NcXHF

STAGE I TESTICULAR GERM CELL CANCER
Group multicenter trial discussed previously had 15 recurrences
in 191 patients who were randomly assigned to undergo
RPLND (92% of patients achieved 2 years of relapsefree
survival), of which seven patients had disease
involvement in the retroperitoneal nodes. 10 Single, specialized
center experience suggests that careful staging and selection
for adjuvant chemotherapy can increase the proportion
of patients with stage II found to have low volume node disease
and achieve a very low recurrence. 13
RADIOTHERAPY
This has been a standard adjuvant approach in patients with
stage I seminoma, traditionally to a fıeld including both paraaortic
and ipsilateral pelvic lymph nodes. Many series reported
recurrence risk of less than 5%. More recently,
prospective, randomized trials have shown that reducing the
fıeld to just the para-aortic region 14 and reducing the dose to
only 20 Gy 15 did not reduce effıcacy. The disadvantage of RT
is that it is carcinogenic. For example, a multicenter U.K. and
Norwegian study of 2,692 patients with stage I seminoma
demonstrated a cancer Standardized Incidence Ratio of 1.53
when second testicular cancers were excluded, 16 with increased
risk mainly affecting cancers of abdominal organs.
This risk has led to the option of adjuvant RT for patients
with stage I seminoma being abandoned or reduced considerably
in some communities. 17-19
DISCUSSION
In most oncology centers, the primary management options
in 2015 for patients who have undergone an orchiectomy for
stage I testicular cancer are surveillance or adjuvant chemotherapy.
There are advocates in favor of surveillance for almost
all patients with stage I testicular cancer on the grounds
that it is safe in terms of ultimate cure rate and that it confınes
the potential toxicities of treatment to the minority of patients
whose disease has already formed subclinical metastases.
20 The arguments for adjuvant chemotherapy suggest that
the limited total drug doses in one treatment cycle are safer for
patients than the drug doses in a full treatment for metastatic
relapse. In addition, adjuvant chemotherapy has a particular indication
in patients with high risk features, in patients who are
unlikely to adhere to surveillance, and in patients with comorbidities
that might compromise a full course of treatment for
metastases. This leads to a so-called risk-adapted strategy, with
surveillance for patients at low risk and adjuvant chemotherapy
for patients at a high risk of developing metastasis, as promoted
particularly in the Spanish Germ Cell Cancer Group trials. 21
There is a strong argument to involve the individual patient in
the discussion of both approaches. 22
Disclosures of Potential Conflicts of Interest
Relationships are considered self-held and compensated unless otherwise noted. Relationships marked “L” indicate leadership positions. Relationships marked “I” are those held by an immediate
family member; those marked “B” are held by the author and an immediate family member. Institutional relationships are marked “Inst.” Relationships marked “U” are uncompensated.
Employment: None. Leadership Position: None. Stock or Other Ownership Interests: None. Honoraria: Alan Horwich, Astellas Pharma. Consulting or
Advisory Role: None. Speakers’ Bureau: None. Research Funding: None. Patents, Royalties, or Other Intellectual Property: None. Expert Testimony:
None. Travel, Accommodations, Expenses: Alan Horwich, Astellas Pharma. Other Relationships: None.
References
1. Powles TB, Bhardwa J, Shamash J, et al. The changing presentation of
germ cell tumours of the testis between 1983 and 2002. BJU Int. 2005;
95:1197-1200.
2. Rustin GJ, Mead GM, Stenning SP, et al. Randomized trial of two or fıve
computed tomography scans in the surveillance of patients with stage I
nonseminomatous germ cell tumors of the testis: Medical Research
Council Trial TE08, ISRCTN56475197-the National Cancer Research
Institute Testis Cancer Clinical Studies Group. J Clin Oncol. 2007;25:
1310-1315.
3. van As NJ, Gilbert DC, Money-Kyrle J, et al. Evidence-based pragmatic
guidelines for the follow-up of testicular cancer: optimising the detection
of relapse. Br J Cancer. 2008;98:1894-1902.
4. Groll RJ, Warde P, Jewett MA. A comprehensive systematic review of
testicular germ cell tumor surveillance. Crit Rev Oncol Hematol. 2007;
64:182-197.
5. Kollmannsberger C, Tandstad T, Bedard PL, et al. Patterns of relapse in
patients with clinical stage I testicular cancer managed with active surveillance.
J Clin Oncol. 2015;33:51-57.
6. Warde P, Specht L, Horwich A, et al. Prognostic factors for relapse in
stage I seminoma managed by surveillance: a pooled analysis. J Clin Oncol.
2002;20:4448-4452.
7. Tandstad T, Ståhl O, Håkansson U, et al. for SWENOTECA. One
course of adjuvant BEP in clinical stage I nonseminoma mature and
expanded results from the SWENOTECA group. Ann Oncol. 2014;
25:2167-2172.
8. Aparicio J, Maroto P, García del Muro X, et al. Prognostic factors for
relapse in stage I seminoma: a new nomogram derived from three consecutive,
risk-adapted studies from the Spanish Germ Cell Cancer
Group (SGCCG). Ann Oncol. 2014;25:2173-2178.
9. Cullen MH, Stenning SP, Parkinson MC, et al. Short-course adjuvant
chemotherapy in high-risk stage I nonseminomatous germ cell tumors
of the testis: a Medical Research Council report. J Clin Oncol. 1996;14:
1106-1113.
10. Albers P, Siener R, Krege S, et al. Randomized phase III trial comparing
retroperitoneal lymph node dissection with one course of bleomycin
and etoposide plus cisplatin chemotherapy in the adjuvant treatment of
asco.org/edbook | 2015 ASCO EDUCATIONAL BOOK
e251