Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Management of stage I nonseminomatous germ cell tumors

Timothy D Gilligan, MD
Philip W Kantoff, MD
Section Editor
William K Oh, MD
Deputy Editor
Michael E Ross, MD


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 [1]; in the United States, there are approximately 400 deaths each year [2].

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 germ cell tumors (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".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 08, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Huyghe E, Matsuda T, Thonneau P. Increasing incidence of testicular cancer worldwide: a review. J Urol 2003; 170:5.
  2. Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin 2017; 67:7.
  3. Kollmannsberger C, Moore C, Chi KN, et al. Non-risk-adapted surveillance for patients with stage I nonseminomatous testicular germ-cell tumors: diminishing treatment-related morbidity while maintaining efficacy. Ann Oncol 2010; 21:1296.
  4. Sturgeon JF, Moore MJ, Kakiashvili DM, et al. Non-risk-adapted surveillance in clinical stage I nonseminomatous germ cell tumors: the Princess Margaret Hospital's experience. Eur Urol 2011; 59:556.
  5. Klepp O, Flodgren P, Maartman-Moe H, et al. Early clinical stages (CS1, CS1Mk+ and CS2A) of non-seminomatous testis cancer. Value of pre- and post-orchiectomy serum tumor marker information in prediction of retroperitoneal lymph node metastases. Swedish-Norwegian Testicular Cancer Project (SWENOTECA). Ann Oncol 1990; 1:281.
  6. Stephenson AJ, Sheinfeld J. Management of patients with low-stage nonseminomatous germ cell testicular cancer. Curr Treat Options Oncol 2005; 6:367.
  7. Pectasides D, Pectasides E, Constantinidou A, Aravantinos G. Current management of stage I testicular non-seminomatous germ cell tumours. Crit Rev Oncol Hematol 2009; 70:114.
  8. Hermans BP, Sweeney CJ, Foster RS, et al. Risk of systemic metastases in clinical stage I nonseminoma germ cell testis tumor managed by retroperitoneal lymph node dissection. J Urol 2000; 163:1721.
  9. Pohar KS, Rabbani F, Bosl GJ, et al. Results of retroperitoneal lymph node dissection for clinical stage I and II pure embryonal carcinoma of the testis. J Urol 2003; 170:1155.
  10. Tandstad T, Dahl O, Cohn-Cedermark G, et al. Risk-adapted treatment in clinical stage I nonseminomatous germ cell testicular cancer: the SWENOTECA management program. J Clin Oncol 2009; 27:2122.
  11. Dearnaley DP, Fossa SD, Kaye SB, et al. Adjuvant bleomycin, vincristine and cisplatin (BOP) for high-risk stage I non-seminomatous germ cell tumours: a prospective trial (MRC TE17). Br J Cancer 2005; 92:2107.
  12. Kollmannsberger C, Tandstad T, Bedard PL, et al. Patterns of relapse in patients with clinical stage I testicular cancer managed with active surveillance. J Clin Oncol 2015; 33:51.
  13. Daugaard G, Gundgaard MG, Mortensen MS, et al. Surveillance for stage I nonseminoma testicular cancer: outcomes and long-term follow-up in a population-based cohort. J Clin Oncol 2014; 32:3817.
  14. Heidenreich A, Sesterhenn IA, Mostofi FK, Moul JW. Prognostic risk factors that identify patients with clinical stage I nonseminomatous germ cell tumors at low risk and high risk for metastasis. Cancer 1998; 83:1002.
  15. Sweeney CJ, Hermans BP, Heilman DK, et al. Results and outcome of retroperitoneal lymph node dissection for clinical stage I embryonal carcinoma--predominant testis cancer. J Clin Oncol 2000; 18:358.
  16. Freedman LS, Parkinson MC, Jones WG, et al. Histopathology in the prediction of relapse of patients with stage I testicular teratoma treated by orchidectomy alone. Lancet 1987; 2:294.
