Stage I seminoma of the testis. Adjuvant radiotherapy or surveillance?

Lately the role of radiotherapy in stage I seminoma of the testis has been questioned by some authors who reported on a "surveillance" strategy for these patients. Since 1980, 124 patients with seminoma of the testis have been referred to this institution; 97 of 116 patients analysed presented with stage I disease and 10 of these had elevated levels of beta HCG. A total of 64 patients were given radiotherapy after orchiectomy and 33 entered a surveillance protocol. After a median follow-up of 48 months, 3 patients in the surveillance group relapsed after 5, 13 and 49 months and 2 of the irradiated patients did so after 25 and 33 months. Elevation of beta HCG was not significant because none of these patients showed progression. A low rate of progression and excellent survival are associated with standard treatment (orchiectomy and radiotherapy) and good results have been achieved with chemotherapy in cases of relapse. A surveillance policy is not recommended in stage I seminoma because of its slower growth compared with non-seminomatous germ cell tumours (NSGCT), the absence of a specific tumour marker, the 10% risk of occult metastases and the 3-fold higher progression rate compared with irradiated patients. We suggest the use of a reduced dosage and radiation field.     

Therapeutical options for seminomas at clinical stage I-IIA/B

Seminomas represent the most common histological subgroup of all testicular germ cell tumors. About 75% of all seminomas present as clinical stage I disease at time of initial diagnosis and exhibit a long-term cure rate of 99%. Management strategies maintaining these high cure rates but minimizing the risks need are actively pursued. Currently, three treatment strategies are available for stage I seminomas: surveillance, radiotherapy and chemotherapy. Pathohistological prognostic factors allow an individualized risk-adapted therapeutic approach. Tumor size < or =4 cm and absence of rete testis invasion define a low-risk group with a recurrence rate of 12% being best managed by surveillance. Tumor size >4 cm and presence of rete testis invasion define a high-risk with a 35% risk of relapse, best managed by active therapy. Active treatment either consists of radiation of the ipsilateral paracaval or paraaortic lymph nodes with 20 Gy or of adjuvant chemotherapy with 2 cycles of carboplatin. It is currently unclear if 1 cycle carboplatin is as effective as 2 cycles; if this approach is performed follow-up has to be standardized and a compliance of both patient and physician are mandatory.     

Management of stage I testis cancer

OBJECTIVE: Over the last 5 years the management of stage I testis cancer has changed tremendously. This review focuses on the latest changes in diagnostics and treatment of clinical stage I non-seminomatous and seminomatous germ cell tumors. METHODS: A non-structured literature search (MEDLINE) was performed, including recently published papers (up to March 2006) on the subject. RESULTS: Organ-sparing surgery has become an accepted approach to treat malignant and nonmalignant tumours in a solitary testis. With certain precautions and adjuvant radiotherapy, this approach has proven to be as effective as orchidectomy. Prognostic factors strongly influence the decision for or against adjuvant treatment in seminoma and non-seminoma. With the help of a risk-adapted approach, about 50% of patients with clinical stage I testis cancer will favour close surveillance instead of immediate adjuvant treatment. Several well-conducted trials have helped to substantiate the management. Surgical staging by retroperitoneal lymph node dissection became an exception. Patients with non-seminoma with high risk for occult metastatic disease will favour adjuvant chemotherapy and in patients with seminoma radiotherapy with reduced dosage will be challenged by carboplatin monotherapy. CONCLUSION: With adequate diagnostics and treatment, 100% of patients with stage I testis cancer will survive. Future research will focus on quality control, adherence to guideline recommendations, and further reduction of treatment to diminish the risk of late sequalae for patients with adjuvant radiotherapy or chemotherapy.     

