Surgery After Relapse in Stage I Nonseminomatous Testicular Cancer
Authors: Gedske Daugaard, Maria Gry Gundgaard, Mette Saksø Mortensen, Mads Agerbæk, Niels Vilstrup Holm, Mikael Rahbek Rørth, Hans von der Maase, Ib Jarle Christensen, Jakob Lauritsen
Journal: Journal of Clinical Oncology (2015)

In a planned editorial 1 attached to our article concerning surveillance for stage I nonseminomatous testicular cancer (CSI NSGCT), 2 de Wit highlights an unexpected high frequency of postchemotherapy surgery in patients with relapse.This is put forward as an argument for risk-adapted treatment with adjuvant chemotherapy for high-risk patients.It is stated that if surveillance remains the preferred treatment modality, intensified monitoring is suggested with computed tomography scans every 3 to 4 months during the first 2 years of follow-up.The main conclusion of our study is that surveillance in CSI NSGCT is a safe management option encompassing a more than 99% disease-specific 15-year survival.Assuming that adjuvant chemotherapy results in equivalent survival (this has not been demonstrated in studies as large and with follow-up as lengthy as in the present), the main focus of discussions between experts and patients should be the long-term consequences of treatment.Chemotherapy with bleomycin etoposide, and cisplatinum has been documented to be associated with increased risk of severe late effects. 3It is beyond matters of belief that adjuvant treatment to high-risk patients results in unnecessary exposure of at least 50% of patients to chemotherapy.Presently, we have no data comparing the consequences of adjuvant treatment with one or two cycles with three cycles in relapsing patients, and only meticulous long-term follow-up of the patients will provide this answer.We found that 26% of relapsing patients, equalling less than 8% of patients in total, were operated on for residual tumor masses Ն 1 cm.In eight patients (8%), malignant tissue was found; 49 patients (50%) had mature teratoma; 31 (32%) had necrosis/fibrosis; and in 10 patients, histology was unknown.Irrespective of surveillance or adjuvant treatment, patients with teratoma in their metastases will be candidates for surgery, as teratoma is not sensitive to chemotherapy and should be removed surgically.This means that at least half of the patients should have had an operation also in case of adjuvant chemotherapy.It is speculative to claim that fewer patients would have residual teratoma if treated with adjuvant chemotherapy.In the remaining 49 patients, status concerning vascular invasion (VI) was known in 22 patients.For these 22 patients, nine had VI and 13 had no VI.This implies that treating high-risk patients with adjuvant chemotherapy will not protect against the risk of having postchemotherapy surgery, and it is a misinterpretation of data if this should lead to a shift of preference toward early definitive treatment.With the present data, we do not find any rationale for an increase in the number of computed tomography scans compared with the number suggested in our study.Before starting risk adapted chemotherapy it is important to use validated risk factors.The use of vascular invasion as the only risk factor is problematic.As shown in the this study, VI alone without any of the other risk factors leads to a 5-year relapse rate of 18%.It is our hope that the presented risk factors can be tested in a prospective international validation study.Evidence-based, informed decision making is not possible before this process has been carried out.