respectively. GCT of the testis is a highly table, often curable, cancer. Germ cell testicular cancers are divided into seminoma and non-seminoma types for treatment planning because seminomatous testicular cancers are more sensitive to radiotherapy. Seminoma (all stages combined) has a cure rate of greater than 90%. For patients with low-stage disease, the cure approaches 100%. For patients with non-seminoma tumours, the cure rate is >95% in stages I and II; it is approximately 70% with standard chemotherapy and resection of residual disease, if necessary, in stages III and IV. Minimum guidelines for clinical, biochemical, and radiological follow-up have been reported by ESMO in 2001.

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.

Part I: testicular cancer--management of early disease

For patients diagnosed with early-stage testicular cancer radical orchidectomy is the primary therapeutic intervention. The major pathological types of testicular cancer are seminoma and non-seminomatous germ-cell cancer. After orchidectomy, most patients with seminoma receive adjuvant radiotherapy as standard of care, although surveillance and adjuvant chemotherapy protocols are being developed. For patients with non-seminomatous tumours there are three therapeutic options; surveillance, adjuvant chemotherapy, or retroperitoneal lymph-node dissection. These patients are classified into groups with high-risk or low-risk of recurrence by presence of vascular invasion in the surgical specimen. After orchidectomy, about 50% of patients with high-risk disease will relapse but this risk is reduced to less than 5% with adjuvant therapy. Surveillance of patients with low-risk disease is acceptable because testicular cancer is still curable if metastatic recurrence occurs. There is no consensus about the management of early non-seminomatous testicular cancer because survival is almost 100% irrespective of the initial treatment decision.

Predictors of Occult Metastasis in Clinical Stage I Nonseminoma: A Systematic Review

Purpose: Patients with clinical stage I nonseminomatous testicular germ cell tumor should ideally receive adjuvant therapy only when they are at high risk for occult metastasis. We aimed to quantify the importance of predictors for occult metastasis by performing a systematic review of the relevant literature. In addition, we reviewed published multivariable models and risk-adapted treatment policies.

Patients and Methods: We identified 23 publications between 1979 and 2001, reporting a total of 2,587 patients. Twenty-nine percent of the patients (759 of 2,587 patients) had occult metastases, which was diagnosed either at retroperitoneal lymph node dissection (n = 193) or during follow-up (n = 566). Odds ratios (OR) were pooled using meta-analysis techniques.

Results: The presence of vascular invasion of the primary tumor cells had the strongest effect (OR, 5.2; 95% CI, 4.0 to 6.8). Immunohistochemical staining of the primary tumor cells with the MIB-1 monoclonal antibody showing proliferative activity was a promising predictor (OR, 4.7; 95% CI, 2.0 to 11). Intermediate effects were found for embryonal carcinoma in the primary tumor (OR, 2.9; 95% CI, 2.0 to 4.4) and a high pathologic stage of the tumor (OR, 2.6; 95% CI, 1.8 to 3.8). Size of the primary tumor and age of the patient had weaker though also statistically significant associations with occult metastasis. Until now, multivariable models often included vascular invasion and embryonal carcinoma with one or two weaker predictors. None of the published risk-adapted treatment policies included MIB-1 staining.

Conclusion: Several strong predictors for occult metastasis were identified. A risk-adapted treatment policy should be developed that incorporates all relevant predictors so that adjuvant therapy is targeted better to those with occult metastases.

A novel surveillance protocol for stage I nonseminomatous germ cell testicular tumours

OBJECTIVES

To report the results of a novel surveillance policy for stage I nonseminomatous germ cell tumours (NSGCTs).

PATIENTS AND METHODS

Between 1978 and 2000, 132 patients (median age 28 years, range 16-52) who were regularly followed were included in a new surveillance policy. All pathology specimens were studied retrospectively by the same pathologist for embryonal carcinoma, yolk sac tumour and lymphovascular invasion components. A loose surveillance protocol was designed in which computed tomography (CT) was used only for the first year.

RESULTS

The median (range) follow-up was 38 (6-265) months; the relapse rate was 24% and all occurred before 23 months, with 87% diagnosed within the first year. Platinum-based chemotherapy was given to patients with relapse, and surgery used after chemotherapy in seven. Among all the risk factors, an embryonal carcinoma component was the only significant predictor of relapse. The overall survival rate was 99%.

CONCLUSION

The presence of embryonal carcinoma in the primary pathology is the only risk factor determining the relapse rate of the present surveillance policy for stage I NSGCTs. The overall survival was no different from those reported for retroperitoneal lymph node dissection and primary chemotherapy. Decreasing the frequency of CT in the first year and totally eliminating it after 1 year reduces the cost of surveillance. The possible compliance problems of patients are also minimized, without changing the overall survival. This surveillance protocol for patients with stage I NSGCT has reduced costs and provided a better quality of life for the patients, without jeopardizing the final outcome.