Management of Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer

Toni K. Choueiri, MDa, Andrew J. Stephenson, MDb, Timothy Gilligan, MDa, Eric A. Klein, MDb*

aDepartment of Solid Tumor Oncology, Taussig Cancer Center, Cleveland Clinic Foundation,

9500 Euclid Avenue, R35, Cleveland, OH 44195-0001, USA hSection of Urologic Oncology, Glickman Urological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195-0001, USA

Approximately one third of patients who have nonseminomatous germ cell testicular cancer (NSGCT) have clinical stage (CS) I disease at diagnosis, defined as normal postorchiectomy serum levels of the tumor markers a-fetoprotein (AFP), human choriogonadotropin (HCG), and lactate dehydrogenase (LDH) without evidence of metastatic disease on imaging studies of the chest, abdomen, and pelvis. The optimal management of these patients continues to generate controversy. Surveillance, retroperitoneal lymph node dissection (RPLND), and chemotherapy with two cycles of bleomycin-etoposide-cisplatin (BEPx2) are established treatment options for CS I and all are associated with long-term survival rates of 97% or greater. Contributing to the controversy is the fact that occult metastases in the retroperito-neum or at distant sites are present in only 25% to 35% of patients overall. Any intervention after orchiectomy, with its associated short- and long-term morbidity, represents over-treatment for the 65% to 75% of patients who have disease limited to the testis.

NSGCT follows a predictable pattern of meta-static spread that has contributed to its successful management. With the exception of choriocarci-noma, the most common route of disease dissemination is by way of lymphatic channels from the primary tumor to the retroperitoneal lymph nodes

* Corresponding author.

E-mail address: [email protected] (E.A. Klein).

and subsequently to distant sites (most commonly the lung, posterior mediastinum, and left supraclavicular fossa). Choriocarcinoma has a propensity for hematogenous dissemination. The retroperito-neum is the initial site of metastatic spread in 70% to 80% of patients who have testicular cancer. Detailed mapping studies from RPLND series have increased our understanding of the testicular lymphatic drainage and identified the most likely sites of metastatic disease [1]. For right-sided testicular tumors, the primary drainage site is the interaortocaval lymph nodes, followed by the paracaval and para-aortic nodes. The primary "landing zone'' for left-sided tumors is the para-aortic lymph nodes, followed by the interaorto-caval nodes [2]. Contralateral spread is common with right-sided tumors but is rarely seen with left-sided tumors and usually is associated with bulky disease. More caudal deposits of metastatic disease usually reflect retrograde spread to distal iliac and inguinal lymph nodes secondary to large volume disease and, more rarely, aberrant testi-cular lymphatic drainage.

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