Skip to main content
SpringerLink
Log in

Management of patients with low-stage nonseminomatous germ cell testicular cancer

  • Published:
Current Treatment Options in Oncology Aims and scope Submit manuscript

Opinion statement

Management options for patients with clinical stage (CS) I nonseminomatous germ cell testicular cancer (NSGCT) include surveillance, retroperitoneal lymph node dissection (RPLND), or two cycles of bleomycin-etoposide-cisplatin (BEPx2) chemotherapy. The optimal management of these patients is controversial, as cure rates of 97% or greater are reported with each of these treatment modalities. Patients without evidence of lymphovascular invasion, a predominant component of embryonal carcinoma, or advanced pathologic (p) T stage (pT2 or greater) are at low risk for occult metastases and are optimal candidates for surveillance. Compliance with diagnostic testing and imaging is essential for a successful surveillance strategy to detect and treat metastases at an early stage. For patients who are not candidates for surveillance, RPLND offers several advantages over chemotherapy. RPLND alone is curative in 50% to 80% of CS I patients with pathologic stage (PS) II, and an estimated 75% of CS I patients avoid chemotherapy (as adjuvant therapy or for treatment of relapse). Virtually all patients are cured following two cycles of adjuvant chemotherapy for PS II disease, which is reserved for patients with high-volume (PN2-3) retroperitoneal disease. The poor outcome of patients with late retroperitoneal recurrence from unresected, chemorefractory germ cell testicular cancer indicates that RPLND is a vital component to the long-term cure of patients with NSGCT. Approximately 20% to 30% of patients with PS II disease have retroperitoneal teratoma (which is chemoresistant), and an estimated 5% of PS II patients have chemoresistant viable cancer following BEPx2 as primary therapy. When RPLND is omitted, these patients are at risk for late recurrence with potentially lethal consequences. Patients who relapse after RPLND are “chemotherapy-naïve” and cured in virtually all cases with good-risk chemotherapy regimens. When nerve-sparing techniques are employed to preserve ejaculation, RPLND is also associated with a more favorable long-term toxicity profile compared with chemotherapy. In the absence of conclusive evidence from a randomized trial, we believe RPLND is the treatment of choice for patients with CS I NSGCT who are not candidates for surveillance, as it offers the greatest likelihood of longterm cure with considerably less morbidity than primary chemotherapy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. Sheinfeld J, McKiernan J, Bosl GJ, eds: Surgery of testicular tumors. In Campbell’s Urology, edn 8. Edited by Walsh PC, Retik AB, Vaughn ED, Wein AJ, eds. Philadelphia: WB Saunders; 2002: 2920–2944.

    Google Scholar 

  2. Greene FL, Page DL, Fleming ID, et al, eds: In AJCC Cancer Staging Manual, edn 6. New York: Springer Verlag; 2002: 131–144.

    Google Scholar 

  3. Stephenson AJ, Bosl GJ, Bajorin DF, et al: Retroperitoneal lymph node dissection for low-stage testicular cancers patients with embryonal carcinoma predominance and/or lymphovascular invasion. J Urol 2005, 174: 557–560. Pathologic staging, chemotherapy requirements, and outcome of retroperitoneal lymph node dissection for “high-risk” patients with low-stage nonseminoma.

    Article  PubMed  Google Scholar 

  4. Stephenson AJ, Bosl GJ, Motzer RJ, et al: Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: impact of patient selection factors on outcome. J Clin Oncol 2005, 23: 2781–2788. Pathologic staging and outcome of retroperitoneal lymph node dissection for patients with low-stage nonseminoma including multivariable analysis of pretreatment parameters that predict for progression.

    Article  PubMed  Google Scholar 

  5. Richie JP: Clinical stage 1 testicular cancer: the role of modified retroperitoneal lymphadenectomy. J Urol 1990, 144: 1160–1163.

    PubMed  CAS  Google Scholar 

  6. Nicolai N, Miceli R, Artusi R, et al.: A simple model for predicting nodal metastasis in patients with clinical stage I nonseminomatous germ cell testicular tumors undergoing retroperitoneal lymph node dissection only. J Urol 2004, 171: 172–176.