Abdominal relapse in stage 1 nonseminomatous germ cell tumours of the testis managed by surveillance or with adjuvant chemotherapy

OBJECTIVE: To assess the impact on patterns of recurrence of adjuvant chemotherapy in patients with stage 1 nonseminomatous germ cell tumours (NSGCT) of the testis, who have a high likelihood of relapse on surveillance if certain risk factors are identified in the orchidectomy specimen, and thus the theoretical need for retroperitoneal lymph node dissection (RPLND). PATIENTS AND METHODS: The incidence of abdominal relapse was recorded in 417 men presenting with stage 1 NSGCT over the past 18 years. Up to 1986, 161 men were managed by surveillance alone, and abdominal relapse occurred in 26. From 1986 onwards, men with positive risk factors in the orchidectomy specimen were offered two courses of chemotherapy; 60 accepted and one relapsed in the abdomen, and 196 underwent surveillance and 19 relapsed in the abdomen. RESULTS: Abdominal relapse was significantly reduced from 16% before 1986 to 8% afterward (P = 0.014). Mortality from testicular tumour or treatment toxicity remained low, at 0.6% before 1986 and 2.0% since then. CONCLUSION: The need for RPLND in stage 1 NSGCT remains highly doubtful.     

Clinical outcomes in patients with stage I non-seminomatous germ cell cancer

This study assesses the long-term outcomes in Han Chinese patients with clinical stage I non-seminomatous germ cell testicular cancer (CSI NSGCT) treated with surveillance, retroperitoneal lymph node dissection (RPLND) and adjuvant chemotherapy. We retrospectively evaluated 89 patients with a mean age of 26.5 years. After orchiectomy, 37 patients were treated with surveillance, 34 underwent RPLND and 18 were managed with chemotherapy. The overall survival rate, the recurrence-free survival rate and the risk factors were evaluated. The median follow-up length was 92 months (range: 6–149 months). Thirteen of the 89 patients (14.6%) had relapses, and one died by the evaluation date. The overall survival rate was 98.9%. The cumulative 4-year recurrence-free rates were 80.2%, 92.0% and 100% for the surveillance, RPLND and chemotherapy groups, respectively. The disease-free period tended to be briefer in patients with a history of cryptorchidism and those with stage Is. Therefore, surveillance, RPLND and adjuvant chemotherapy might be reliable strategies in compliant patients with CSI NSGCT. Surveillance should be recommended for patients with the lowest recurrence rate, especially those without lymphovascular invasion. This study might aid the establishment of a standard therapy for CSI NSGCT in China.     

Prognostic factors in patients with pathological stage I non-seminomatous testicular germ cell tumors and tumor recurrence during follow-up

Clinical staging in patients with stage I nonseminomatous germ cell tumors (NSGCTs) of the testis fails in 30% to correctly assess pathological stage since microscopic and small-volume retroperitoneal disease is not detectable on computed tomography of the abdomen. Patients staged by retroperitoneal lymph node dissection as pathological stage I incur a distant (chest or serological) tumor relapse rate of 7–15% during follow-up. Recently, we reported on new risk factors as predictors of pathological stage by flow cytometric DNA analysis in clinical stage I patients. These same methods were applied to a group of 14 pathological stage I patients who subsequently had either chest or serological recurrence. The findings in this group of patients were compared with those in a group of 47 pathological stage I patients who did not experience recurrence. In pathological stage I NSGCT patients with distant (chest or serological) tumor relapse, we found by histological evaluation and DNA analysis of the original orchiectomy specimen proliferative tumor activity to be significantly predictive of relapse. Much as proliferative activity of the primary tumor is predictive of retroperitoneal metastasis, it may be a predictor of recurrence in pathological stage I patients.     

Treating stage I nonseminomatous germ cell tumours with a single cycle of chemotherapy

OBJECTIVE: To estimate the rate of relapse in men with stage I nonseminomatous germ cell tumours (NSGCT) of the testis treated with one cycle of chemotherapy instead of the usual two cycles. PATIENTS AND METHODS: Between 1992 and 1996, 22 men with stage I NSGCT who had normalized tumour markers after orchidectomy and negative findings on computed tomography, and who were at moderate risk of relapse, were treated with one cycle of platinum-containing chemotherapy (bleomycin and etoposide with either cisplatin or carboplatin). RESULTS: At a median follow-up of 10.2 years, none of the patients have relapsed with malignant GCTs. CONCLUSION: The results after one cycle of chemotherapy are no worse than after two cycles. The present study needs to be replicated in a larger cohort of patients to define the relapse risk more accurately. This approach is soon to be tested in a large multicentre trial randomizing patients between one and two cycles.     

Is surveillance for stage 1 germ cell tumours of the testis appropriate outside a specialist centre?

