Adjuvant chemotherapy after orchiectomy in high-risk patients with clinical stage I non-seminomatous testicular cancer

A Systematic Review Investigating the Difference between 1 Cycle versus 2 Cycles of Adjuvant Chemotherapy in Stage I Testicular Germ Cell Cancers

Standard care for stage I testicular germ cell cancers (seminomatous-STC or non-seminomatous-NSTC) is orchiectomy followed by active surveillance, 1 or 2 cycles of adjuvant chemotherapy, surgery or radiotherapy. The decision on the adjuvant therapeutic approach is guided by the associated risk factors of the patient and the potential related toxicity of the treatment. Currently, there is no consensus regarding the optimal number of adjuvant chemotherapy cycles. Although in terms of overall survival, there is no proven inconsistency regarding the number of cycles of adjuvant chemotherapy, and the rate of relapse may vary.

Management of Germ Cell Tumours of the Testis in Adult Patients. German Clinical Practice Guideline Part I: Epidemiology, Classification, Diagnosis, Prognosis, Fertility Preservation, and Treatment Recommendations for Localized Stages

INTRODUCTION

This is the first German evidence- and consensus-based clinical guideline on diagnosis, treatment, and follow-up on germ cell tumours (GCTs) of the testis in adult patients. We present the guideline content in two publications. Part I covers the topic's background, methods, epidemiology, classification systems, diagnostics, prognosis, and treatment recommendations for the localized stages.

METHODS

An interdisciplinary panel of 42 experts including 1 patient representative developed the guideline content. Clinical recommendations and statements were based on scientific evidence and expert consensus. For this purpose, evidence tables for several review questions, which were based on systematic literature searches (last search was in March 2018) were provided. Thirty-one experts entitled to vote, rated the final clinical recommendations and statements.

RESULTS

We provide 161 clinical recommendations and statements. We present information on the quality of cancer care and epidemiology and give recommendations for staging and classification as well as for diagnostic procedures. The diagnostic recommendations encompass measures for assessing the primary tumour as well as procedures for the detection of metastases. One chapter addresses prognostic factors. In part I, we separately present the treatment recommendations for germ cell neoplasia in situ, and the organ-confined stages (clinical stage I) of both seminoma and nonseminoma.

CONCLUSION

Although GCT is a rare tumour entity with excellent survival rates for the localized stages, its management requires an interdisciplinary approach, including several clinical experts. Quality of care is highly related to institutional expertise and can be reassured by established online-based second-opinion boards. There are very few studies on diagnostics with good level of evidence. Treatment of metastatic GCTs must be tailored to the risk according to the International Germ Cell Cancer Collaboration Group classification after careful diagnostic evaluation. An interdisciplinary approach as well as the referral of selected patients to centres with proven experience can help achieve favourable clinical outcomes.

Management of Clinical Stage I Germ Cell Tumors

Experience demonstrates multiple paths to cure for patients with clinical stage I testicular cancer. Because all options should provide a long-term disease-free rate near 100%, overall survival is no longer relevant in decision making, allowing practitioners to factor in quality of life, toxicity, cost, and impact on compliance. Surveillance for clinical stage I seminoma and clinical stage I nonseminoma has become the preferred option. The contrarian view is that a risk-adapted approach should persist, with surveillance for low-risk individuals and active therapy high-risk individuals. However, results obtained in unselected patients provide a strong argument against the need for such an approach.

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.

Surveillance policy for Japanese patients with stage I testicular germ cell cancer in the multi-detector computed tomography era

BACKGROUND

The outcome of surveillance for Japanese patients with clinical stage I testicular germ cell cancer (GCC) was investigated in the multi-detector computed tomography (MDCT) era.