    Article  PubMed  Google Scholar 

  7. Hermans BP, Sweeney CJ, Foster RS, et al: Risk of systemic metastases in clinical stage I nonseminoma germ cell testis tumor managed by retroperitoneal lymph node dissection. J Urol 2000, 163: 1721–1724.

    Article  PubMed  CAS  Google Scholar 

  8. Donohue JP, Thornhill JA, Foster RS, et al: Retroperitoneal lymphadenectomy for clinical stage A testis cancer (1965 to 1989): modifications of technique and impact on ejaculation. J Urol 1993, 149: 237–243.

    PubMed  CAS  Google Scholar 

  9. Daugaard G, Petersen PM, Rorth M: Surveillance in stage I testicular cancer [discussion 83–85]. APMIS 2003, 111: 76–83.

    Article  PubMed  Google Scholar 

  10. Sogani PC, Perrotti M, Herr HW, et al: Clinical stage I testis cancer: long-term outcome of patients on surveillance. J Urol 1998, 159: 855–858.

    Article  PubMed  CAS  Google Scholar 

  11. Pizzocaro G, Zanoni F, Salvioni R,et al: Difficulties of a surveillance study omitting retroperitoneal lymphadenectomy in clinical stage I nonseminomatous germ cell tumors of the testis. J Urol 1987,138: 1393–1396.

    PubMed  CAS  Google Scholar 

  12. Alexandre J, Fizazi K, Mahe C, et al: Stage I non-seminomatous germ-cell tumours of the testis: identification of a subgroup of patients with a very low risk of relapse. Eur J Cancer 2001, 37: 576–582.

    Article  PubMed  CAS  Google Scholar 

  13. Gels ME, Hoekstra HJ, Sleijfer DT, et al: Detection of recurrence in patients with clinical stage I nonseminomatous testicular germ cell tumors and consequences for further follow-up: a single-center 10-year experience. J Clin Oncol 1995, 13: 1188–1194.

    PubMed  CAS  Google Scholar 

  14. Sturgeon JF, Jewett MA, Alison RE, et al: Surveillance after orchidectomy for patients with clinical stage I nonseminomatous testis tumors. J Clin Oncol 1992, 10: 564–568.

    PubMed  CAS  Google Scholar 

  15. Read G, Stenning SP, Cullen MH, et al: Medical Research Council prospective study of surveillance for stage I testicular teratoma. Medical Research Council Testicular Tumors Working Party. J Clin Oncol 1992, 10: 1762–1768.

    PubMed  CAS  Google Scholar 

  16. Hao D, Seidel J, Brant R, Alexander F, Ernst DS, Summers N, et al: Compliance of clinical stage I nonseminomatous germ cell tumor patients with surveillance. J Urol 1998, 160: 768–771.

    Article  PubMed  CAS  Google Scholar 

  17. Freedman LS, Parkinson MC, Jones WG, et al: Histopathology in the prediction of relapse of patients with stage I testicular teratoma treated by orchidectomy alone. Lancet 1987, 2: 294–298.

    Article  PubMed  CAS  Google Scholar 

  18. Amato RJ, Ro JY, Ayala AG, Swanson DA: Risk-adapted treatment for patients with clinical stage I nonseminomatous germ cell tumor of the testis [discussion 148–149]. Urology 2004, 63: 144–148.

    Article  PubMed  Google Scholar 

  19. Bohlen D, Borner M, Sonntag RW, et al: Long-term results following adjuvant chemotherapy in patients with clinical stage I testicular nonseminomatous malignant germ cell tumors with high risk factors. J Urol 1999, 161: 1148–1152.

    Article  PubMed  CAS  Google Scholar 

  20. Cullen MH, Stenning SP, Parkinson MC, et al.: Shortcourse adjuvant chemotherapy in high-risk stage I nonseminomatous germ cell tumors of the testis: a Medical Research Council report. J Clin Oncol 1996, 14: 1106–1113.

    PubMed  CAS  Google Scholar 

  21. Oliver RT, Ong J, Shamash J, et al: Long-term follow-up of Anglian Germ Cell Cancer Group surveillance versus patients with Stage 1 nonseminoma treated with adjuvant chemotherapy. Urology 2004, 63: 556–561.