OBJECTIVE: To assess the results of treatment for stage 1 germ cell tumours of the testis, outside a specialist centre. PATIENTS AND METHODS: From May 1984 until March 1996, 123 patients with stage 1 disease were treated at our institution. Sixty patients with seminoma and 31 with teratoma were treated with orchidectomy only and surveillance; 32 patients with stage 1 seminoma elected for orchidectomy and adjuvant radiotherapy. The mean ages were 40, 31 and 35 years, and the median follow-up 52, 47 and 49 months, respectively. RESULTS: There were no disease- or treatment-related deaths. However, 18 (30%) patients with seminoma treated by orchidectomy only relapsed (median time 8 months, range 3-19); 14 of these responded to radiotherapy, three to radiotherapy and chemotherapy for second relapses outside the irradiated fields, and one to chemotherapy initially, for large-volume relapse. Fifteen (48%) patients with teratoma relapsed (median time 3 months, range 1-12); all responded to 4-6 courses of bleomycin/etoposide/cisplatin chemotherapy. One patient had a second relapse and is currently disease-free 3 years after surgical excision of a lung metastasis. CONCLUSION: These results show that stage 1 testis tumours can be managed successfully in a district general hospital. However, we are concerned about the high relapse rates and are now attempting to identify patients at greater risk of recurrence, to consider adjuvant therapy in this group.     

Treatment of stage I seminoma: a 15-year review

PURPOSE: To review the treatment and outcomes in patients with stage I seminoma after orchidectomy. METHODS: A retrospective chart review of all patients with stage I seminoma referred for initial treatment during the last 15 years was performed. Initial treatment approaches and outcomes were analyzed. Comparisons were made between patients treated with adjuvant radiotherapy and those receiving no adjuvant therapy (surveillance group). RESULTS: A total of 150 patients with stage I seminoma was seen between 1989 and 2003. Median age at diagnosis was 37.5 years (range 19-79), with a median follow-up of 54 months (range 1-162). Of the patients, 71% were treated with adjuvant radiotherapy, and 29% were placed on a surveillance protocol. The 5-year relapse-free survival and overall survival for the entire group were 95% and 100%, respectively. The 5-year relapse-free survival for the adjuvant radiotherapy group was 100% compared with 79% for the surveillance group (P < 0.001). Of the 6 patients who had a relapse, 5 were salvaged with radiation, but 1 required chemotherapy as well. One patient who had a relapse is currently refusing treatment for recurrence. CONCLUSIONS: Our results confirm the excellent prognosis for patients with stage I seminoma and indicate that surveillance does not compromise survival. This result adds to the evidence that surveillance is a good option for many patients and also supports our current approach, which favors surveillance for most patients with stage I seminoma after orchidectomy who are willing to go on our surveillance protocol.     

Minimizing treatment without compromising cure with primary surveillance for clinical stage I embryonal predominant nonseminomatous testicular cancer: a population based analysis from British Columbia

PURPOSE: We evaluated the outcome of patients with embryonal carcinoma predominant (ECP) clinical stage (CS) I nonseminomatous testicular germ cell tumors (NSGCT) treated with primary surveillance or primary retroperitoneal lymph node dissection (RPLND). MATERIALS AND METHODS: This study was a retrospective evaluation of the pathology, use of chemotherapy, surgery and outcomes in all patients with CS I NSGCT who were diagnosed within the province of British Columbia between 1990 and 2000. RESULTS: A total of 205 patients were identified, of whom 107 (52%) had ECP disease. Of these patients 72 (67%) underwent primary surveillance, 32 (33%) underwent primary RPLND and 3 refused treatment. Median followup was 4 years (range 1 to 10). In the primary surveillance group 24 patients (33%) had relapse and all were treated initially with chemotherapy with 6 also requiring RPLND. The remaining 48 patients (67%) in the surveillance group were cured of disease with orchiectomy alone. In the primary RPLND group 18 patients (56%) had pathological stage I disease and 14 (44%) had pathological stage II disease. In the primary RPLND group 15 patients (46%) required chemotherapy with 11 (34%) receiving adjuvant chemotherapy and 4 receiving chemotherapy for post-RPLND relapse. No deaths from ECP testicular cancer occurred in either group. The 4-year chemotherapy-free survival rate was 65% in the surveillance group vs 50% in the RPLND group (p = 0.2). CONCLUSIONS: For appropriately selected patients with CS I ECP NSGCT, primary surveillance results in fewer therapeutic interventions compared to RPLND without compromising the probability of cure.     

