Elsevier

European Urology

Volume 51, Issue 1, January 2007, Pages 34-44
European Urology

Review – Testis Cancer
Management of Stage I Testis Cancer

https://doi.org/10.1016/j.eururo.2006.08.022Get rights and content

Abstract

Objective

Over the last 5 years the management of stage I testis cancer has changed tremendously. This review focuses on the latest changes in diagnostics and treatment of clinical stage I non-seminomatous and seminomatous germ cell tumors.

Methods

A non-structured literature search (MEDLINE) was performed, including recently published papers (up to March 2006) on the subject.

Results

Organ-sparing surgery has become an accepted approach to treat malignant and nonmalignant tumours in a solitary testis. With certain precautions and adjuvant radiotherapy, this approach has proven to be as effective as orchidectomy. Prognostic factors strongly influence the decision for or against adjuvant treatment in seminoma and non-seminoma. With the help of a risk-adapted approach, about 50% of patients with clinical stage I testis cancer will favour close surveillance instead of immediate adjuvant treatment. Several well-conducted trials have helped to substantiate the management. Surgical staging by retroperitoneal lymph node dissection became an exception. Patients with non-seminoma with high risk for occult metastatic disease will favour adjuvant chemotherapy and in patients with seminoma radiotherapy with reduced dosage will be challenged by carboplatin monotherapy.

Conclusion

With adequate diagnostics and treatment, 100% of patients with stage I testis cancer will survive. Future research will focus on quality control, adherence to guideline recommendations, and further reduction of treatment to diminish the risk of late sequalae for patients with adjuvant radiotherapy or chemotherapy.

Introduction

Testicular germ-cell tumours (TGCTs) represent the most frequent solid tumours in young men, with an incidence peak between the ages of 17 and 35 years. According to regional cancer registries in Europe, about 90% of patients present with low-stage disease (TNM stages I-IIB). Most of the patients with testis cancer (61–78%) have clinical stage I disease confined to the testis with normalised markers after orchidectomy [1], [2]. About half the patients are diagnosed with seminoma and non-seminomatous histology, respectively. Patients with clinical stage I testis cancer are expected to be cured in 100% of cases. Treatment options after orchidectomy have changed over the last two decades and regional differences of adjuvant treatment throughout Europe have been minimised after the implementation of guidelines-based treatment recommendations [3]. This review will focus on (1) the modern treatment of the primary tumour including organ-sparing surgery, (2) the research on prognostic factors predicting those patients who will relapse with clinical stage I, and (3) the current treatment recommendations in seminoma and non-seminoma after publication of several large randomised trials.

Section snippets

Treatment of the primary tumour and organ-sparing surgery

Standard treatment of a testicular cancer with a normal contralateral testis is orchidectomy via an inguinal approach. This allows for an exact histopathologic diagnosis and in true stage I patients orchidectomy is the only necessary treatment for the patient.

According to the current European guidelines, the patient should be informed about the possibility of a contralateral biopsy and this should be recommended for patients with risk factors for a testicular intraepithelial neoplasia (TIN)

Staging

The clinical staging of the non-seminomatous germ cell tumours (NSGSTs) should be performed at the earliest convenience (if possible before orchidectomy). It includes serum tumor markers (α–fetoprotein [AFP], human chorionic gonadotropin, and lactate dehydrogenase), computed tomography [CT] staging of the chest and abdomen, and ultrasound of the contralateral testis. After orchidectomy, markers should normalise although the AFP normalisation may take some weeks (half-time 6 d). With normalised

Observation studies and prognostic factors

In the group of patients with clinical stage I seminoma, observation studies have shown that about 16% of patients are at risk for recurrent disease (Table 2). The median time to relapse is 12–15 mo with 96% of relapses occuring in the retroperitoneum or inguinal region.

In a multivariate analysis of several retrospective observation studies a tumour size >4 cm and rete testis invasion remained of adverse prognostic value and were suggested as defining a high-risk group for relapse [68]. If both

References (74)

  • G.M. Duchesne et al.

    Orchidectomy alone for stage I seminoma of the testis

    Cancer

    (1990)
  • P. Warde et al.