    Article  PubMed  CAS  Google Scholar 

  22. Pont J, Albrecht W, Postner G, et al: Adjuvant chemotherapy for high-risk clinical stage I nonseminomatous testicular germ cell cancer: long-term results of a prospective trial. J Clin Oncol 1996, 14: 441–448.

    PubMed  CAS  Google Scholar 

  23. Sheinfeld J: Nonseminomatous germ cell tumors of the testis: current concepts and controversies. Urology 1994, 44: 2–14.

    Article  PubMed  CAS  Google Scholar 

  24. Donohue JP, Zachary JM, Maynard BR: Distribution of nodal metastases in nonseminomatous testis cancer. J Urol 1982, 128: 315–320.

    PubMed  CAS  Google Scholar 

  25. Fernandez EB, Moul JW, Foley JP, et al: Retroperitoneal imaging with third and fourth generation computed axial tomography in clinical stage I nonseminomatous germ cell tumors. Urology 1994, 44: 548–552.

    Article  PubMed  CAS  Google Scholar 

  26. Albers P, Siener R, Kliesch S, et al: Risk factors for relapse in clinical stage I nonseminomatous testicular germ cell tumors: results of the German Testicular Cancer Study Group Trial. J Clin Oncol 2003, 21: 1505–1512.

    Article  PubMed  Google Scholar 

  27. Heidenreich A, Sesterhenn IA, Mostofi FK, Moul JW: Prognostic risk factors that identify patients with clinical stage I nonseminomatous germ cell tumors at low risk and high risk for metastasis. Cancer 1998, 83: 1002–1011.

    Article  PubMed  CAS  Google Scholar 

  28. Bredael JJ, Vugrin D, Whitmore WF, Jr: Autopsy findings in 154 patients with germ cell tumors of the testis. Cancer 1982, 50: 548–551.

    Article  PubMed  CAS  Google Scholar 

  29. Foster RS, Baniel J, Leibovitch I, et al: Teratoma in the orchiectomy specimen and volume of metastasis are predictors of retroperitoneal teratoma in low stage nonseminomatous testis cancer. J Urol 1996, 155: 1943–1945.

    Article  PubMed  CAS  Google Scholar 

  30. Sheinfeld J, Motzer RJ, Rabbani F, et al: Incidence and clinical outcome of patients with teratoma in the retroperitoneum following primary retroperitoneal lymph node dissection for clinical stages I and IIA nonseminomatous germ cell tumors. J Urol 2003, 170: 1159–1162.

    Article  PubMed  Google Scholar 

  31. Logothetis CJ, Samuels ML, Trindade A, Johnson DE: The growing teratoma syndrome. Cancer 1982, 50: 1629–1635.

    Article  PubMed  CAS  Google Scholar 

  32. Motzer RJ, Amsterdam A, Prieto V, et al.: Teratoma with malignant transformation: diverse malignant histologies arising in men with germ cell tumors. J Urol 1998, 159: 133–138.

    Article  PubMed  CAS  Google Scholar 

  33. Sheinfeld J: Late recurrence of testicular cancer. AUA News 2001, 6: 12–14.

    Google Scholar 

  34. Baniel J, Foster RS, Gonin R, et al: Late relapse of testicular cancer. J Clin Oncol 1995, 13: 1170–1176.

    PubMed  CAS  Google Scholar 

  35. George DW, Foster RS, Hromas RA, et al.: Update on late relapse of germ cell tumor: a clinical and molecular analysis. J Clin Oncol 2003, 21: 113–122.

    Article  PubMed  Google Scholar 

  36. Sheinfeld J: Risks of the uncontrolled retroperitoneum. Ann Surg Oncol 2003, 10: 100–101.

    Article  PubMed  Google Scholar 

  37. Stephenson AJ, Bosl GJ, Bajorin DF, et al.: Primary retroperitoneal lymph node dissection (P-RPLND) versus induction chemotherapy (IC) for the management of clinical stage (CS) IIA and IIB nonseminomatous germ cell testicular cancer (NSGCT) [abstract]. J Urol 2005, 173(4 Suppl): 196.

