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Case Reports: Recurrence of a Nonseminomatous Germ Cell Tumor 9 Years Postoperatively: Is Surveillance Alone Acceptable?
0022-5347/95/1533-100$03.00/0 THE JOURNAL OF UROLOOY Copyright 0 1995 by AMnUW UROLOGICAL ASSOClAnON, INC.
Vol. 153,1060-1062,March 1995 Printed in U.S.A.
RECURRENCE OF A NONSEMINOlMATOUS GERM CELL TUMOR 9 YEARS POSTOPEMTWLY: IS SURVEILLANCE ALONE ACCEPTABLE? LIAM J. HURLEY AND JOHN A. LIBERTINO* From the Department of Urology, Lahey Clinic, Burlington, Massachusetts
ABSTRACT
We report on a patient who underwent left radical orchiectomy for a nonseminomatous germ cell tumor and was placed into a surveillance program only to experience recurrence 9 years later. The deficiencies with surveillance protocols, including inadequate followup, imaging study difficulties, possible higher mortality with relapse of carcinoma during the surveillance period, and increased cost and labor for longer surveillance protocols are discussed. Methods of distinguishing patients at low and high risk of relapse are still evolving and further studies are required. KEYWORDS:testicular neoplasms, teratoma, orchiectomy quadrant with dysuria. CT of the abdomen and pelvis showed a large (11X 8 X 6 cm.) mass in the lower pelvis adjacent to the left inguinal ring, with no adenopathy in the retroperitoneum. This mass distorted the bladder and impinged on the ureter but no ureteral obstruction was seen. Involvement appeared to include the proximal extent of the previously divided spermatic cord. Tumor markers included 6 nglml. a-fetoprotein and PHCG was not measured. A biopsy of this mass was consistent with immature teratoma. The patient underwent excision of this large pelvic mass with lysis of the left ureter and retroperitoneal lymph node dissection. Pathological study of the retroperitoneal nodes CASE REPORT negative and the pelvic mass showed a mixed germ cell A 35-year-old white man had undergone left radical orchi- was tumor with elements of teratoma and embryonal carcinoma. ectomy 9 years previously for nonseminomatous germ cell tumor. Medical history was remarkable for repair of a hernia DISCUSSION at age 2 years as well as hypertension diagnosed 15 years previously, for which he was being treated. Evaluation at this Much debate has been generated about the treatment optime included ultrasonography for a tender left testicle, tions for nonseminomatous germ cell tumor, including chewhich revealed a 1.3 cm.nodule consistent with a testicular motherapy, radiation therapy and retroperitoneal lymph tumor. Tumor markers included elevated levels (14 mIU/ml., node dissection after radical orchiectomy. As multimodal apnormal less than 5 mIU/ml.) of human chorionic gonado- proaches have been used the survival rate has approached tropin (HCG) and normal levels of (5 ng./ml., normal less During the last 30 years debate has included the than 10 ng./ml.) of a-fetoprotein. Computerized tomography modality of surveillance for stage I nonseminomatous germ (CT) of the abdomen was negative for adenopathy and CT of cell tumor after radical orchiectomy versus the more aggresthe chest was negative. sive approaches listed previously. The patient underwent left radical orchiectomy and inserNumerous surveillance protocols have been started during tion of a testicular prosthesis through an inguinal incision. the last 10 years because the proportion of patients cured Original pathological study revealed embryonal cell carci- with orchiectomy alone was estimated to be as high as 60 to noma with syncytial giant cells and a foci of mature teratoma 80%.2 Herr noted that 617 patients had been entered into that did not invade the tunica albuginea or the epididymal surveillance protocols worldwide, with a reported rate of structures (stage Tl). Postoperative pedal lymphangiogra- relapse of 25%.3With appropriate therapy for these relapses phy was negative for disease, and it was decided that the the survival rate was 98.7%. patient would be a