Laparoscopic and open retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testis tumors

BACKGROUND AND PURPOSE: Laparoscopic retroperitoneal lymph node dissection (L-RPLND) has been reported as efficacious for staging of the retroperitoneum in patients with stage I nonseminomatous germ-cell testis tumors (NSGCT). However, reports are limited to a few centers, and this procedure has yet to be widely accepted as an alternative to open retroperitoneal lymph node dissection (O-RPLND). Thus, we compared our contemporary open and laparoscopic experience with RPLND. PATIENTS AND METHODS: A retrospective chart review identified 28 patients who underwent either open (N = 6) or laparoscopic (N = 22) RPLND for clinical stage I NSGCT since 2000. Each patient received the appropriate modified template dissection. Perioperative demographic data, histologic nodal status, and recurrence data were evaluated. The mean follow-up was similar in the two groups. RESULTS: The mean operative time was not significantly different (313 minutes for L-RPLND v 284 minutes for O-RPLND). However, L-RPLND did have a significantly shorter hospitalization (1.2 v 8.5 days). Significantly more lymph nodes were removed with O-LPLND than with L-RPLND (mean 33 v 17). There was a single recurrence outside the modified template after both L-RPLND and O-RPLND and one within-the-template recurrence in the O-RPLND group. CONCLUSIONS: The L-RPLND is associated with less blood loss and a shorter hospital stay than O-RPLND, whereas the lymph-node yield of O-RPLND is greater. However, during the critical early follow-up period, the oncologic effectiveness and morbidity of L-RPLND for clinical stage I NSGCT appears similar to that of O-RPLND.     

Surveillance Study for Clinical Stage I Testicular Seminomas and Nonseminomatous Germ Cell Tumors

Background: Optimal therapy for stage I testicular tumors is still controversial. This study evaluated the efficacy of a surveillance policy for patients with testicular stage I seminomas and nonseminomatous germ cell tumors (NSGCT).
Methods: From 1984 to 1996, 24 patients with stage I semi noma and 20 with stage I NSGCT were fol lowed after radical orchiectomy with tumor markers and imaging studies. All patients were followed for at least 2 years except for those who recurred within 2 years. Recurrent patients were treated with cisplatin-based chemotherapy.
Results: The median follow-up periods for seminoma and NSGCT patients were 41 and 54 months, respectively. Recurrences were detected in 2 seminoma (8.3%) and 10 NSGCT (50%) patients. Eleven of the 1 2 recurrent patients (92%) were detected within 2 years after orchiectomy. The seminoma patients both recurred in the retroperitoneal lymph nodes, while 70% of the NSGCT patients recurred in the lung and/or retroperitoneal lymph nodes. The recurrent seminoma patients were treated with chemotherapy and are alive without disease for 1 7 and 24 months after orchiectomy. One NSGCT patient died of cancer, but the other 9 recurrent NSGCT patients are alive without disease at 25 to 11 3 months after orchiectomy.
Conclusions: Surveillance alone is reliable for monitoring patients with stage I testicular seminoma and NSGCT. The majority of recurrences occurred within 2 years, necessitating intensive follow-up for 3 years. As the lung metastatic rates in NSGCT patients were high, a more accurate assessment for lung metastasis is desirable in these patients.     

Prognostic indicators for failure of surveillance management of stage I non-seminomatous germ cell tumours

Fifty-three patients presenting with non-seminomatous germ cell tumours (NSGCT) of the testis were examined. Particular interest was directed towards the association of several morphological features of the primary tumour with metastatic disease, either at presentation or later in the course of the tumour. It is apparent from this study that the presence of vascular invasion in the primary tumour, high T stage (advanced local disease) and the presence of choriocarcinoma are poor prognostic signs in NSGCT. In such tumours presenting as clinical stage I, surveillance management may not be appropriate because of the high rate of relapse.     

Testicular tumors in men with human immunodeficiency virus.