    Prognostic factors for relapse in stage I testicular seminoma treated with surveillance

    J Urol

    (1997)
  • S.F. Hain et al.

    Fluorodeoxyglucose PET in the initial staging of germ cell tumours

    Eur J Nucl Med

    (2000)
  • J. Pont et al.

    Adjuvant chemotherapy for high-risk clinical stage I nonseminomatous testicular germ cell cancer: long-term results of a prospective trial

    J Clin Oncol

    (1996)
  • P. Albers et al.

    Risk factors for relapse in clinical stage I non-seminomatous testicular germ cell tumors: results of the German Testicular Cancer Study Group Trial

    J Clin Oncol

    (2003)
  • R.J. Amato et al.

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

    Urology

    (2004)
  • C. Chevreau et al.

    Long-term efficacy of two cycles of BEP regimen in high-risk stage I nonseminomatous testicular germ cell tumors with embryonal carcinoma and/or vascular invasion

    Eur Urol

    (2004)
  • H. Sagstuen et al.

    Blood pressure and body mass index in long-term survivors of testicular cancer

    J Clin Oncol

    (2005)
  • M. Boyer et al.

    Toxicity of treatment of germ cell tumors

    Semin Oncol

    (1992)
  • S. Krege et al.

    Phase II study: adjuvant single-agent carboplatin therapy for clinical stage I seminoma

    Eur Urol

    (1997)
  • J.R. Germa-LLuch

    Adjuvant treatment for stage I germ-cell testicular tumours: preliminary experience of the Spanish Germ-Cell Cancer Group

  • S.D. Fossa et al.

    Optimal planning target volume for stage I testicular seminoma: a Medical Research Council randomized trial

    J Clin Oncol

    (1999)
  • T.B. Powles et al.

    The changing presentation of germ cell tumours of the testis between 1983 and 2002

    BJU Int

    (2005)
  • D.J. Sonneveld et al.

    The changing distribution of stage in nonseminomatous testicular germ cell tumours from 1997 to 1996

    BJU Int

    (1999)
  • H.J. Schmoll et al.

    European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

    Ann Oncol

    (2004)
  • P. Albers et al.

    Guidelines on testicular cancer

    Eur Urol

    (2005)
  • S.J. Harland et al.

    Intratubular germ cell neoplasia of contralateral testis in testicular cancer: defining high risk group

    J Urol

    (1998)
  • K.P. Dieckmann et al.

    Prevalence of contralateral testicular intraepithelial neoplasia in patients with testicular germ cell neoplasm

    J Clin Oncol

    (1996)
  • A. Elert et al.

    Accuracy of frozen section examination of testicular tumors of uncertain origin

    Eur Urol

    (2002)
  • A. Heidenreich et al.

    Organ sparing surgery for malignant germ cell tumors of the testis

    J Urol

    (2001)
  • A. Heidenreich et al.

    Management of bilateral testicular germ cell tumours—experience of the German Testicular Cancer Study Group (GTCSG)

    Eur Urol Suppl

    (2006)
  • J.F. Sturgeon et al.

    Surveillance after orchidectomy for patients with clinical stage I nonseminomatous testis tumors

    J Clin Oncol

    (1992)
  • G. Read et al.

    Medical Research Council prospective study of surveillance for stage I testicular teratoma. Medical Research Council Testicular Tumors Working Party

    J Clin Oncol

    (1992)
  • M.E. Gels et al.

    Detection of recurrence in patients with clinical stage I nonseminomatous testicular germ cell tumors and consequences for further follow-up: a single-center 10-year experience

    J Clin Oncol

    (1995)
  • P.C. Sogani et al.

    Clinical stage I testis cancer: long-term outcome of patients on surveillance [see comments]

    J Urol

    (1998)
  • S. Sharir et al.

    Progression detection of stage I nonseminomatous testis cancer on surveillance: implications for the followup protocol

    J Urol

    (1999)
  • R.T. Oliver et al.

    Long-term follow-up of Anglian Germ Cell Cancer Group surveillance versus patients with stage 1 nonseminoma treated with adjuvant chemotherapy

    Urology

    (2004)
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