candidate for a surveillance protocol. Factors predictive of relapse have been reviewed by numerRoentgenography of the chest was performed and tumor ous authors. Oliver4 and Freedman5 et al stated that the markers were followed every 2 months for the first year and most significant predictor of relapse was vascular invasion then each year for 4 years, the results of which were normal. followed by lymphatic invasion, with relapse developing in 36 The last tumor marker values were less than 3 mIU/ml. for to 96% of patients (mean 52%)."1° Our patient had embry&HCG and 4 ng./ml. for a-fetoprotein. CT every 3 months for onal cell carcinoma with a foci of mature teratoma without the first year and then yearly for 4 years was normal. vascular invasion. Nine years later the pelvic mass was a Two years before the most recent hospitalization the pa- mixed eerm cell tumor with elements of teratoma and emtient experienced chronic low back pain that was ill-defined bryo& carcinoma. It appeared that the recurrence was at and worse a h r activity. One year ago he had an episode of the distal end of the transected cord structures from the hemospermia and after evaluation he was treated with an previous radical orchiectomy. This finding suggests that diantibiotic for prostatitis. The symptoms improved, although rect metastasis from the testis may indeed have been the he had several minor relapses. Three months before hospl- cause since the retroperitoneal nodes in our patient were talization the patient experienced tenderness in the left lower negative for disease. Can institutional protocols accurately identify patients at Accepted for publication August 1, 1994. uests for r e p h a : De ahment of u r o l o ~Lahey , Clinic, 4 1 low versus high risk of relapse after orchiectomy for nonsedI&?% Burlington, ., MassacKusetts 01805. nomatous germ cell tumor t o pursue either surveillance or
Followup treatments for nonseminomatous germ cell tumors have included surveillance protocols, retroperitoneal lymph node dissection, radiation or chemotherapy. Surveillance protocols have been a reasonable option with low stage disease and compliant patients because most relapses occur within 24 months. We report, to our knowledge, the first instance of a patient who underwent left radical orchiectomy for nonseminomatous germ cell tumor and was placed into a surveillance program only to experience recurrence 9 years later.
v
1060
RECURRENCE OF NONSEMINOMATOUS GERM CELL TUMOR
1061
adjuvant therapy? The appropriate time frame for followup ugh risk of relapse remains difficult. Proponents for proceedexaminations t o detect relapses has not been determined. ng with retroperitoneal lymph node dissection state the One criticism of surveillance protocols has concerned inadeherapeutic aspects of surgery, staging benefits, ability of quate followup periods. Most relapses will occur within 6 to lissection to modify the relapse model, ease of postoperative 12 months but in numerous studies relapses have occurred as bllowup, lower chance of ultimately receiving chemotherapy ~ -our '~ late as 64 months after radical o r c h i e ~ t o m y . ~ , ~To f surgery is the initial management, and the reduced cost knowledge we report the first case in which a documented md labor not seen with longer observation periods." These relapse was found 9 years after radical orchiectomy. How- kctors may make modified retroperitoneal lymph node dissection more attractive, especially if longer followup periods ever, because of the size of the mass found in the pelvis (11x 8 x 6 cm.), it must be assumed that this recurrence was 1Kith surveillance display a higher rate of mortality with present much earlier but that it occurred after the 4-year CT, salvage chemotherapy after relapses. which was negative. At present it appears that close followup is needed for the first 6 to 12 months, with surveillance REFERENCES continuing for a minimum of 4 to 5 years as suggested by some s t ~ d i e s ' ~ .to' ~detect late recurrence. If slow growing 1. Loehrer, P. J., Sr., Williams, S. D. and Einhorn, L. H.: Status of teratomatous elements are involved, surveillance protocols of chemotherapy for testis cancer. Urol. Clin. N. Amer., 14: 713, 1987. up to 5 to 10 years may be more appropriate. 