METHODS

The medical records of 92 Japanese patients with stage I GCC, who received treatment in our institution between March 1999 and February 2013, were reviewed. As six patients requested and received prophylactic chemotherapy and two patients seriously deviated from surveillance schedule, these patients were excluded from the study. Data from a total 84 patients were analyzed,

RESULTS

The median follow-up period following diagnosis was 5.1 years (inter-quartile range: IQR, 2.3-7.7 years). Of the 84 patients, eight (9.5 %) had a recurrence of their cancer in this observation period. Regarding histologic subtypes, the recurrence rates were five (9.3 %) of the 54 patients with seminoma and three (10 %) of the 30 patients with nonseminomatous germ cell tumor (NSGCT). All eight patients who experienced a recurrence did so within 2 years; they all underwent induction chemotherapy and remain alive at the time of writing, with no evidence of disease. Among 31 seminoma patients with a tumor more than 4 cm in size and rete testis invasion, cancer recurred in three (9.7 %) during the surveillance period. On the other hand, among the 13 patients with NSGCT and vascular invasion, three (23 %) experienced a recurrence, whereas the figure was zero for the 11 (0 %) patients without vascular invasion.

CONCLUSION

Fewer than 10 % of Japanese patients with stage I testicular GCC suffered a recurrence in the 5-year observation period of this study. The risk of occult disease, which will result in relapse, might be decreased in the MDCT era. All patients must be fully informed of the anticipated recurrence rate and the potential risks of exposure to chemotherapy agents.

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.

[Chemotherapy in male external genital organs (testicular and penile cancer)]

AIM

To describe drugs used in the chemotherapy of testis and penis neoplasms.

MATERIAL

Bibliographical search was performed from the database Medline (National Library of Medicine, PubMed) and websites of the HAS and the ANSM. The search was focused on the characteristics, the mode of action, the efficiency and the side effects of the various drugs concerned.

RESULTS

Nowadays, the chemotherapy is perfectly codified in adjuvant treatment or in first-line treatment of metastatic testis cancer. A single dose of carboplatin for seminoma testicular (stage I) in adjuvant treatment situation is one of the latest advances. Concerning penis cancer, the optimal protocols validated by a high level of evidence are missing.

CONCLUSION

The chemotherapy in testis and penis neoplasms knew few advances in recent years. So, it is necessary to include patients in clinical research protocols.

[EAU guidelines on testicular cancer: 2011 update. European Association of Urology]

CONTEXT

On behalf of the European Association of Urology (EAU), guidelines for the diagnosis, therapy, and follow-up of testicular cancer were established.

OBJECTIVE

This article is a short version of the EAU testicular cancer guidelines and summarises the main conclusions from the guidelines on the management of testicular cancer.

EVIDENCE ACQUISITION

Guidelines were compiled by a multidisciplinary guidelines working group. A systematic review was carried out using Medline and Embase, also taking Cochrane evidence and data from the European Germ Cell Cancer Consensus Group into consideration. A panel of experts weighted the references, and a level of evidence and grade of recommendation were assigned.

RESULTS

There is a paucity of literature especially regarding longer term follow-up, and results from a number of ongoing trials are awaited. The choice of treatment centre is of the utmost importance, and treatment in reference centres within clinical trials, especially for poor-prognosis nonseminomatous germ cell tumours, provides better outcomes. For patients with clinical stage I seminoma, based on recently published data on long-term toxicity, adjuvant radiotherapy is no longer recommended as first-line adjuvant treatment. The TNM classification 2009 is recommended.

CONCLUSIONS

These guidelines contain information for the standardised management of patients with testicular cancer based on the latest scientific insights. Cure rates are generally excellent, but because testicular cancer mainly affects men in their third or fourth decade of life, treatment effects on fertility require careful counselling of patients, and treatment must be tailored taking individual circumstances and patient preferences into account.

TAKE HOME MESSAGE

Although testicular cancer has excellent cure rates, the choice of treatment centre is of the utmost importance. Expert centres achieve better results for both early stage testicular cancer (lower relapse rates) and overall survival (higher stages within clinical trials). For patients with clinical stage I seminoma, adjuvant radiotherapy is no longer recommended as first-line adjuvant treatment.

EAU guidelines on testicular cancer: 2011 update

CONTEXT

On behalf of the European Association of Urology (EAU), guidelines for the diagnosis, therapy, and follow-up of testicular cancer were established.

