Management of Clinical Stage I (CSI) Disease in Testicular Cancer
Though imaging does not give any hint to metastases, clinical stage I testis cancer patients might harbor micrometastases within the retroperitoneal lymph nodes. For this reason it was standard to offer adjuvant treatment at least to patients with a high risk for occult metastases. In seminoma a tumor size >4 cm and a rete testis infiltration were identified as risk factors; in nonseminoma it was vascular invasion. High-risk seminoma patients received adjuvant radiation of the paraaortal/paracaval region. Later, one course of carboplatinum became the favored option as application was short and with few side effects. Radiotherapy also became unattractive after reports about an increase of secondary malignancies in the long term. Recent data showed a decrease of recurrences (15–20% in case of high risk and 2–3% in case of low risk) even without adjuvant treatment, while recent publications about carboplatinum report about a 9–10% relapse rate in the long term. Therefore actually it is discussed to recommend surveillance for all clinical stage I seminoma patients.
Risk-adapted treatment in clinical stage I nonseminoma offered one course of PEB chemotherapy to high-risk patients with 30–50% occult metastases and recommended surveillance for low-risk patients with 10–15% micrometastases. As large series from Canada and the northern European countries reported excellent survival data also for high-risk patients under surveillance, the latter is discussed as general recommendation for all clinical stage I nonseminoma patients. Another argument for such a recommendation is long-term toxicity of polychemotherapy, especially cardiovascular events.
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