Management of patients with clinical stage I or II nonseminomatous germ cell tumors of the testis. Evolving therapeutic options
J. P. Richie, M. A. Socinsky, C. Y. Fung, G. L. Brodsky, L. A. Kalish and M. B. Garnick
Department of Surgery/Urology, Brigham and Women's Hospital, Boston, MA 02115.
Eighty patients with clinical stage I or II nonseminomatous germ cell
tumors of the testis were managed with modified protocols, including
modified nerve-sparing retroperitoneal lymph node dissection for patients
with stage I cancer, retroperitoneal lymph node dissection for patients
with low-volume stage II cancer, and initial chemotherapy with or without
subsequent retroperitoneal lymphadenectomy for patients with high-volume
stage II cancer. Patients with low-stage disease (clinical stage I) were
treated successfully with modified retroperitoneal lymph node dissection
(relapse rate, three of 40 patients). Clinical understaging was evidenced
in 14 of 48 patients with clinical stage I disease who were found to have
pathologic involvement of the retroperitoneal lymph nodes, including six
patients with extensive retroperitoneal nodal involvement (pathologic stage
B2). Of nine patients with retroperitoneal tumors less than 3 cm in
diameter, four patients were satisfactorily treated with retroperitoneal
lymph node dissection alone while five patients required chemotherapy after
retroperitoneal lymph node dissection. Of 26 patients with retroperitoneal
tumors 3 to 5 cm in diameter, 17 patients were treated with chemotherapy
alone. All patients remain free of disease after the completion of
definitive therapy. We conclude that therapeutic options should be modified
based on histologic factors in the primary tumor, extent of retroperitoneal
disease as indicated on a computed tomographic scan, and presence or
absence of elevated tumor markers. By consideration these factors, optimum
therapy can be selected to achieve the highest long-term survival rate with
the least morbidity.