0022-5347 /85/1:342-0427$02.00/0 VoL 134,
THE ,JOURNAL OF UROLOGY
Copyright (9 1985 by The Williams & Wilkins Co.
CHANGING CONCEPTS IN THE MANAGEMENT OF CLINICAL STAGE I NONSEMINOMATOUS TESTICULAR CANCER: SIGNIFICANCE OF PROGNOSTIC FACTORS Because of the dramatic progress in the management of nonseminomatous testicular cancer the ultimate goal of treatment in such patients should include 100 per cent survival, minimal complications, excellent quality of life and cost-benefit ratio. Historically, the treatment of patients with stage I nonseminomatous testicular cancer in the United States has been inguinal orchiectomy followed by retroperitoneal lymphadenectomy. With these procedures the primary and retroperitoneal metastases are removed and help is provided in the staging of the tumor, determining further therapy and forecasting the prognosis.' However, the advent of effective chemotherapeutic agents, and the availability of sensitive and specific tumor markers and other noninvasive modalities for staging and followup of these patients have raised some questions concerning the routine role of retroperitoneal lymphadenectomy in cases of stage I nonseminomatous testicular cancer.' Therefore, the current trends are to observe patients with clinical stage I nonseminomatous testicular cancer meticulously after orchiectomy. Several studies, including our program, have advocated carefully designed protocols for followup of patients with clinical stage I nonseminomatous testicular cancer. 2 •3 The results of these studies have been rather impressive but they require a careful protocol and meticulous patient compliance. These requirements are not always met in those centers and clinics that do not have a specific protocol for such patients. Therefore, the factors that lead to the recurrence of these tumors are important in the decision as to which patients with clinical stage I nonseminomatous testicular cancer should be observed with a minimal chance of recurrence. To define the predictors of recurrence, 60 patients with clinical stage I nonseminomatous testicular cancer undergoing pathological staging with adequate followup were studied prospectively. Followup for the 60 patients ranged from 3 to 5 years, with a median of 26 months. Ten of the 60 patients had either recurrence or staging errors. There were 7 patients with staging errors. Three patients had recurrences in the lung only and 1 patient had recurrence in the retroperitoneal area and lung. Patients in whom certain predictors of metastases can be found will require further treatment in addition to initial orchiectomy. The cell types usually associated with metastases were embryonal carcinoma with or without an element of choriocarcinoma. Of the 10 patients 8 (80 per cent) with clinical stage I disease had lymph node metastases at retroperitoneal lymphadenectomy or suffered lung metastases during followup and had vascular invasion into the primary tumor (p <0.001). Extension of the tumor into the epididymis and/or spermatic cord was seen in 6 patients (60 per cent p <0.01). The majority of the patients were referred to this institution after orchiectomy. Although all of the pathological slides were available for some patients, the size of the primary tumors was not detected before referral. Therefore, the actual impact of the tumor size on metastases cannot be determined with certainty. However, among those patients in whom the size of primary tumors could be correlated it appeared that tumor size also predicted future recurrence. The results indicated that embryonal carcinoma with or without choriocarcinoma has more tendency to metastasize (p <0.01). Other important predictors of recurrence are vascular and/or lymphatic invasions of primary tumors (p <0.001), extensions of the primary tumor into the spermatic cord (p <0.01) and, perhaps, the size of the primary tumors.
We previously reported on 22 patients with clinical stage I nonseminomatous testicular cancer undergoing surgical staging that included retroperitoneal lymph node sampling of the primary lymphatic involvement. If these lymph nodes were positive, retroperitoneal lymphadenectomy was done. A median of 26 months of followup (range 3 to 5 years) has not revealed any recurrence in the retroperitoneal area. 4 Based on these studies and others, we currently observe patients with stage I nonseminomatous testicular cancer who have had no predictors of metastases. Evaluation includes monthly physical examination, measurement of serum a-fetoprotein and human chorionic gonadotropin, and chest x-ray for 1 year, then every 3 months for 1 year and yearly thereafter. Other studies, such as abdominal computerized tomography and/or chest tomograms, may be required depending on the findings of the chest x-ray, serum a-fetoprotein and human chorionic gonadotropin, and physical examination. Patient compliance and the facilities of the center to deal with tumor recurrence also should be considered. We advocate that this type of study should be continued as a protocol, with careful attention to the prognostic factors and realizing the importance of close followup for detection of recurrences. Patients with one or more predictors of metastases undergo surgical staging with removal of landing zone lymph nodes, including the left renal pedicle, aortocaval lymph nodes and ipsilateral spermatic vessels, If there is no evidence of tumor on frozen section, the other lymph nodes and abdominal contents are examined meticulously before closure of the abdomen. However, if the lymphatics are positive for metastases on frozen section the patients undergo retroperitoneal lymphadenectomy.4 If patients have bulky stage II disease after retroperitoneal lymphadenectomy, we advocate adjuvant chemotherapy. In this study it appears that embryonal carcinoma with or without an element of choriocarcinoma is associated more frequently with metastases in patients with stage I nonseminomatous testicular cancer. Also, vascular invasion, extension to the spermatic cord and, perhaps, the size of the primary tumors are important predictors of recurrences in these patients. Nasser Javadpour Division of Urology University of Maryland Baltimore, Maryland
REFERENCES L Javadpour, N.: The National Cancer Institute experience with
testicular cancer. J. Urol., 120: 651, 1978. 2. Peckham, M.: Surveillance of clinical stage I nonseminomatous testicular cancer. Presented at the Second Conference on Germ Cell Tumors, Leeds, England, April 1985. 3. Johnson, D. E., Lo, R. K., von Eschenbach, A. C. and Swanson, D. A.: Surveillance alone for patients with clinical stage I nonseminomatous germ cell tumors of the testis: preliminary results. J. Urol., 131: 491, 1984. 4. Javadpour, N. and Moley, J.: Alternative to retroperitoneal lymphadenectomy with preservation of ejaculation and fertility in stage I nonseminomatous testicular cancer: a prospective study. Cancer, 55: 1604, 1985.