Review – Testis CancerManagement of Stage I Testis Cancer☆
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
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Cited by (35)
Current management of stage I testicular germ cell tumors in a French cancer institute. A practice analysis over the 10 past years
2019, Bulletin du CancerCitation Excerpt :Histologically, TGCTs are classified evenly between seminomatous germ cell tumors (SGCT) or non-seminomatous germ cell tumors (NSGCT) respectively in 55% and 45% of cases [2]. Near 70% of TGCTs are diagnosed precociously at stage I which lead to an overall survival rate close to 100% at 10 years regardless risk factor or adjuvants strategies employed after orchiectomy [3]. These treatments are most likely indicated in presence of clinical-histological risk factor such as the lympho-vascular invasion for NSGCT.
The management of testis cancer
2016, Surgery (United Kingdom)Citation Excerpt :The traditional approach of standard bilateral lymphadenectomy is associated with loss of ejaculatory function in most patients. By contrast, the use of ‘template’ based nerve sparing techniques utilizing knowledge relating to the course of ejaculatory nerves and the likely site of metastatic deposits has resulted in more than 75% of patients preserving ejaculatory function post operatively.8 The surgery required is major and there are significant complications even in expert centres (adhesion obstruction, wound infection, leg oedema etc).
Recommendations in Onco-Urology 2010: Testicular germ cell tumors
2010, Progres en UrologieLaparoscopic Retroperitoneal Lymph Node Dissection: Does It Still Have a Role in the Management of Clinical Stage I Nonseminomatous Testis Cancer? A European Perspective
2008, European UrologyCitation Excerpt :Further studies have to prove the therapeutic efficacy in stage IIA/pN+; however, the operation still remains challenging. Risk factors have been identified to define low-risk and high-risk group of patients with a risk of 13% and 64%, respectively [58]. Apart from the reduced rate and intervals of follow-up examination, L-RPLND does not offer any advantages for the low-risk group, but in the presence of vascular invasion, the morbidity of adjuvant CTx versus L-RPLND has to be compared.
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