    Google Scholar 

  38. Swanson DA, von Eschenbach AC, Babaian RJ, et al.: Is retroperitoneal lymph node dissection (RPLND) alone optimal or sufficient therapy for clinical stage I nonseminomatous germ cell testicular tumors (NSGCTT) at high risk for relapse? J Urol 1998, 158: 179A.

    Google Scholar 

  39. Williams SD, Stablein DM, Einhorn LH, et al: Immediate adjuvant chemotherapy versus observation with treatment at relapse in pathological stage II testicular cancer. N Engl J Med 1987, 317: 1433–1438.

    Article  PubMed  CAS  Google Scholar 

  40. Donohue JP, Thornhill JA, Foster RS, et al: Clinical stage B non-seminomatous germ cell testis cancer: the Indiana University experience (1965-1989) using routine primary retroperitoneal lymph node dissection. Eur J Cancer 1995, 31A: 1599–1604.

    Article  PubMed  CAS  Google Scholar 

  41. Vogelzang NJ, Fraley EE, Lange PH, et al.: Stage II non-seminomatous testicular cancer: a 10-year experience. J Clin Oncol 1983, 1: 171–178.

    PubMed  CAS  Google Scholar 

  42. Socinski MA, Garnick MB, Stomper PC, et al.: Stage II non-seminomatous germ cell tumors of the testis: an analysis of treatment options in patients with low volume retroperitoneal disease. J Urol 1988, 140: 1437–1441.

    PubMed  CAS  Google Scholar 

  43. Javadpour N, Young JD, Jr: Prognostic factors in nonseminomatous testicular cancer. J Urol 1986,135: 497–499.

    PubMed  CAS  Google Scholar 

  44. Pizzocaro G, Monfardini S: No adjuvant chemotherapy in selected patients with pathologic stage II nonseminomatous germ cell tumors of the testis. J Urol 1984, 131: 677–680.

    PubMed  CAS  Google Scholar 

  45. Kondagunta GV, Sheinfeld J, Mazumdar M, et al: Relapse-free and overall survival in patients with pathologic stage II nonseminomatous germ cell cancer treated with etoposide and cisplatin adjuvant chemotherapy. J Clin Oncol 2004, 22: 464–467. Outcome following adjuvant chemotherapy for pathologic stage II disease. Toxicity following two cycles of cisplatin-based chemotherapy.

    Article  PubMed  CAS  Google Scholar 

  46. Baniel J, Foster RS, Rowland RG, et al: Complications of primary retroperitoneal lymph node dissection. J Urol 1994, 152: 424–427.

    PubMed  CAS  Google Scholar 

  47. McLeod DG, Weiss RB, Stablein DM, et al: Staging relationships and outcome in early stage testicular cancer: a report from the Testicular Cancer Intergroup Study [discussion 1182–1183]. J Urol 1991, 145: 1178–1183.

    PubMed  CAS  Google Scholar 

  48. Sheinfeld J: Complications of retroperitoneal lymph node dissection. AUA News 2002, 7: 10–14.

    Google Scholar 

  49. Donohue JP, Foster RS: Retroperitoneal lymphadenectomy in staging and treatment. The development of nerve-sparing techniques. Urol Clin North Am 1998, 25: 461–468.

    Article  PubMed  CAS  Google Scholar 

  50. Jewett MA, Kong YS, Goldberg SD, et al: Retroperitoneal lymphadenectomy for testis tumor with nerve sparing for ejaculation. J Urol 1988, 139: 1220–1224.

    PubMed  CAS  Google Scholar 

  51. Jewett MA: Nerve-sparing technique for retroperitoneal lymphadenectomy in testis cancer. Urol Clin North Am 1990, 17: 449–456.

    PubMed  CAS  Google Scholar 

  52. Bhayani SB, Ong A, Oh WK, et al: Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a longterm update. Urology 2003, 62: 324–327.

    Article  PubMed  Google Scholar 

  53. Janetschek G, Hobisch A, Peschel R,et al: Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular carcinoma: longterm outcome. J Urol 2000, 163: 1793–1796.

    Article  PubMed  CAS  Google Scholar 

  54. Nelson JB, Chen RN, Bishoff JT, et al: Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular tumors. Urology 1999, 54: 1064–1067.