During a 2-year period 5 men positive for the human immunodeficiency virus (HIV) presented with 6 testis tumors among a total of 3,015 men seen at our hospital acquired immunodeficiency syndrome (AIDS) clinic. This testis tumor incidence of 0.2% is 57 times that of the United States average of 3.5 cases per 100,000 men. Two patients were only HIV positive and 3 others already had AIDS-related complex for 2 to 15 months at the time of tumor diagnosis. Tumor histology was mixed germ cell tumor in 4 patients, pure seminoma in 1 and Burkitt's lymphoma in 1. Patients underwent routine staging evaluations. Three patients had low stage mixed germ cell tumor (clinical stage 1 or 2A) and underwent retroperitoneal lymphadenectomy, which revealed pathological stage 1 or 2A disease in 1 and 2, respectively. These patients did not receive adjuvant chemotherapy. Two patients had advanced mixed germ cell tumor (clinical stage 2C) or Burkitt's lymphoma (clinical stage 4) and received combination chemotherapy from the onset. Outcome was evaluated with regard to progression of HIV disease and tumor status. The 2 patients who were only HIV positive remained so for 9 and 48 months. The 3 patients with AIDS-related complex had progression to AIDS within 1 to 9 months and 2 of these patients died 1 1/2 and 7 months after tumor diagnosis. All 3 patients with resected low stage disease had tumor recurrence within 1 to 9 months and were begun on platinum-based combination chemotherapy. The risk of false low clinical staging and early tumor progression may be higher in HIV positive men than in other testis tumor patients. Patient ability to tolerate chemotherapy and to obtain a satisfactory tumor response appeared to be primarily related to lack of progression of HIV disease to frank AIDS.     

Recurrence pattern and proposed surveillance protocol following post-chemotherapy retroperitoneal lymph node dissection

PURPOSE: We evaluated the recurrence pattern in patients with nonseminomatous germ cell tumors treated with post-chemotherapy retroperitoneal lymph node dissection and determined the optimal surveillance strategy in these patients. MATERIALS AND METHODS: Between 1980 and 2003, 236 patients with clinical stage IIA-III nonseminomatous germ cell tumors underwent post-chemotherapy retroperitoneal lymph node dissection. Patients with increased preoperative tumor markers (alpha-fetoprotein greater than 15 ng/ml and/or beta-human chorionic gonadotropin greater than 2.2 U/ml) were excluded from study resulting in 198 patients for analysis. We retrospectively reviewed medical records for pertinent clinical and treatment related outcomes. In our patient population recurrence developed in 45 (23%) patients and 22 (11%) died of disease at a median followup of 41 months (range 6 to 250) after retroperitoneal lymph node dissection. RESULTS: The clinical stage of testis cancer was IIA in 17, IIB in 49, IIC in 83 and III in 49 patients. Of the 45 patients with postoperative recurrence, 16 had concomitant multiple sites of recurrence with a total of 64 sites reported. Of the cases of recurrence 21 (46.7%) were in those of clinical stage III, 18 (40%) stage IIC and 6 (11.8%) stage IIB disease. The most frequent site of recurrence was the chest (32, 49%), followed by the abdomen (14, 22%), supraclavicular lymph nodes (8, 13%), brain (5, 8%) and other sites (5, 8%). CONCLUSIONS: Based on the recurrence pattern we propose stage specific surveillance guidelines for the followup of patients after post-chemotherapy retroperitoneal lymph node dissection. These guidelines help identify patients at high risk for disease progression and, thus, requiring more stringent postoperative followup.     

The role of (18)fluoro-2-deoxyglucose positron emission tomography in initial staging and re-staging after chemotherapy for testicular germ cell tumours

