The Role of Surveillance versus Adjuvant Treatment in Stage I Germ Cell Tumors: Outcomes and Challenges

Germ cell cancers of the testis arise in young adults, and, if identified in stage I, have an excellent prognosis. Thus, we should minimize management-related toxicities. Surveillance (observation) following orchiectomy can avoid further treatment; however, patients who experience relapse receive more treatment than what would have been used during initial adjuvant therapy. For the individual patient, it is important to be aware of their particular risk of relapse, the treatment they would receive for the treatment of relapse and the alternative adjuvant approaches. For seminoma, the risk of relapse during surveillance is 15% to 20%; the size of the primary tumor and the presence of rete testis invasion are prognostic factors. Most relapses occur within 3 years; however, approximately 10% occur more than 5 years after orchiectomy. The alternative adjuvant strategies are either one cycle of carboplatin or radiotherapy (RT), which reduce recurrence risk to less than 5%. The cure rate is around 99%, regardless of which management option is implemented. For stage I nonseminoma, the risk of relapse during surveillance in unselected series is 26% to 30%. Lymphovascular invasion and the amount of embryonal carcinoma are risk factors. Most relapses occur within the first year after orchiectomy, and relapse after 3 years is rare. Ninety percent of relapse patterns are classified as "good prognosis," and cure rates are 99%. The alternatives to surveillance include adjuvant strategies such as one cycle of adjuvant bleomycin/etoposide/cisplatin (BEP) chemotherapy; however, evidence is emerging that a single cycle is effective. There is controversy whether to offer surveillance for all patients or to offer adjuvant chemotherapy to select patients.