Management of stage I nonseminomatous germ cell tumors
- Timothy D Gilligan, MD
Timothy D Gilligan, MD
- Associate Professor of Medicine
- Cleveland Clinic Lerner College of Medicine
- Vice-Chair for Education
- Cleveland Clinic Taussig Cancer Institute
- Director of Coaching, Center for Excellence in Healthcare Communication
- Cleveland Clinic
- Philip W Kantoff, MD
Philip W Kantoff, MD
- Section Editor — Testicular Cancer
- Chairman of Medicine
- Memorial Sloan Kettering Cancer Center
Testicular cancers, the majority of which are germ cell tumors (GCTs), are one of the most curable solid neoplasms, with a five-year survival rate of over 95 percent. The incidence of testicular cancer accounts worldwide is less than 10 per 100,000 men ; in the United States, there are fewer than 400 deaths each year .
Testicular GCTs are more sensitive to systemic chemotherapy than most adult solid tumors. As a result, chemotherapy is the standard treatment for men with advanced seminoma or nonseminomatous GCTs (NSGCTs) and for those with persistently elevated serum tumor markers following orchiectomy. The success of chemotherapy in advanced disease has led to its use in selected men with stage I and II disease.
The management of men with stage I NSGCT following orchiectomy, including the choice between adjuvant chemotherapy, retroperitoneal lymph node dissection (RPLND), and active surveillance, will be reviewed here. The management of men with stage II NSGCT and a general overview of the management of testicular GCTs are presented separately. (See "Management of stage II nonseminomatous germ cell tumors" and "Overview of the treatment of testicular germ cell tumors".)
With only rare exceptions (eg, men who present with widely disseminated disease requiring emergent treatment), men with testicular cancer undergo a radical inguinal orchiectomy for diagnosis and initial treatment. If radiographic imaging studies show no evidence of regional or distant metastases and serum tumor markers are normal after orchiectomy, patients are defined as having clinical stage I nonseminomatous germ cell tumor (NSGCT) (table 1 and table 2). (See "Overview of the treatment of testicular germ cell tumors" and "Radical inguinal orchiectomy for testicular germ cell tumors", section on 'Surgical treatment of the testis' and "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors", section on 'CT scan'.)
The majority (75 percent) of clinical stage I NSGCTs are cured with orchiectomy alone and do not require further treatment. However, it is difficult to identify which patients with stage I NSGCT are at highest risk for recurrence and thus have the most to gain from adjuvant treatment. While treatment immediately following orchiectomy can reduce the risk of relapse, it represents overtreatment for most patients and can result in both short- and long-term complications. In addition, although the risk of recurrence is approximately 25 percent for men undergoing surveillance, treatment at the time of recurrence is almost always curative [3,4]. Long-term, disease-specific survival exceeds 99 percent. (See "Approach to the care of long-term testicular cancer survivors".)
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- GENERAL PRINCIPLES
- RISK STRATIFICATION
- TREATMENT APPROACH
- Low-risk disease
- - SWENOTECA
- - British Columbia Cancer Agency and the Oregon Testis Cancer Program
- - Other data
- High-risk disease
- - Active surveillance
- British Columbia Cancer Agency and the Oregon Testis Cancer Program
- Princess Margaret Hospital
- Other data
- - Adjuvant chemotherapy
- German Testicular Cancer Study Group
- Other data
- One versus two cycles
- - Retroperitoneal lymph node dissection
- SUMMARY AND RECOMMENDATIONS