2. Whitmore, W. F., Jr.: Surgical treatment of clinical stage 1 A second criticism of surveillance protocols involves the 90 nonseminomatous germ cell tumors of the testis. Cancer to 100% survival rate of patients who experience relapse with Treat. Rep., 66.5, 1982. minimal disease and receive salvage chemotherapy.' The 3. Herr, H. W.: Treatment of locoregional germ cell tumor. In: highest success rates in the treatment of metastatic disease Progress in Clinical and Biological Research V. Uro-Oncology: are found in patients with the smallest amount of tumor at Current Status and Future Trends. New York: Wiley-Liss, pp. the start of treatment. Any person enrolled in a surveillance 295-299, 1990. protocol will experience relapse with a more advanced stage 4. Oliver, R. T., Freedman, L. S., Parkinson, M. C. and Peckham, of disease before the initiation of therapy compared to a M. J.: Medical options in the management of stages 1 and 2 (NO-N3, MO) testicular germ cell tumors. Urol. Clin. N. Amer., patient who underwent retroperitoneal lymph node resection 1 4 721, 1987. after orchiectomy. This is true because of the longer interval 5. Freedman, L. S.,Parkinson, M. C., Jones, W. G., Oliver, R. T., between diagnosis and detection of metastasis, and the limPeckham, M. J., Read, G., Newlands, E. S. and Williams, C. J.: itations of any imaging procedures. However, the prelimiHistopathology in the prediction of relapse of patients with nary reports that showed no differences in survival when stage I testicular teratoma treated by orchiectomy alone. Lantreatment was deferred (that is most cases could be salvaged cet, 2 294, 1987. by chemotherapy) actually underestimated relapse rates be6. Pizzocaro, G., Zanoni, F., Milani, A,, Salvioni, R., F'iva, L., Pilotti, cause of too short a followup.16,16 More than 90% of patients S., Bombardieri, E., Tesoro-Tess, J. D. and Musumeci, R.: with minimal metastatic disease are cured by chemotherapy, Orchiectomy alone in clinical stage 1 nonseminomatous testis cancer: a critical appraisal. J. Clin. Oncol., 4:35, 1986. although this figure decreases to 84% for those with moder7. Costello, A. J., Mortensen, P. H. and Stillwell, R. G.: Prognostic ate disease and to 57% for patients with advanced disease.17 indicators for failure of surveillance management of stage I Modern surveillance series with longer followup show the non-seminomatous germ cell tumours. Aust. New Zeal. J. rate of relapse to be approximately 30%, with 7 to 10% Surg., 6 9 119,1989: mortality in patients who experience relapse of carcino8. DunDhv. C. H., A d a , A. G., Swanson, D. A, Ro, J.Y. and ma. 17-19 Ldgoihetis, C:: Clinical stage I nonseminomatous and mixed A third criticism of surveillance studies involves followup germ cell tumors of the testis. A clinicopathologic study of 93 imaging, which makes surveillance of metastases to retroperpatients on a surveillance protocol after orchiectomy alone. itoneal lymph nodes difficult. The retroperitoneum is the Cancer, 62 1202, 1988. 9. Jacobsen, G. K, N r t h , M., Osterlind, K., von der Maase, H., most common site of relapse but it is the least well monitored Jacobsen, A, Madsen, E. L., Pedersen, M.and Schultz, H.: Hissite of Of clinical stage I nonseminomatous germ cell topathologid features in stage I non-seminomatous testicular tumors 20 to 30% are actually pathological stage 11, and germ cell tumours correlated to relapse. Danish Testicular Canthese false-negative results only increase with longer folcer Study Group. APMIS, 98: 377,1990. lowup. Colls et a1 reported only a 35% rate of relapse discov- 10. Wishnow, K I., Johnson, D. E. and Tenney, D.: Are lymphangioered by a radiographic abnormality, whereas 30% were disgrams necessruy before placing patients with nonseminomacovered by elevation of a tumor marker and 30% by a tous testicular tumors on surveillance? J. Urol., 141: 1133, combination of both.20 However, 2 patients in this series had 1989. 