Treatment options for stage 1 (CS1) non-seminoma testicular cancer (NSGCT) following surgery include active surveillance (AS) or adjuvant bleomycin, etoposide and cisplatin (BEP). Presence of lymphovascular invasion (LVI) and embryonal carcinoma (EC) have been associated with an increased risk of relapse.(1)
Data on CS1 testicular cancer patients presenting to two sites in Western Sydney between 1990 and 2019 were analysed. Tumour characteristics including tumour markers, size of primary, LVI, rete testis involvement (RTI) and histology were correlated with relapse.
A total of 168 cases of CS1 NSGCT were identified. None of the 20 patients who received 2 cycles of adjuvant BEP relapsed, compared to 47 of 148 (32%) on AS. All relapsed patients received BEP and 19 (40%) had post-chemotherapy surgery. 14 out of 19 resection samples showed residual teratoma, and the remaining showed necrotic tumour. There were 2 deaths from relapse, and 1 from other causes. RFS at 5 years was 71% and OS 97%. In AS patients, LVI and RTI were predictors of relapse with HR of 8.50 (95% CI 4.12, 17.54, p=<.0001)) and 3.12 (95% CI 1.46, 6.70, p=0.01). 29 of 44 pts (66%) with LVI relapsed compared to 10 of 85 (12%) without LVI. EC was not associated with relapse. (HR 1.80; CI 0.71, 4.57, p=0.2).
In our series, relapse rate of 32% in AS group is in keeping with published data from a large population-cohort study.(1) LVI was associated with an almost 9-fold increase in risk of recurrence, also consistent with previous findings. Of those, 40% required post-chemotherapy surgery. Although long term outcomes remain good, treatments for relapse are associated with increased morbidity. Therefore, we recommend CS1 NSGCT patients with LVI be considered for a single cycle of BEP rather than AS to reduce risk of relapse and prevent relapse related treatment morbidity.(2) References: 1. Daugaard G, Gundgaard MG, Mortensen MS, Agerbaek M, Holm NV, Rorth M, et al. Surveillance for stage I nonseminoma testicular cancer: outcomes and long-term follow-up in a population-based cohort. J Clin Oncol. 2014;32(34):3817-23. 2. Cullen M, Huddart R, Joffe J, Gardiner D, Maynard L, Hutton P, et al. The 111 Study: A Single-arm, Phase 3 Trial Evaluating One Cycle of Bleomycin, Etoposide, and Cisplatin as Adjuvant Chemotherapy in High-risk, Stage 1 Nonseminomatous or Combined Germ Cell Tumours of the Testis. Eur Urol. 2020;77(3):344-51.
The authors.
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M. Arasaratnam: Travel/Accommodation/Expenses, educational meeting 2019: Pfizer. H. Gurney: Advisory/Consultancy, Advisory board: BMS; Advisory/Consultancy, Advisory board: Astellas; Advisory/Consultancy, Advisory board: Pfizer; Advisory/Consultancy, Advisory board: MSD; Advisory/Consultancy, Advisory board: Merck; Advisory/Consultancy, Advisory board: Ipsen; Advisory/Consultancy, Advisory board: AstraZeneca. All other authors have declared no conflicts of interest.