Non-risk-adapted Surveillance for Stage I Testicular Cancer: Critical Review and Summary

Phillip Martin Pierorazio; Peter Albers; Peter C Black; Torgrim Tandstad; Axel Heidenreich; Nicola Nicolai; Craig Nichols

doi:10.1016/j.eururo.2017.12.030

Non-risk-adapted Surveillance for Stage I Testicular Cancer: Critical Review and Summary

Eur Urol. 2018 Jun;73(6):899-907. doi: 10.1016/j.eururo.2017.12.030. Epub 2018 Jan 12.

Authors

Phillip Martin Pierorazio¹, Peter Albers², Peter C Black³, Torgrim Tandstad⁴, Axel Heidenreich⁵, Nicola Nicolai⁶, Craig Nichols⁷

Affiliations

¹ Brady Urological Institute, Johns Hopkins Medicine, Baltimore, MD, USA; Department of Urology, Johns Hopkins Medicine, Baltimore, MD, USA. Electronic address: philpierorazio@jhmi.edu.
² Department of Urology, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany.
³ Department of Urologic Sciences, The University of British Columbia, Vancouver, BC, Canada.
⁴ St Olavs University Hospital, Trondheim, Norway.
⁵ Department of Urology and Uro-Oncology, Universitätsklinikum Köln, Köln, Germany.
⁶ Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy.
⁷ Section of Urology, Virginia Mason Medical Center, Seattle, WA, USA.

PMID: 29338978
DOI: 10.1016/j.eururo.2017.12.030

Abstract

Context: Cancer-specific survival for men with clinical stage I testicular cancer (CSITC) is uniformly excellent. Non-risk-adapted active surveillance (NRAS) is a management strategy for CSITC to minimize overtreatment and avoid possible long-term side effects of adjuvant therapy.

Objective: To review the evidence regarding oncologic outcomes for men with CSITC undergoing NRAS and discuss ongoing controversies in the management of CSITC.

Evidence acquisition: MEDLINE/PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 1987 through January 1, 2017.

Evidence synthesis: A total of 68 studies were included in the critical review. The rationale for NRAS, oncologic outcomes, surveillance protocols, and comparative efficacy of risk-adjusted active surveillance (AS) were reported with strength of evidence and risk of bias evaluated. Cancer-specific survival approaches 100% for men with CSITC undergoing NRAS. Active treatment is limited to 20-30% of patients who will recur; these patients will require salvage chemotherapy and possible retroperitoneal lymph node dissection. Existing AS protocols include imaging and laboratory evaluations that are initially intensive but less frequent with increasing follow-up.

Conclusions: NRAS is an attractive management option for men with CSITC, which maintains outstanding long-term cancer cure while sparing most patients treatment by avoiding prophylactic chemotherapy, radiation, or surgery.

Patient summary: Men with clinically localized (stage I) testicular cancer have an excellent prognosis, regardless of management. Non-risk-adapted active surveillance is an attractive management option where only patients destined to relapse will receive any treatment following orchiectomy. However, individual patient preferences should be discussed in selecting a management strategy.

Keywords: Active surveillance; Germ cell tumor; Testicular cancer.

Publication types

Review

MeSH terms

Antineoplastic Agents / therapeutic use
Humans
Lymph Node Excision
Lymphatic Metastasis
Male
Neoplasm Recurrence, Local / drug therapy*
Neoplasm Staging
Orchiectomy
Postoperative Period
Risk Factors
Salvage Therapy
Survival Rate
Testicular Neoplasms / pathology*
Testicular Neoplasms / therapy*
Watchful Waiting / methods*

Substances

Antineoplastic Agents