Postsurgical surveillance sufficient for stage I nonseminoma germ cell cancer
Most men with stage I nonseminoma germ cell cancer who undergo radical orchiectomy can be followed with surveillance, according to results of a retrospective study conducted in Denmark.
“Danish national data show that approximately 70% of patients with germ cell cancer have clinical stage I disease at presentation. Of these, 40% have nonseminoma [germ cell cancer],” the researchers wrote. “Without treatment, a significant proportion of patients with stage I disease will relapse. These relapses can be treated when they appear, or adjuvant therapies can be applied immediately after orchiectomy.”
Researchers evaluated outcomes of 1,226 patients with stage I nonseminoma germ cell cancer who underwent surveillance between 1984 and 2007. All patients underwent an inguinal orchiectomy, followed by staging with tumor markers, abdominal CT, and chest X-ray or CT.
Researchers used the Kaplan-Meier method to approximate OS, disease-specific survival probabilities and risk of relapse. They calculated OS from date of orchiectomy until death by any cause. They defined disease-specific survival events as death from germ cell cancer or treatment-related death.
About one-third of patients (30.6%) experienced relapse within 5 years.
The combined presence of vascular invasion, along with embryonal carcinoma and rete testis invasion in the testicular primary, was associated with 50% risk for recurrence. Risk for relapse was 12% without those factors.
Eighty percent of relapses were identified within 1 year after orchiectomy. The majority of early relapses were detected by increase in tumor markers, whereas late relapses were detected by CT scans.
Median time to relapse was 5 months. Researchers observed relapses beyond 5 years in 0.5% of the whole cohort, or in 1.6% of all patients who relapsed. Almost all patients (99.1%) achieved 15-year disease-specific survival.
“A surveillance policy for patients with stage I nonseminoma germ cell cancer is a safe approach associated with an excellent cure rate and an overall low treatment burden despite a high relapse rate in a small group of patients,” the researchers wrote. “We recommend surveillance for patients with stage I NSGCC with immediate systemic treatment at relapse. Clearly defined risk factors for relapse are presented if an option of risk-adapted treatment is preferred.”
The results highlight the importance of informed decision-making in determining the benefit of definitive treatment over surveillance, Ronald de Wit, MD, PhD, of Erasmus Medical Center and Cancer Institute in Rotterdam, the Netherlands, wrote in an accompanying editorial.
“For those who maintain that surveillance is the preferred option, it becomes more critical than ever to detect recurrent disease at the earliest possible time to reduce the morbidity of the treatment that is needed for rendering patients disease free,” de Wit wrote. “In that regard, the goal of surveillance should no longer simply be to detect recurrences that are highly curable with chemotherapy, but also to reduce the need for postchemotherapy surgery by detecting small-volume relapses.”
Disclosure: The researchers report no relevant financial disclosures.