OBJECTIVE

This article is a short version of the EAU testicular cancer guidelines and summarises the main conclusions from the guidelines on the management of testicular cancer.

EVIDENCE ACQUISITION

Guidelines were compiled by a multidisciplinary guidelines working group. A systematic review was carried out using Medline and Embase, also taking Cochrane evidence and data from the European Germ Cell Cancer Consensus Group into consideration. A panel of experts weighted the references, and a level of evidence and grade of recommendation were assigned.

RESULTS

There is a paucity of literature especially regarding longer term follow-up, and results from a number of ongoing trials are awaited. The choice of treatment centre is of the utmost importance, and treatment in reference centres within clinical trials, especially for poor-prognosis nonseminomatous germ cell tumours, provides better outcomes. For patients with clinical stage I seminoma, based on recently published data on long-term toxicity, adjuvant radiotherapy is no longer recommended as first-line adjuvant treatment. The TNM classification 2009 is recommended.

CONCLUSIONS

These guidelines contain information for the standardised management of patients with testicular cancer based on the latest scientific insights. Cure rates are generally excellent, but because testicular cancer mainly affects men in their third or fourth decade of life, treatment effects on fertility require careful counselling of patients, and treatment must be tailored taking individual circumstances and patient preferences into account.

Testicular germ cell tumors: pathogenesis, diagnosis and treatment

Testicular germ cell tumors represent the most common solid malignancy of young men aged 15-40 years. Histopathologically, testicular germ cell tumors are divided into two major groups: pure seminoma and nonseminoma. The pathogenesis of testicular germ cell tumors remains unknown; however, cryptorchidism is the main risk factor, and molecular studies have shown strong evidence of an association between genetic alterations and testicular germ cell tumors. In cases of suspicion for testicular germ cell tumor, a surgical exploration with orchiectomy is obligatory. After completion of diagnostic procedures, levels of serum tumor markers and the clinical stage based on the International Union Against Cancer tumor-node-metastasis classification should be defined. Patients with early-stage testicular germ cell tumors are treated by individualized risk stratification within a multidisciplinary approach. The individual management (surveillance, chemotherapy or radiotherapy) has to be balanced according to clinical features and the risk of short-term and long-term toxic effects. Treatment for metastatic tumors is based on risk stratification according to International Germ Cell Cancer Collaborative Group classification and is performed with cisplatin-based chemotherapy and residual tumor resection in cases of residual tumor lesion. High-dose chemotherapy represents a curative option for patients with second or subsequent relapses.

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.

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.

The management of stage I nonseminomatous testicular germ cell tumors

Testicular germ cell tumors represent the most common malignancies in young males; 70% of patients with seminomas and 50% of those with nonseminomatous germ cell tumors (NSGCT) have clinical stage I at diagnosis. Lymphovascular invasion, embryonal-cell carcinoma component, absence of yolk sac histology and MIB1 proliferation rate represent predictors of micrometastatic diseasein stage I NSGCT. Therapeutic options following orchiectomy in patients with stage I NSGCT comprise nerve-sparing retroperitoneal lymph node dissection, surveillance or adjuvant cisplatin-based chemotherapy. 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 patient's preferences and their ability to comply with each one of the modalities is the key to the management of stage I testicular cancer.

Retroperitoneal lymph node dissection in testicular cancer

With long-term survival in excess of 90% across all stages, testicular cancer has come to represent the model for successful multidisciplinary cancer care. Retroperitoneal lymph node dissection (RPLND) remains an integral component of testis cancer management strategies for both early- and advanced-stage disease. Commensurate with improvements made in clinical staging and in our understanding of the natural history of testis cancer, lymphatic spread, and neuroanatomy, considerable modifications in the technique and template of RPLND have taken place. The morbidity of primary RPLND and postchemotherapy RPLND is low when performed by experienced surgeons. This article reviews the evolution, role, and technique of RPLND in contemporary practice.

Risk-adapted treatment for patients with clinical stage I nonseminomatous germ cell tumor of the testis

OBJECTIVES

To evaluate whether two courses of chemotherapy after orchiectomy in patients with clinical Stage I nonseminomatous germ cell testicular tumor at high risk of relapse will spare patients additional chemotherapy or surgery.