11. Hoskin, P., Dilly, S., Easton, D., Horwich, A., Hendry, W. and relapse apparent only on clinical examination. Peckham, M.J.: Prognostic fadors in stage 1 non-seminomaA fourth criticism of surveillance protocols is tous germ-cell testicular tumors managed by orchiectomy and Lowe reported the average cost for treatment programs using surveillance: implications for adjuvant chemotherapy. J. Clin. retroperitoneal lymphadenectomy as the initial form of manOncol., 4 1031, 1986. agement to be 25 to 30% greater than that of treatment 12. Crawford, S. M., Rustin, G. J., Begent, R. H., Newlands, E. S. programs using a surveillance protocol.21 This cost would and Bagshawe, K. D.: Safety of surveillance in the managevary from hospital to hospital but, even assuming these valment of stage I anaplastic germ cell tumours of the testis. Brit. ues are accurate, as surveillance programs lengthen to detect J. Urol., 61: 250,1988. relapses, the cost will no doubt increase, making it less eco- 13. Rgrth, M., Jacobsen, G. K., von der Maase, H., Madsen, E. L., Nielsen, 0. S., Pedersen, M. and Schultz, H.: Surveillance nomically advantageous. In addition, surveillance is laboralone versus radiotherapy after orchiectomy for clinical stage intensive and should only be considered with compliant paI nonseminomatous testicular cancer. Danish Testicular Cantients who are willing to undergo followup for 5 years or cer Study Group. J. Clin. Oncol., 9 1543,1991. longer. G., Stenning, S. P., Cullen, M. H., Parkinson, M. C., In summary, we report a case of testicular tumor relapse 9 14. Read, Horwich, A., Kaye, S. B. and Cook, P. A.: Medical Research years after radical orchiectomy, which to our knowledge is Council prospective study of surveillance for stage I testicular the longest interval to relapse reported in a surveillance teratoma. Medical Research Council Testicular Tumors Workstudy. As more surveillance studies report long-term foling Party. J. Clin. Oncol., 1 0 1762, 1992. lowup similar intervals to relapse may be seen in the future. 15. Peckham, M. J., Barrett, A., Husband, J. E. and Hendry, W. F.: Surveillance Drotocols are still evolving and are justified for Orchidectomv alone in testicular stam I non-seminomatous germ-cell tumours. Lancet, 2 678,1982. some patient;. However, distinguishing patients- at low and
1062
RECURRENCE OF NONSEMINOMATOUS GERM CELL TUMOR
16. Read, G.,Johnson, R. J., W i b n , P. M. and Eddleston, B.: Prospective study of follow up alone in stage I teratoma of the testis. Brit. Med. J., 281: 1503,1983. 17. Thompson, P. I., Nixon, J, and Harvey, V. J.: Disease relapse in patients with stage 1 nonseminomatousgerm cell tumor of the testis on active surveillance. J . Clin. Oncol., 6 1597, 1988. 18. Sogani, P.C. and Fair, W. R.: Surveillance alone in the treatment of clinical stage 1 nonseminomatous germ cell tumor of the testis (NSGCT). Sem. Urol., 6: 53, 1988. 19. Raghavan, D., Colls,B., Levi, J., Fitzharris,B., Tattersall, M. H., Atkinson, C., Woods,R., Coorey, G., Farrell, C. and Wines, R.: Surveillance for stage I non-seminomatousgerm cell tumours
of the testis: the optimal protocol has not yet been defined. Brit. J. Urol., 81: 522, 1988. 20. Colls, B. M.,Harvey, V. J., Skelton, L.,Thompson, P. I., Dady, P. J., Forgeson, G. V. and Perez, D. J.: Results of the surveillance policy of stage I non-seminomatous germ cell testicdar tumours. Brit. J. Urol., 7 0 423,1992. 21. Lowe, B. A.: Surveillance versus nerve-sparing retroperitoneal lymphadeneetomy in stage 1 nonseminomatous germ-cell tumors. Urol. Clin. N. Amer., 2 0 75, 1993. 22. Donohue, J. P.:Options in management of low stage testicular cancer. A.U.A. Update Series. Houston: American Urological Association, Inc., Office of Education, vol. VI,lesson 27,1987.
Vol. 153,1060-1062,March 1995 Printed in U.S.A.
