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STAGE I TESTICULAR GERM CELL CANCER
The Role of Surveillance versus Adjuvant Treatment in Stage I
Germ Cell Tumors: Outcomes and Challenges
Alan Horwich, MBBS, MRCP, FRCR, PhD
OVERVIEW
Germ cell cancers of the testis arise in young adults, and, if identified in stage I, have an excellent prognosis. Thus, we should minimize
management-related toxicities. Surveillance (observation) following orchiectomy can avoid further treatment; however, patients who
experience relapse receive more treatment than what would have been used during initial adjuvant therapy. For the individual patient,
it is important to be aware of their particular risk of relapse, the treatment they would receive for the treatment of relapse and the
alternative adjuvant approaches. For seminoma, the risk of relapse during surveillance is 15% to 20%; the size of the primary tumor
and the presence of rete testis invasion are prognostic factors. Most relapses occur within 3 years; however, approximately 10% occur
more than 5 years after orchiectomy. The alternative adjuvant strategies are either one cycle of carboplatin or radiotherapy (RT), which
reduce recurrence risk to less than 5%. The cure rate is around 99%, regardless of which management option is implemented. For
stage I nonseminoma, the risk of relapse during surveillance in unselected series is 26% to 30%. Lymphovascular invasion and the
amount of embryonal carcinoma are risk factors. Most relapses occur within the first year after orchiectomy, and relapse after 3 years
is rare. Ninety percent of relapse patterns are classified as “good prognosis,” and cure rates are 99%. The alternatives to surveillance
include adjuvant strategies such as one cycle of adjuvant bleomycin/etoposide/cisplatin (BEP) chemotherapy; however, evidence is
emerging that a single cycle is effective. There is controversy whether to offer surveillance for all patients or to offer adjuvant
chemotherapy to select patients.
Germ cell cancers of the testis are defıned as stage I when
radiologic investigations show no evidence of metastasis.
These generally comprise of CT scans of the thorax and
abdomen, although the pelvis should also be included in patients
with previous inguinal or scrotal surgery. Serum tumor
markers elevated prior to orchiectomy should fall with an appropriate
half-life (less than 5 days for alpha-fetoprotein and
less than 2 days for human chorionic gonadotropin) after resection
of the primary tumor. Men with normal radiology
but persisting elevated blood tumor markers are regarded as
having metastases and will not be considered further in this
manuscript. Despite an increase in the sensitivity of radiologic
staging tests, there appears to be an increase over recent
decades in the proportion of patients with germ cell cancer in
stage I, 1 with approximately 80% of seminomas and 60% of
nonseminomas presenting in this stage.
A number of management policies have been followed postorchiectomy,
and all are associated now with very high cure
rates (around 99%). The shared aim of these policies is to address
patients in stage I who actually have subclinical metastasis.
These policies include surveillance, adjuvant chemotherapy,
retroperitoneal lymph node dissection (RPLND), and RT.
SURVEILLANCE
This management policy involves regular monitoring of
patients postorchiectomy to detect any development of clinically
overt metastases at a stage in which the disease would
still be highly curable. Initially, there was anxiety about allowing
subclinical disease to progress, and consequently, surveillance
was rather intensive. There are few prospective
studies, but a Medical Research Council trial that randomly
assigned 414 patients who were undergoing surveillance for
stage I nonseminomas to receive fıve scans at months 3, 6, 9,
12, and 24, or two scans at months 3 and 12 reported similar
outcomes. 2 The Royal Marsden schedule for the surveillance
of patients with nonseminoma involves monthly tumor
markers and chest radiographs for the fırst year, chest radiographs
every 3 months for the second year, and chest radiographs
every 4 months in the third year, as well as CT scans of
the abdomen at 3, 12, and 24 months. However, a number of
guidelines recommend fewer assessments without clear
detriment. Similarly, there are few prospective seminoma
studies; an ongoing U.K. trial is comparing CT scan schedules
and MRI versus CT imaging. The Royal Marsden schedule
has clinic assessments every 3 months in the fırst and
From the Department of Clinical Oncology, Institute of Cancer Research and Royal Marsden Hospital, London, United Kingdom.
Disclosures of potential conflicts of interest are found at the end of this article.
Corresponding author: Alan Horwich, MBBS, MRCP, FRCR, PhD, Department of Clinical Oncology, Royal Marsden NHS Trust, Downs Rd., Sutton, Surrey, SM2 5PT, United Kingdom; email:
alan.horwich@icr.ac.uk.
© 2015 by American Society of Clinical Oncology.
asco.org/edbook | 2015 ASCO EDUCATIONAL BOOK
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