Evolution of the management of stage I nonseminomatous germ-cell tumors of the testis

Abstract

The sequence of treatment modalities for stage I nonseminomatous germ-cell cancer presented herein represents the evolution of treatment over the past three decades: from retroperitoneal lymphadenectomy or radiation therapy to surveillance to modified retroperitoneal lymphadenectomy or nerve-sparing retroperitoneal lymphadenectomy. Each new concept has prompted investigators to critically assess patient eligibility criteria and predictors of response and relapse. Primary predictors of treatment success have been local tumor stage (T status), the presence of vascular or lymphatic invasion, and primary tumor histology. These studies have also allowed critical review of the accuracy of radiologic staging, which, although markedly improved over the past decade, remains imperfect. With the advent of effective chemotherapy and improved patient salvage at relapse, these studies have allowed quality of life issues to become incorporated into management decisions. If there can be one conclusion concerning the management of stage I nonseminomatous germ-cell cancer, it must be that there is no one best treatment for all patients. Each treatment is associated with advantages and disadvantages. The treatment therefore should be individualized for each patient. As patients are evaluated, emphasis must be placed on the identification of relapse risk factors through meticulous pathologic review and accurate radiologic staging. Thus, the patients with clinical stage I disease and unfavorable prognostic factors (such as the presence of vascular invasion in the primary tumor, embryonal carcinoma, T2-T4 tumor) should be advised to undergo retroperitoneal lymphadenectomy; if the nodes are negative on frozen section, then modified retroperitoneal lymphadenectomy or nerve-sparing retroperitoneal lymphadenectomy should be performed; otherwise, bilateral retroperitoneal lymphadenectomy would provide the best chance of cure. Patients with stage I disease and favorable prognostic factors (such as T1 tumor, teratocarcinoma, absence of vascular invasion in the primary tumor) are suitable for either surveillance or modified or nerve-sparing retroperitoneal lymphadenectomy; these options should be thoroughly explained to the patient before any decision is made. Future efforts in this field may take a number of directions. As fertility remains a paramount issue to most patients, long-term studies will be necessary to investigate changes in semen characteristics and eventual paternity in patients followed on surveillance protocols or after either nerve-sparing or modified retroperitoneal lymphadenectomy. With continuing improvements in chemotherapy--improved efficacy with reduced toxicity--pathologic, radiographic, or serologic predictors of the site of eventual relapse will become of increasing importance. Indeed, if patients can be identified who are at a significant risk of distant relapse, an initial chemotherapy protocol may be warranted.(ABSTRACT TRUNCATED AT 400 WORDS)