RECURRENCE OF A NONSEMINOlMATOUS GERM CELL TUMOR 9 YEARS POSTOPEMTWLY: IS SURVEILLANCE ALONE ACCEPTABLE? LIAM J. HURLEY AND JOHN A. LIBERTINO* From the Department of Urology, Lahey Clinic, Burlington, Massachusetts
ABSTRACT
We report on a patient who underwent left radical orchiectomy for a nonseminomatous germ cell tumor and was placed into a surveillance program only to experience recurrence 9 years later. The deficiencies with surveillance protocols, including inadequate followup, imaging study difficulties, possible higher mortality with relapse of carcinoma during the surveillance period, and increased cost and labor for longer surveillance protocols are discussed. Methods of distinguishing patients at low and high risk of relapse are still evolving and further studies are required. KEYWORDS:testicular neoplasms, teratoma, orchiectomy quadrant with dysuria. CT of the abdomen and pelvis showed a large (11X 8 X 6 cm.) mass in the lower pelvis adjacent to the left inguinal ring, with no adenopathy in the retroperitoneum. This mass distorted the bladder and impinged on the ureter but no ureteral obstruction was seen. Involvement appeared to include the proximal extent of the previously divided spermatic cord. Tumor markers included 6 nglml. a-fetoprotein and PHCG was not measured. A biopsy of this mass was consistent with immature teratoma. The patient underwent excision of this large pelvic mass with lysis of the left ureter and retroperitoneal lymph node dissection. Pathological study of the retroperitoneal nodes CASE REPORT negative and the pelvic mass showed a mixed germ cell A 35-year-old white man had undergone left radical orchi- was tumor with elements of teratoma and embryonal carcinoma. ectomy 9 years previously for nonseminomatous germ cell tumor. Medical history was remarkable for repair of a hernia DISCUSSION at age 2 years as well as hypertension diagnosed 15 years previously, for which he was being treated. Evaluation at this Much debate has been generated about the treatment optime included ultrasonography for a tender left testicle, tions for nonseminomatous germ cell tumor, including chewhich revealed a 1.3 cm.nodule consistent with a testicular motherapy, radiation therapy and retroperitoneal lymph tumor. Tumor markers included elevated levels (14 mIU/ml., node dissection after radical orchiectomy. As multimodal apnormal less than 5 mIU/ml.) of human chorionic gonado- proaches have been used the survival rate has approached tropin (HCG) and normal levels of (5 ng./ml., normal less During the last 30 years debate has included the than 10 ng./ml.) of a-fetoprotein. Computerized tomography modality of surveillance for stage I nonseminomatous germ (CT) of the abdomen was negative for adenopathy and CT of cell tumor after radical orchiectomy versus the more aggresthe chest was negative. sive approaches listed previously. The patient underwent left radical orchiectomy and inserNumerous surveillance protocols have been started during tion of a testicular prosthesis through an inguinal incision. the last 10 years because the proportion of patients cured Original pathological study revealed embryonal cell carci- with orchiectomy alone was estimated to be as high as 60 to noma with syncytial giant cells and a foci of mature teratoma 80%.2 Herr noted that 617 patients had been entered into that did not invade the tunica albuginea or the epididymal surveillance protocols worldwide, with a reported rate of structures (stage Tl). Postoperative pedal lymphangiogra- relapse of 25%.3With appropriate therapy for these relapses phy was negative for disease, and it was decided that the the survival rate was 98.7%. patient would be a candidate for a surveillance protocol. Factors predictive of relapse have been reviewed by numerRoentgenography of the chest was performed and tumor ous authors. Oliver4 and Freedman5 et al stated that the markers were followed every 2 months for the first year and most significant predictor of relapse was vascular invasion then each year for 4 years, the results of which were normal. followed by lymphatic invasion, with relapse developing in 36 The last tumor marker values were less than 3 mIU/ml. for to 96% of patients (mean 52%)."1° Our patient had embry&HCG and 4 ng./ml. for a-fetoprotein. CT every 3 months for onal cell carcinoma with a foci of mature teratoma without the first year and then yearly for 4 years was normal. vascular invasion. Nine years later the pelvic mass was a Two years before the most recent hospitalization the pa- mixed eerm cell tumor with elements of teratoma and emtient experienced chronic low back pain that was ill-defined bryo& carcinoma. It appeared that the recurrence was at and worse a h r activity. One year ago he had an episode of the distal end of the transected cord structures from the hemospermia and after evaluation he was treated with an previous radical orchiectomy. This finding suggests that diantibiotic for prostatitis. The symptoms improved, although rect metastasis from the testis may indeed have been the he had several minor relapses. Three months before hospl- cause since the retroperitoneal nodes in our patient were talization the patient experienced tenderness in the left lower negative for disease. Can institutional protocols accurately identify patients at Accepted for publication August 1, 1994. uests for r e p h a : De ahment of u r o l o ~Lahey , Clinic, 4 1 low versus high risk of relapse after orchiectomy for nonsedI&?% Burlington, ., MassacKusetts 01805. nomatous germ cell tumor t o pursue either surveillance or
Followup treatments for nonseminomatous germ cell tumors have included surveillance protocols, retroperitoneal lymph node dissection, radiation or chemotherapy. Surveillance protocols have been a reasonable option with low stage disease and compliant patients because most relapses occur within 24 months. We report, to our knowledge, the first instance of a patient who underwent left radical orchiectomy for nonseminomatous germ cell tumor and was placed into a surveillance program only to experience recurrence 9 years later.
