Therapeutic Concepts And Patient Selection Nonseminomatous Germ Cell Tumors Clinical Stage I

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Surveillance, risk-adapted primary chemotherapy, and retroperitoneal lymphadenec-tomy are advocated for the management in this stage, although with overall disagreement on the optimal treatment regimen (9,10).

■ If surveillance is opted:

15% to 20% of patients will relapse (11,12). Death rates are up to 10% in the relapsing patients (13). The primary advantage of surveillance is to avoid the morbidity of open surgery, which is minimized by the introduction of the modified unilateral retroperitoneal lymph node dissection and the nerve-sparing technique, which is feasible by laparoscopic means.

■ If risk-adapted primary chemotherapy is opted:

In several studies involving more than 200 high-risk patients with nonseminoma-tous germ cell tumors of the testes (embryonic carcinoma as the primary tumor or tumors with vascular or lymphatic invasions) treated with two cycles of bleomycin, etoposide, and cisplatin (BEP) a relapse rate of 2.7% was found . Median follow-up in some studies approached eight years (11,14).

CAVEATS

■ The risk of slow growing retroperitoneal teratomas.

■ The risk of chemoresistant cancer relapses.

■ Follow-up protocol is not clear.

■ A total of 4% to 50% of patients in this group will be overtreated.

■ Relapse in patients under treatment because they are considered low-risk.

All patients diagnosed having nonseminomatous germ cell tumors clinical stage I are candidates for diagnostic laparoscopic retroperitoneal lymph node dissection as the first line of management. This is followed by surveillance if the retroperitoneal lymph nodes histology is negative or two cycles of chemotherapy if lymph nodes metastases are found.

■ Retroperitoneal lymphadenectomy:

Laparoscopic retroperitoneal lymph node dissection is our preferred choice because it has equal diagnostic accuracy, but lower morbidity than open surgery. At the time of this writing, 103 patients with clinical stage I disease underwent laparoscopic retroperitoneal lymph node dissection between August 1992 and June 2004 with a mean follow up of 62 months (range, 6-113) (Table 1).

All patients diagnosed having nonseminomatous germ cell tumors clinical stage I are candidates for diagnostic laparoscopic retroperitoneal lymph node dissection as the first line of management. Laparoscopic retroperitoneal lymph node dissection is followed by surveillance if the retroperitoneal lymph nodes histology is negative or two cycles of chemotherapy if lymph nodes metastases are found.

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