OBJECTIVE: To investigate the role of 18fluoro-2-deoxyglucose positron emission tomography (FDG-PET) in the initial staging of clinical stage I and II nonseminomatous germ cell tumours (NSGCTs) and in re-staging (non)seminomatous GCTs after chemotherapy. PATIENTS AND METHODS: FDG-PET studies were undertaken in 50 patients. FDG uptake was interpreted visually and when possible the standardized uptake value was determined. A FDG-PET scan was taken in five patients with clinical stage I and in seven with stage II NSGCT. The scans were validated by histology. Stage I patients underwent a retroperitoneal lymph node dissection because of vascular invasion in the primary tumour. Thirty-eight scans were taken after completing chemotherapy (28 NSGCTs and 10 seminomatous GCTs), and validated by histology or clinical follow-up. RESULTS: In stage I NSGCT, FDG-PET staging was equivalent to computed tomography (CT) staging. One small lesion, consisting of mature teratoma, was missed by both FDG-PET and CT. In stage II NSGCT, FDG-PET missed two lesions (mature teratoma and retroperitoneal mass with a small component of embryonal cell carcinoma) whereas CT correctly classified all. In 20 of 28 patients with NSGCT, histology was obtained after chemotherapy. In one of three patients with viable tumorous residual mass the FDG-PET scan was clearly positive; in four of 12 with mature teratoma and inflammation components retroperitoneally, the FDG-PET was also positive. In contrast, eight patients with solitary mature teratoma had a negative PET result. In four of five patients with necrosis after chemotherapy the PET result was correctly negative. All eight patients on surveillance had a negative PET scan and were free of disease at median (range) of 14 (8-18) months. Interestingly, of the 12 patients with a correct negative PET result, 11 had no mature teratoma in their primary tumour. Nine of 10 patients with SGCT were correctly staged. Two FDG-PET studies showed increased uptake; in one, a viable seminomatous mass was found and in the other there was inflammation in the residual mass. In all other patients the FDG-PET scan correctly predicted absence of viability in the residual mass. CONCLUSIONS: In primary staging, FDG-PET has no benefit over CT. In re-staging, a negative FDG-PET result predicts fibrotic residual mass in seminomatous GCT. Moreover, it could be useful to predict fibrotic residual mass in NSGCT in those patients with no teratoma component in their primary tumour.     

Outcome of different post‐orchiectomy management for stage I seminoma: Japanese multi‐institutional study including 425 patients

Objectives: To clarify the contemporary clinical outcome of stage I seminoma and to provide information on treatment options to patients. Methods: A retrospective analysis of 425 patients who underwent orchiectomy for stage I seminoma between 1985 and 2006 at 25 hospitals in Japan. Relapse‐free survival rates were calculated using the Kaplan–Meier method and clinicopathological factors associated with relapse were examined by univariate and multivariate analyses using the Cox proportional hazards model. Results: A total of 30 out of 425 patients had relapsed. Relapse‐free survival rates at 10 years were 79, 94 and 94% in the surveillance, chemotherapy and radiotherapy groups, respectively. Post‐orchiectomy management and rete testis invasion were identified as independent predictive factors associated with relapse. Rete testis invasion remained to be an independent predictive factor, even if the cases with relapses in the contralateral testis were censored. Only one patient, who relapsed after adjuvant radiotherapy, died of the disease. Overall survival at 10 years was 100, 100 and 99% in the surveillance, chemotherapy and radiotherapy groups, respectively. More than half of the patients were lost to follow up within 5 years. Conclusions: The outcome of Japanese patients with stage I seminoma is similar to previously published Western reports. Surveillance policy is becoming a popular option in Japan, although the relapse rate in patients opting for surveillance policy is higher than those opting for adjuvant chemotherapy or radiotherapy. Rete testis invasion is an independent predictive factor associated with relapse regardless of the post‐orchiectomy management. Long‐term follow up is mandatory for detection of late relapse.     

Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular tumors

Objectives. To assess retrospectively whether laparoscopic retroperitoneal lymph node dissection (RPLND) in patients with clinical Stage I nonseminomatous germ cell testicular tumor (NSGCT) provides useful pathologic staging information on which subsequent management can be based. Approximately 30% of patients with clinical Stage I NSGCT will have pathologic Stage II disease.Methods. A retrospective review of 29 patients with clinical Stage I NSGCT who underwent transperitoneal laparoscopic RPLND by a single surgeon was performed. Selection criteria included the presence of embryonal carcinoma in the primary tumor or vascular invasion. A modified left (n = 18) or right (n = 11) template was used.Results. Positive retroperitoneal nodes were detected in 12 (41%) of 29 patients. Ten of these patients received immediate adjuvant platinum-based chemotherapy, and 2 patients refused chemotherapy. The nodes were negative in 17 (59%) of 29 patients; all but 2 patients (one with recurrence in the chest, the other with biochemical recurrence) have undergone observation. No evidence of disease recurrence has been found in the retroperitoneum of any patient (follow-up range 1 to 65 months). Prospectively, the dissection was limited if grossly positive nodes were encountered; therefore, the total number of nodes removed was significantly different if the nodes were positive or negative (14 ± 2 and 25 ± 3, respectively; P <0.004). Two patients required an open conversion because of hemorrhage. Complications included lymphocele (n = 1) and flank compartment syndrome (n = 1).Conclusions. Laparoscopic RPLND is a feasible, minimally invasive surgical alternative to observation or open RPLND for Stage I NSGCT. Disease outcomes are favorable to date. Longer follow-up in a larger series is necessary to determine therapeutic efficacy.     