v
1060
RECURRENCE OF NONSEMINOMATOUS GERM CELL TUMOR
1061
adjuvant therapy? The appropriate time frame for followup ugh risk of relapse remains difficult. Proponents for proceedexaminations t o detect relapses has not been determined. ng with retroperitoneal lymph node dissection state the One criticism of surveillance protocols has concerned inadeherapeutic aspects of surgery, staging benefits, ability of quate followup periods. Most relapses will occur within 6 to lissection to modify the relapse model, ease of postoperative 12 months but in numerous studies relapses have occurred as bllowup, lower chance of ultimately receiving chemotherapy ~ -our '~ late as 64 months after radical o r c h i e ~ t o m y . ~ , ~To f surgery is the initial management, and the reduced cost knowledge we report the first case in which a documented md labor not seen with longer observation periods." These relapse was found 9 years after radical orchiectomy. How- kctors may make modified retroperitoneal lymph node dissection more attractive, especially if longer followup periods ever, because of the size of the mass found in the pelvis (11x 8 x 6 cm.), it must be assumed that this recurrence was 1Kith surveillance display a higher rate of mortality with present much earlier but that it occurred after the 4-year CT, salvage chemotherapy after relapses. which was negative. At present it appears that close followup is needed for the first 6 to 12 months, with surveillance REFERENCES continuing for a minimum of 4 to 5 years as suggested by some s t ~ d i e s ' ~ .to' ~detect late recurrence. If slow growing 1. Loehrer, P. J., Sr., Williams, S. D. and Einhorn, L. H.: Status of teratomatous elements are involved, surveillance protocols of chemotherapy for testis cancer. Urol. Clin. N. Amer., 14: 713, 1987. up to 5 to 10 years may be more appropriate. 2. Whitmore, W. F., Jr.: Surgical treatment of clinical stage 1 A second criticism of surveillance protocols involves the 90 nonseminomatous germ cell tumors of the testis. Cancer to 100% survival rate of patients who experience relapse with Treat. Rep., 66.5, 1982. minimal disease and receive salvage chemotherapy.' The 3. Herr, H. W.: Treatment of locoregional germ cell tumor. In: highest success rates in the treatment of metastatic disease Progress in Clinical and Biological Research V. Uro-Oncology: are found in patients with the smallest amount of tumor at Current Status and Future Trends. New York: Wiley-Liss, pp. the start of treatment. Any person enrolled in a surveillance 295-299, 1990. protocol will experience relapse with a more advanced stage 4. Oliver, R. T., Freedman, L. S., Parkinson, M. C. and Peckham, of disease before the initiation of therapy compared to a M. J.: Medical options in the management of stages 1 and 2 (NO-N3, MO) testicular germ cell tumors. Urol. Clin. N. Amer., patient who underwent retroperitoneal lymph node resection 1 4 721, 1987. after orchiectomy. This is true because of the longer interval 5. Freedman, L. S.,Parkinson, M. C., Jones, W. G., Oliver, R. T., between diagnosis and detection of metastasis, and the limPeckham, M. J., Read, G., Newlands, E. S. and Williams, C. J.: itations of any imaging procedures. However, the prelimiHistopathology in the prediction of relapse of patients with nary reports that showed no differences in survival when stage I testicular teratoma treated by orchiectomy alone. Lantreatment was deferred (that is most cases could be salvaged cet, 2 294, 1987. by chemotherapy) actually underestimated relapse rates be6. Pizzocaro, G., Zanoni, F., Milani, A,, Salvioni, R., F'iva, L., Pilotti, cause of too short a followup.16,16 More than 90% of patients S., Bombardieri, E., Tesoro-Tess, J. D. and Musumeci, R.: with minimal metastatic disease are cured by chemotherapy, Orchiectomy alone in clinical stage 1 nonseminomatous testis cancer: a critical appraisal. J. Clin. Oncol., 4:35, 1986. although this figure decreases to 84% for