Outcomes of surveillance protocol of clinical stage I nonseminomatous germ cell tumors-is shift to risk adapted policy justified?

Purpose: We evaluated the potential risk factors for disease relapse in patients with clinical stage I nonseminomatous germ cell tumors treated with surveillance and reevaluated our treatment of these patients.

Materials And Methods: A total of 211 consecutive patients with clinical stage I nonseminomatous germ cell tumors treated with surveillance after orchiectomy between 1993 and 2005 were included in this retrospective study. Risk factors evaluated were presence of vascular invasion, proportion of embryonal carcinoma, age, tumor size, preoperatively increased serum alpha-fetoprotein and the absence of yolk sac component.

Results: Of the 211 patients 66 (31.3%) had disease relapse. Recurrence ranged from 2 to 32 months after orchiectomy (median 6). A total of 52 (78.8%) cases of relapse were diagnosed in year 1 of followup, 11 (16.7%) during year 2 and only 3 cases were diagnosed thereafter. The first evidence of relapse was most commonly the increase in serum tumor markers alone (28.8%) or in combination with other modalities (66.7%, overall 95.5%). While 40.9% of patients with more than 50% embryonal carcinoma had disease relapse, the relapse rate was 20.8% in patients with less than 50% embryonal carcinoma (p = 0.002). Relapse rates in patients with and without vascular invasion were 75.5% and 17.9%, respectively (p = 0.000). The relapse rates were 6.1% and 75.7% in patients with no risk factors (no vascular invasion and less than 50% embryonal carcinoma) and 2 risk factors (vascular invasion and more than 50% embryonal carcinoma), respectively (p < 0.001). Multivariate analysis revealed that vascular invasion was the most powerful predictor of relapse (OR 16.350, 95% CI 5.582-47.893). Disease-free and disease specific survival rates were 97.6% at a median followup of 75 months.

Conclusions: In light of our results we suggest that all patients with vascular invasion should receive chemotherapy. However, patients with no risk factors and those with more than 50% embryonal carcinoma but without vascular invasion should be on surveillance after orchiectomy since the relapse rate is less than 30%. Although strict followup in the first year is justified, followup schemas may be reassessed for the frequency of radiological investigations.