    Article  PubMed  CAS  Google Scholar 

  55. Janetschek G: Laparoscopic retroperitoneal lymph node dissection. Urol Clin North Am 2001, 28: 107–114.

    PubMed  CAS  Google Scholar 

  56. Steiner H, Peschel R, Janetschek G, et al: Long-term results of laparoscopic retroperitoneal lymph node dissection: a single-center 10-year experience. Urology 2004, 63: 550–555.

    Article  PubMed  Google Scholar 

  57. Peschel R, Gettman MT, Neururer R, et al: Laparoscopic retroperitoneal lymph node dissection: description of the nerve-sparing technique [discussion 343]. Urology 2002, 60: 339–343.

    Article  PubMed  Google Scholar 

  58. Bajorin DF, Sarosdy MF, Pfister DG, et al: Randomized trial of etoposide and cisplatin versus etoposide and carboplatin in patients with good-risk germ cell tumors: a multiinstitutional study. J Clin Oncol 1993, 11: 598–606.

    PubMed  CAS  Google Scholar 

  59. Howard GC, Clarke K, Elia MH, et al: A Scottish national audit of current patterns of management for patients with testicular non-seminomatous germ-cell tumours. The Scottish Radiological Society and the Scottish Committee of the Royal College of Radiologists. Br J Cancer 1995, 72: 1303–1306.

    PubMed  CAS  Google Scholar 

  60. Leibovitch L, Foster RS, Kopecky KK, Donohue JP: Improved accuracy of computerized tomography based clinical staging in low stage nonseminomatous germ cell cancer using size criteria of retroperitoneal lymph nodes.J Urol 1995, 154: 1759–1763.

    Article  PubMed  CAS  Google Scholar 

  61. Hilton S, Herr HW, Teitcher JB, et al: CT detection of retroperitoneal lymph node metastases in patients with clinical stage I testicular nonseminomatous germ cell cancer: assessment of size and distribution criteria. AJR Am J Roentgenol 1997, 169: 521–525.

    PubMed  CAS  Google Scholar 

  62. Behnia M, Foster R, Einhorn LH, et al.: Adjuvant bleomycin, etoposide and cisplatin in pathological stage II non-seminomatous testicular cancer the Indiana University experience. Eur J Cancer 2000, 36: 472–475.

    Article  PubMed  CAS  Google Scholar 

  63. Kollmannsberger C, Kuzcyk M, Mayer F, et al.: Late toxicity following curative treatment of testicular cancer. Semin Surg Oncol 1999, 17: 275–281.

    Article  PubMed  CAS  Google Scholar 

  64. Boyer M, Raghavan D: Toxicity of treatment of germ cell tumors. Semin Oncol 1992, 19: 128–142.

    PubMed  CAS  Google Scholar 

  65. Meinardi MT, Gietema JA, van der Graaf WT, et al.: Cardiovascular morbidity in long-term survivors of metastatic testicular cancer. J Clin Oncol 2000, 18: 1725–1732.

    PubMed  CAS  Google Scholar 

  66. Bajorin DF, Motzer RJ, Rodriguez E, et al.: Acute non-lymphocytic leukemia in germ cell tumor patients treated with etoposide-containing chemotherapy. J Natl Cancer Inst 1993, 85: 60–62.

    Article  PubMed  CAS  Google Scholar 

  67. Huddart RA, Norman A, Shahidi M, et al: Cardiovascular disease as a long-term complication of treatment for testicular cancer. J Clin Oncol 2003, 21: 1513–1523.

    Article  PubMed  CAS  Google Scholar 

  68. Nichols CR, Roth BJ, Williams SD, et al.: No evidence of acute cardiovascular complications of chemotherapy for testicular cancer: an analysis of the Testicular Cancer Intergroup Study. J Clin Oncol 1992, 10: 760–765.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, 10021, New York, NY, USA

    Andrew J. Stephenson MD & Joel Sheinfeld MD

Authors
  1. Andrew J. Stephenson MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joel Sheinfeld MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Stephenson, A.J., Sheinfeld, J. Management of patients with low-stage nonseminomatous germ cell testicular cancer. Curr. Treat. Options in Oncol. 6, 367–377 (2005). https://doi.org/10.1007/s11864-005-0040-z

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11864-005-0040-z

Keywords

Search

Navigation