Long-term Results of Adjuvant Irradiation or Surveillance in Stage I Testicular Seminoma

Background : Excellent treatment results are obtained for stage I testicular seminoma treated with orchiectomy and prophylactic radiotherapy. In patients with stage I nonseminomatous testicular tumors, surveillance alone is successful, however, this treatment option for stage I testicular seminomas is controversial. There have been few reports of long-term follow-up of surveillance alone for patients with stage I testicular seminoma.
Methods : To assess the appropriateness of this treatment option, a retrospective survey of stage I testicular seminoma was undertaken. Twenty-seven patients who underwent prophylactic radiation therapy (RT group) and 41 patients followed only by surveillance (S group) after high orchiectomy were evaluated. Their follow-up consisted of frequent clinical examinations, abdominal CT scans, chest x-rays and serum tumor markers.
Results : In the RT group, with a median follow-up period of 15 years, 1 patient (3.6%) had a recurrence in the lung at 4 months after orchiectomy and died, but the remaining 26 are alive with no evidence of disease (NED). In the S group, with a median follow-up period of 7.3 years, 5 (12.2%) relapsed in the retroperitoneal lymph nodes, but all are alive with NED following chemotherapy. The remaining 36 are all alive without recurrence (follow-up period, 38 to 132 months). Although the relapse rate in the S group was relatively higher than in the RT group, there was no significant difference between the 2 groups.
Conclusion : If a frequent follow-up protocol is administered and followed by the patient, surveillance alone may be a recommended management for stage I testicular seminoma.     

Long-term followup results of 1 cycle of adjuvant bleomycin, etoposide, and cisplatin chemotherapy for high risk clinical Stage I nonseminomatous germ cell tumors of the testis Westermann DH, Schefer H, Thalmann GN, Karamitopoulou-Diamantis E, Fey MF, Studer UE, Department of Urology, University of Bern, Bern, Switzerland

PURPOSE: We evaluated the long-term outcome after 1 cycle of adjuvant modified bleomycin, etoposide, and cisplatin chemotherapy in patients who underwent orchiectomy for high risk clinical Stage I nonseminomatous germ cell tumor of the testis. MATERIALS AND METHODS: Between 1995 and 1999, a consecutive series of 44 patients underwent orchiectomy for clinical Stage I nonseminomatous germ cell tumor of the testis, followed by a single postoperative cycle of adjuvant modified bleomycin, etoposide, and cisplatin for vascular or lymphatic tumor invasion, and/or a predominance (50% or greater) of embryonal carcinoma. RESULTS: Four of the 44 patients were excluded from analysis. Of the patients, 35 had no evidence of disease at a median followup of 99 months (range 60-134). One patient with progression after 13 months showed complete remission after 3 cycles of salvage bleomycin, etoposide, and cisplatin chemotherapy but he died of pneumonia 4 weeks after the third course. Two patients underwent orchiectomy for contralateral testis cancer at 18 and 42 months, respectively, followed by an additional 3 cycles of adjuvant chemotherapy. They remained relapse-free for 4 and 92 months, respectively. The former patient was lost to follow-up after 4 months. Two other patients were disease-free at 10 and 31 months, respectively, and were lost to follow-up thereafter. Late side effects were tinnitus in 3 patients and involuntary childlessness in 3, of whom 2 had cryptorchidism of the contralateral testis. Nine patients fathered children. CONCLUSIONS: One cycle of bleomycin, etoposide, and cisplatin effectively decreases the risk of relapse in patients with high risk Stage I nonseminomatous germ cell tumor of the testis. It has minimal side effects and can be a valuable alternative to retroperitoneal lymph node dissection.