METHODS

High-risk patients had one or more of the following: preorchiectomy alpha-fetoprotein level of 80 ng/dL or greater, 80% embryonal cell carcinoma or greater, or vessel invasion in the primary tumor. 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 of carboplatin, etoposide, and bleomycin. Low-risk patients and high-risk patients not receiving chemotherapy were observed.

RESULTS

Of 99 patients, we classified 76 as high risk and 23 as low risk of relapse. All but eight of the high-risk patients received chemotherapy. No patient who underwent chemotherapy developed relapse, although 1 patient with normal biomarkers and a late-appearing mass underwent retroperitoneal lymphadenectomy for mature teratoma. Two of the 23 low-risk patients had disease relapse; both successfully underwent chemotherapy. The nonhematologic toxicity was mild in patients receiving chemotherapy, and no patient required hospitalization. The median follow-up was 38 months (range 9 to 69).

CONCLUSIONS

Two courses of postorchiectomy adjuvant chemotherapy were safe and well tolerated and markedly decreased the relapse rate in high-risk patients with clinical Stage I nonseminomatous germ cell testicular tumor without additional surgery or more protracted chemotherapy. This approach may avoid potential problems with compliance and diminish the cost of scrupulous follow-up. Our results support that surveillance for carefully selected patients at a low risk of relapse is appropriate.

Carcinoma of the kidney, testis, and rare urologic malignancies

The purpose of this symposium was to provide a forum for discussion on current information on the etiology and diagnosis of, and therapy for, tumors of the kidney, testis, and several uncommon malignancies of the genitourinary tract. The most recent contributions in epidemiology and molecular genetics were discussed with specific reference to their importance for clinical practice. Contemporary treatment approaches with the emphasis on multidisciplinary patient management of tumors commonly seen in the clinic as well as those that are only rarely diagnosed by urooncologists were presented. Major stress was given to the management optimization as it pertains to short- and long-term quality of life issues of patients treated for these tumors. Methods to reduce treatment toxicity including carcinogenic potential of chemotherapy, radiotherapy, or their combination were found to be of nearly equal importance to patient survival. Symposium participants reached consensus on a number of important points: 1) The management of patients with several malignancies discussed requires the presence of a multidisciplinary team of specialist who are interested in diagnosis and treatment of genitourinary tumors; 2) Patients managed in such an environment are expected to have optimal survival and the best possible quality of life; 3) Real advances in the management of patients can be best obtained through well-designed prospective clinical trials; and 4) There is a need for timely introduction of relevant advances in epidemiology and molecular genetics to clinics.

Surgery versus surveillance in stage I non-seminoma testicular cancer

Today, the standard treatment for patients with clinical Stage I non-seminomatous testicular germ cell tumors (NSTGCT) following orchidectomy is either primary retroperitoneal lymph node dissection (RPLND) or close surveillance with cisplatin-based polychemotherapy in case of a relapse. Both treatment modalities provide excellent overall survival rates up to 100%. Consequently, selection of the most appropriate management option is not primarily guided by survival considerations. The choice between the available options, each having its merits and its drawbacks, should be made based on a number of factors including treatment-related morbidity, views and expertise of the physician, patient preferences, the expected degree of patient compliance, and prognostic factor analysis. To date, the role of adjuvant chemotherapy as an alternative management option for patients with clinical Stage I NSTGCT at high risk of occult metastases is limited. This systemic treatment modality would be a realistic alternative if the reliability of prognostic factors to identify high-risk Stage I patients could be improved. This review addresses relevant issues in the management of patients with clinical Stage I NSTGCT to provide information that will allow a rational selection of the most appropriate management option.

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.

