CS I NSGCT can be effectively managed with surveillance, RPLND, or primary chemotherapy. Each is associated with a roughly 1% risk for death from testis cancer and no randomized trials have been conducted to evaluate whether one approach is superior. Surveillance offers 70% of patients the benefit of avoiding any postorchiectomy therapy but is associated with a higher risk for relapse and a more burdensome follow-up schedule. The ideal surveillance patients are those who do not have risk factors for relapse because they are most likely to enjoy the benefit of avoiding chemotherapy and RPLND. It must be emphasized that patient compliance with follow-up clinical assessments and imaging studies is essential to a successful surveillance strategy to detect relapses at an early and curable stage. If questions exist regarding patient compliance, patients should be recommended to receive active treatment. RPLND lowers the risk for relapse and offers patients the best chance of avoiding chemotherapy and late relapse. Although RPLND carries a small risk for acute and chronic complications, chemotherapy seems to be associated with greater risks. One limitation to RPLND is that 15% ofaverage-riskandupto30% of high-risk patients end up receiving chemotherapy after RPLND either for PS II disease or for subsequent relapse. The combination of RPLND followed by adjuvant chemotherapy results in the lowest relapse rate (1%) of any treatment strategy, however. Primary chemotherapy offers the benefit of the lowest relapse rate achievable with a single postorchiectomy treatment modality. This benefit must be balanced against the potential risk for late relapse with chemoresistant disease and short- and long-term chemotherapy complications, including but not limited to secondary malignancies and cardiovascular events.

At this time, none of these three approaches can be definitely labeled as superior. Given this uncertainty and the contentious disagreement over optimal management among leading experts, it is appropriate for patients to be informed of all three options. We believe that surveillance is preferable for low-risk patients and that RPLND is supported by a larger body of long-term follow-up survival data compared with primary chemotherapy. Primary chemotherapy is best reserved for patients refusing RPLND and surveillance and for high-risk patients who do not have access to surgeons who have extensive experience performing RPLND.

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