Management of stage I non-seminomatous testicular cancer: a systematic review and meta-analysis.

After orchidectomy and staging, patients with clinical stage I (CS I) non-seminomatous testicular cancer (NSTC) may be offered chemotherapy, surgery or active surveillance. The optimal postoperative approach is undefined. Therefore, a systematic review was carried out to assess these management approaches. Eligible studies, systematic reviews and clinical practice guidelines included patients with CS I NSTC or a mixed seminoma/non-seminoma diagnosis. The primary outcomes of interest included cancer cure, long-term toxicity and quality of life. In total, 32 unique reports met the selection criteria. Cancer cure rates were excellent regardless of the management option selected. Overall and disease-free survival rates were over 95% for all management approaches; recurrence rates were higher in the patients managed by surveillance. In conclusion, patients with CS I NSTC should be assessed and managed at multidisciplinary centres by health care professionals experienced in the treatment of testicular cancer. On the basis of the available evidence, the Genitourinary Disease Site Group recommended primary surveillance for all patients with CS I NSTC, with treatment if relapse occurs. As cancer cure rates are similar with primary surveillance, adjuvant chemotherapy and retroperitoneal lymphadenectomy, patient preference with respect to the risk of recurrence and the timing and toxicities of treatment must be considered. For patients who prefer immediate treatment, or who are unsuitable for primary surveillance, adjuvant chemotherapy with two cycles of bleomycin, etoposide (500mg/m(2)/cycle) and cisplatin was recommended. Surgeons involved in the development of this guideline suggested that retroperitoneal lymphadenectomy may be a useful option for patients at high risk of relapse. There is currently insufficient evidence from prospective trials to support or refute this position.