Risk-Adapted Management of Clinical Stage I Nonseminomatous Testicular Germ Cell Tumours

Abstract

Introduction and objectives Optimal management for clinical stage I nonseminomatous testicular germ cell tumours (NSGCTs) is still controversial. The main options for standard care surveillance, primary chemotherapy, and nerve-sparing retroperitoneal lymph node dissection (nsRPLND) result in the same high cure rate of close to 100%. It is the purpose to critically review recent developments concerning primary therapy of clinical stage I NSGCT and to identify potential new prognostic risk factors predicting occult metastatic retroperitoneal lymph node disease and enabling an individualized risk-adapted therapeutic approach. Methods Analysis of published full-length papers that were identified with Medline and Cancerlit from January 1987 to January 2006. Paper was structured according the recommendations of the European Germ Cell Cancer Consensus Group (EGCCCG). Results In accordance with the primary goal to improve quality of life, protect fertility, and reduce long-term toxicity in survivors of testis 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 and residual tumor resection in 30%. Surveillance is recommended as the treatment of choice for low-risk tumours defined by absence of vascular invasion, <50% embryonal carcinoma, and MIB-1 score <70%. Primary nsRPLND has diagnostic and therapeutic capabilities in low-volume disease associated with preservation of fertility in 95% of the patients; the 5-yr progression-free survival even in pathologic stage IIA disease is 90% without chemotherapy. Because local relapses are extremely rare an effective and cost-saving follow-up concentrating on pulmonary recurrences can be initiated. nsRPLND represents the initial approach to pure mature teratomas and predominantly teratomatous primaries; furthermore, it represents a therapeutic option for those who are not amenable to chemotherapy or surveillance. Advantages of nsRPLND have to be balanced against surgery-related complications developing in about 17% of the patients. Primary chemotherapy is recommended for high-risk germ cell tumours defined by presence of vascular invasion, >50% embryonal carcinoma, and MIB-1 score >70%; however, the predictive accuracy of these markers is only 60% resulting in a high rate of overtreatment. An advantage of primary chemotherapy is the absence of surgical morbidity; disadvantages are short- and long-term toxicity, lower cure rate of relapses, and potential affect on fertility. Conclusions Surveillance, primary chemotherapy, and primary nsRPLND result in the same high cure rate approaching 100%. Evidence-based recommendations with regard to the potentially best treatment are available but still advantages and disadvantages of all treatment modalities have to be discussed extensively with the patient.