Testicular cancer

The following article provides a comprehensive review of male germ cell tumors; the pathology and the clinical manifestations of the tumors are discussed, as are the modern concepts of clinical staging. Patients with bulky stage II and stage III non-seminomatous germ cell tumors are treated with chemotherapy. The new international classification system has provided a very useful way to categorize these patients by prognosis. Patients with good- or intermediate-risk tumors may be treated with 3 courses of cisplatin, etoposide, and bleomycin (BEP) or 4 courses of etoposide and cisplatin (EP), and more than 90% of these patients will survive. Randomized trials have shown that, if only 3 courses of chemotherapy are to be given, the substitution of carboplatin for cisplatin and the omission of bleomycin are deleterious to outcome. Patients who still have a significant residual mass and normal markers after treatment should undergo a surgical resection of the residual tumor. Patients who are classified by the international classification system as having poor-risk tumors have about a 50% likelihood of survival, and many of these patients will require surgical resection of a residual tumor after chemotherapy. No randomized trial has proved a regimen to be superior to that of 4 courses of BEP. Currently, an ongoing trial is evaluating the effect of the early use of high-dose therapy in combination with hematopoietic rescue in patients with these types of tumors. Patients with small-volume stage II tumors are generally treated with retroperitoneal lymph node dissection (RPLND). About 25% of the patients selected for this procedure will actually have pathologically negative nodes. Those with positive nodes may elect to receive adjuvant chemotherapy (2 courses of BEP), which will almost always prevent relapse. An alternate approach for patients willing to comply with monthly follow-up is surveillance, with chemotherapy deferred until relapse is noted. About 50% of these patients will be cured with surgery (as many as 75% have microscopic disease only). With careful follow-up, those destined to relapse can be treated promptly and at a time when they have small-volume tumors and an excellent prognosis if they go on to receive chemotherapy. Patients with clinical stage I nonseminomatous germ cell tumors may also undergo RPLND, although an acceptable alternative for these patients is surveillance. The advantages and the disadvantages of each approach are discussed. The overall risk of recurrence is about 30%, but there have been patient groups defined that may vary in risk from 10% to 15% up to 50% or more. Patients with advanced seminoma are treated with chemotherapy. When this procedure is used, outcomes are favorable and all patients are either in good- or intermediate-risk groups, according to the international classification system. Patients with small-volume stage II tumors are treated with radiotherapy. Radiation is also generally used for the treatment of clinical stage I patients, although surveillance is growing in prominence as a means to treat these patients. Late effects of treatment are also discussed in this article. Ejaculatory function can be preserved in most patients who have early stage tumors and who undergo RPLND and in some patients who undergo surgery after chemotherapy. The most troubling effect of chemotherapy is the development of etoposide-induced leukemia, a unique--and fortunately rare--clinical entity.

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.

Accuracy of clinical staging in non-seminomatous testicular cancer--a single centre experience of retroperitoneal lymph node dissection

The management of low stage non-seminomatous testicular cancer remains a controversial issue. Programs of surveillance or primary retroperitoneal lymph node dissection (RPLND) after orchiectomy show equally good survival rates. Current focus is therefore on reduction of toxicity or side effects of the treatment while maintaining maximal prognostic safety. The clinician's decision of therapy is based on clinical staging methods including computerized tomography, pulmonary x-rays and serum tumour marker levels. In this study, the accuracy of clinical staging was compared with histopathology in 64 patients with clinical stages (CS) I and IIa, operated upon with RPLND between 1980 and 1992. Lymph node metastases were histopathologically verified in 37% of CS I and in 47% of CS IIa tumours. Thus, the clinical staging was inaccurate in 37% in CS I and in 53% in CS IIa patients. No clear relationship was shown between the risk factors: vascular invasion and/or tumour marker levels and metastatic spread. The specificity of clinical staging in non seminomatous testicular cancer was low. RPLND, on the other hand, is a reliable method for assessment of metastatic spread and will minimise unnecessary use of chemotherapy. Modern techniques for lymphadenectomy have a very low rate of post-operative morbidity. Development of better non-invasive imaging techniques for detection of lymph node metastases is hoped for, in order to improve the information on tumour spread and make it possible to individualize therapy. Thus, unnecessary therapy and following side-effects can be avoided, improving the patient's quality of life during and after treatment.