Clinical stage I nonseminomatous testicular germ-cell tumors: surgery or watchful waiting, still an issue?

Abstract

The optimal management for clinical stage I nonseminomatous testicular germ-cell tumors is still a subject open to controversy. The main options of standard-care surveillance and primary nerve-sparing retroperitoneal lymph node dissection result in the same high cure rate (close to 100%). It is the purpose, here, to present a critical review of recent developments concerning primary therapy for clinical stage I nonseminomatous testicular germ-cell tumors and to identify potential new prognostic risk factors predicting occult metastatic retroperitoneal lymph node disease. In accordance with the primary goal to improve quality of life, to protect fertility and to reduce long-term toxicity in survivors of testicular cancer, the major advantage of surveillance protocols is that adjuvant therapy will be administered only to those patients who require therapy. This advantage has to be balanced against a constant psychological threat and a relapse rate of 20-25% necessitating extensive polychemotherapy. Primary nerve-sparing retroperitoneal lymph-node dissection has diagnostic and therapeutic capabilities in low-volume disease; as local relapses are extremely rare, an effective and cost-saving follow-up concentrating on pulmonary recurrences can be initiated. Nerve-sparing retroperitoneal lymph node dissection represents the initial approach for mature teratomas; patients with purely embryonal carcinoma have a high risk for systemic relapses and might be better served by primary chemotherapy. The advantages of nerve-sparing retroperitoneal lymph-node dissection have to be balanced against surgery-related complications, which develop in about 17% of the patients. With regard to prognostic risk factors, the percentages of embryonal carcinoma and vascular invasion remain the most significant predictors for lymph node metastases. Surveillance and primary nerve-sparing retroperitoneal lymph-node dissection result in the same high cure rate (approaching 100%). The advantages and disadvantages of both treatment modalities must be discussed extensively with the patient, and it will be basically his decision as to which therapeutic approach is chosen.