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Wood et al.

Figure 2: Schema for Management of Stage I Non-Seminoma
times of the included studies varied, all had sufficient fol-
NONSEMINOMA CS I
Low and High Risk low-up that almost all recurrences that would occur among
these patients were included. Across the 8 studies, 23 recur-
rences were reported, corresponding to an overall estimat-
Preferred Option Adjuvant Therapy Chosen
ed recurrence rate of 3.8% (95% CI, 2.6% to 5.5%; p =
0.42; I2=2.6%). For patients treated with BEP or cisplatin,
vinblastine, and bleomycin (PVB), the estimated recurrence
RPLND +/– Adjuvant
Surveillance Adjuvant Chemotherapy
Chemotherapy rates were 3.9% (95% CI, 1.6% to 9%), 3.9% (95% CI,
2.1% to 7%), and 7.2% (95% CI, 2.1% to 22.1%) for 1, 2,
and 3 cycles of adjuvant chemotherapy, respectively. Two
RELAPSE
recurrences with 2 cycles of BEP or PVB and 1 with 3 cycles
of BEP were pure mature teratoma. In the randomized trial
by Albers and colleagues, one course BEP versus RPLND,
Treatment According 65
To IGCCC Critera the two-year recurrence-free survival was 99.46%. The
results of the studies are summarized in Table 7. 65,71,74-81
Fig 2. Schema for the management of stage I nonseminoma.
Consensus recommendations
salvage treatment. The survival outcomes are summarized
in Table 5. 13,45-63 The presence of microscopic vascular or Patients should be informed of all treatment options, includ-
lymphatic invasion in the primary tumour is the most impor- ing the potential benefits and side effects of each treatment.
tant factor predicting relapse and the presence or absence In a patient willing and able to adhere to a surveillance
of this factor has been used to divide patients: those with program, for all risk groups, surveillance should be con-
high-risk disease (a third of the cases) who have about a sidered as the management option of choice (Fig 2).
50% risk of relapse, and those with low-risk disease who Some experts involved in the development of these rec-
have about a 15% to 20% risk of relapse. 45 ommendations suggested that RPLND may be a useful option
for patients at high risk of relapse. It was agreed that there
Retroperiteonal lymph node dissection is currently not enough evidence from prospective trials to
support or refute this position. Patients who undergo RPLND
Two non-randomized studies of adjuvant RPLND in the should have their surgery performed by surgeons who are
management of stage I NSGCT were identified in a recent experienced with the procedure. Otherwise, RPLND should
systematic review of the literature. 39,48,64 Across these stud- be offered in the context of a clinical trial.
ies, 344 patients were followed for a median time ranging For patients who prefer immediate treatment or who are
from 21 to 40 months, and a total of 41 recurrences were unsuitable for primary surveillance, adjuvant chemotherapy
found. There was 1 death from testicular cancer and 1 other with 2 cycles of BEP is recommended, although RPLND
death from unrelated causes. In addition, Albers and col- remains an option.
leagues recently reported the results of a randomized clin-
ical trial (RCT) comparing 1 course of BEP versus RPLND 4. Stage IIA/IIB testicular nonseminoma
in 382 patients with CS I RPLND (all risk groups). 65 In the
173 patients who received RPLND, 18.5% had stage II dis- The cure rate for CS IIA and IIB nonseminoma is close to
ease at surgery and these patients were given 2 courses of 98%. Three treatment options have been used in the past:
BEP. In those patients treated with adjuvant chemothera- primary RPLND alone, primary RPLND with adjuvant
py, no relapses were observed. In patients managed with chemotherapy and primary chemotherapy followed by resid-
RPLND alone, 13 recurrences were observed, 7 of which ual tumour resection. Primary RPLND alone has been demon-
occurred in the retroperitoneum. Outcomes from published strated in high relapse rates with 30% for patients with stage
studies are shown in Table 6. 48,64-70 IIA and 50% for patients with stage IIB disease. 82-85 Primary
RPLND followed by adjuvant chemotherapy with two cycles
Adjuvant chemotherapy of BEP exposes all patients to two different treatment modali-
ties including surgery-related complications, such as retro-
One RCT and 7 non-randomized studies with 10 treatment grade ejaculation. Primary chemotherapy with three cycles
arms (total 873 evaluable patients) were identified in a recent of BEP or, if contraindications for bleomycin, 4 cycles of etopo-
meta-analysis. 39,48,65,71-75 Because the RCT compared adju- side and cisplatin (EP) induce a complete remission in 83%
vant chemotherapy to RPLND, only the chemotherapy arm to 91% of patients with clinical stage IIA and in 61% to 87%
was included in the meta-analysis. Although the follow-up of patients with clinical stage IIB. 86,87 Most of these patients

E26 CUAJ • April 2010 • Volume 4, Issue 2