Surveillance or adjuvant treatments in stage 1 testis germ-cell tumours

Abstract

All patients with stage 1 testicular germ-cell tumours (TGCT) can expect to be permanently cured with currently available management approaches. Orchidectomy alone cures 80% of pure seminomas and 70%-75% of nonseminomatous and combined seminoma plus nonseminomatous germ-cell tumours of the testis (NSGCTT). Currently there are well-validated criteria for estimating recurrence risk in NSGCTT. The presence of vascular invasion (VI+) in the testicular primary identifies a group with a recurrence risk approaching 50%. In VI-cases, the risk is ≤20%. Adjuvant chemotherapy with two cycles of bleomycin, etoposide, and cisplatin (BEP) is increasingly recommended in VI+ cases, and when offered is selected in place of surveillance by many VI- patients. In seminomatous germ-cell testicular tumours (SGCTT), there are no validated criteria for estimating recurrence risk. Concerns about second cancers complicating adjuvant radiotherapy are reducing its popularity and the absence of tumour markers, the need for frequent scans, long follow-up and evidence of poor compliance argue against surveillance. Single-dose carboplatin is well tolerated, cheap, reduces recurrence rates to <5% and also the risk of second primary TGCT. There remain concerns about long-term toxicity although evidence is accumulating to allay these. This article discusses the relevant issues affecting decision-making and choice in these intriguing, curable cancers.