  17. Read G, Stenning SP, Cullen MH, 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; 10:1762.
  18. Klepp O, Olsson AM, Henrikson H, et al. Prognostic factors in clinical stage I nonseminomatous germ cell tumors of the testis: multivariate analysis of a prospective multicenter study. Swedish-Norwegian Testicular Cancer Group. J Clin Oncol 1990; 8:509.
  19. Tandstad T, Cohn-Cedermark G, Dahl O, et al. Long-term follow-up after risk-adapted treatment in clinical stage 1 (CS1) nonseminomatous germ-cell testicular cancer (NSGCT) implementing adjuvant CVB chemotherapy. A SWENOTECA study. Ann Oncol 2010; 21:1858.
  20. Albers P, Siener R, Krege S, et al. Randomized phase III trial comparing retroperitoneal lymph node dissection with one course of bleomycin and etoposide plus cisplatin chemotherapy in the adjuvant treatment of clinical stage I Nonseminomatous testicular germ cell tumors: AUO trial AH 01/94 by the German Testicular Cancer Study Group. J Clin Oncol 2008; 26:2966.
  21. Pont J, Albrecht W, Postner G, 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; 14:441.
  22. Cullen MH, Stenning SP, Parkinson MC, et al. Short-course adjuvant chemotherapy in high-risk stage I nonseminomatous germ cell tumors of the testis: a Medical Research Council report. J Clin Oncol 1996; 14:1106.
  23. Böhlen D, Borner M, Sonntag RW, et al. Long-term results following adjuvant chemotherapy in patients with clinical stage I testicular nonseminomatous malignant germ cell tumors with high risk factors. J Urol 1999; 161:1148.
  24. Oliver RT, Ong J, Shamash J, 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; 63:556.
  25. Oliver RT, Raja MA, Ong J, Gallagher CJ. Pilot study to evaluate impact of a policy of adjuvant chemotherapy for high risk stage 1 malignant teratoma on overall relapse rate of stage 1 cancer patients. J Urol 1992; 148:1453.
  26. Abratt RP, Pontin AR, Barnes RD, Reddi BV. Adjuvant chemotherapy for stage I non-seminomatous testicular cancer. S Afr Med J 1994; 84:605.
  27. Ondrus D, Goncalves F, Kausitz J, et al. The value of prognostic factors in the management of stage I nonseminomatous germ cell testicular tumors (NSGCTT). Neoplasma 1996; 43:195.
  28. Chevreau C, Soulie M, Rischmann P, et al. Adjuvant chemotherapy in high risk stage I non-seminomatous germ cell tumors (abstract). Proc Am Soc Clin Oncol 1997; 16:320a.
  29. Amato RJ, Ro JY, Ayala AG, Swanson DA. Risk-adapted treatment for patients with clinical stage I nonseminomatous germ cell tumor of the testis. Urology 2004; 63:144.
  30. Böhlen D, Burkhard FC, Mills R, et al. Fertility and sexual function following orchiectomy and 2 cycles of chemotherapy for stage I high risk nonseminomatous germ cell cancer. J Urol 2001; 165:441.
  31. Huddart RA, Joffe JK, White JD, et al. A single-arm trial evaluating one cycle of BEP as adjuvant chemotherapy in high-risk, stage 1 non-seminomatous or combined germ cell tumors of the testis (NSGCTT). J Clin Oncol 2017; 35:abstract 400.
  32. Hendry WF, Norman A, Nicholls J, et al. Abdominal relapse in stage 1 nonseminomatous germ cell tumours of the testis managed by surveillance or with adjuvant chemotherapy. BJU Int 2000; 86:89.
  33. Mourey L, Flechon A, Droz JP, Chevreau C. Cohort study of surveillance (S) and adjuvant chemotherapy (CT) in high risk stage I non seminomatous germ cell testicular tumors (NSGCTT I). Proc Am Soc Clin Oncol 2003; 22:389 (abstr 1562).
  34. Pont J, De Santis M, Albrecht W. Risk-adapted management for clinical stage I nonseminomatous germ cell cancer of the testis (NSGCT I) by regarding vascular invasion (VI): A-17 year experience from the Vienna Testicular Tumor Study Group. Proceedings of the American Society of Clinical Oncology 2003; 22:388.