those with moder7. Costello, A. J., Mortensen, P. H. and Stillwell, R. G.: Prognostic ate disease and to 57% for patients with advanced disease.17 indicators for failure of surveillance management of stage I Modern surveillance series with longer followup show the non-seminomatous germ cell tumours. Aust. New Zeal. J. rate of relapse to be approximately 30%, with 7 to 10% Surg., 6 9 119,1989: mortality in patients who experience relapse of carcino8. DunDhv. C. H., A d a , A. G., Swanson, D. A, Ro, J.Y. and ma. 17-19 Ldgoihetis, C:: Clinical stage I nonseminomatous and mixed A third criticism of surveillance studies involves followup germ cell tumors of the testis. A clinicopathologic study of 93 imaging, which makes surveillance of metastases to retroperpatients on a surveillance protocol after orchiectomy alone. itoneal lymph nodes difficult. The retroperitoneum is the Cancer, 62 1202, 1988. 9. Jacobsen, G. K, N r t h , M., Osterlind, K., von der Maase, H., most common site of relapse but it is the least well monitored Jacobsen, A, Madsen, E. L., Pedersen, M.and Schultz, H.: Hissite of Of clinical stage I nonseminomatous germ cell topathologid features in stage I non-seminomatous testicular tumors 20 to 30% are actually pathological stage 11, and germ cell tumours correlated to relapse. Danish Testicular Canthese false-negative results only increase with longer folcer Study Group. APMIS, 98: 377,1990. lowup. Colls et a1 reported only a 35% rate of relapse discov- 10. Wishnow, K I., Johnson, D. E. and Tenney, D.: Are lymphangioered by a radiographic abnormality, whereas 30% were disgrams necessruy before placing patients with nonseminomacovered by elevation of a tumor marker and 30% by a tous testicular tumors on surveillance? J. Urol., 141: 1133, combination of both.20 However, 2 patients in this series had 1989. 11. Hoskin, P., Dilly, S., Easton, D., Horwich, A., Hendry, W. and relapse apparent only on clinical examination. Peckham, M.J.: Prognostic fadors in stage 1 non-seminomaA fourth criticism of surveillance protocols is tous germ-cell testicular tumors managed by orchiectomy and Lowe reported the average cost for treatment programs using surveillance: implications for adjuvant chemotherapy. J. Clin. retroperitoneal lymphadenectomy as the initial form of manOncol., 4 1031, 1986. agement to be 25 to 30% greater than that of treatment 12. Crawford, S. M., Rustin, G. J., Begent, R. H., Newlands, E. S. programs using a surveillance protocol.21 This cost would and Bagshawe, K. D.: Safety of surveillance in the managevary from hospital to hospital but, even assuming these valment of stage I anaplastic germ cell tumours of the testis. Brit. ues are accurate, as surveillance programs lengthen to detect J. Urol., 61: 250,1988. relapses, the cost will no doubt increase, making it less eco- 13. Rgrth, M., Jacobsen, G. K., von der Maase, H., Madsen, E. L., Nielsen, 0. S., Pedersen, M. and Schultz, H.: Surveillance nomically advantageous. In addition, surveillance is laboralone versus radiotherapy after orchiectomy for clinical stage intensive and should only be considered with compliant paI nonseminomatous testicular cancer. Danish Testicular Cantients who are willing to undergo followup for 5 years or cer Study Group. J. Clin. Oncol., 9 1543,1991. longer. G., Stenning, S. P., Cullen, M. H., Parkinson, M. C., In summary, we report a case of testicular tumor relapse 9 14. Read, Horwich, A., Kaye, S. B. and Cook, P. A.: Medical Research years after radical orchiectomy, which to our knowledge is Council prospective study of surveillance for stage I testicular the longest interval to relapse reported in a surveillance teratoma. Medical Research Council Testicular Tumors Workstudy. As more surveillance studies report long-term foling Party. J. Clin. Oncol., 1 0 1762, 1992. lowup similar intervals to relapse may be seen in the future. 15. Peckham, M. J., Barrett, A., Husband, J. E. and Hendry, W. F.: Surveillance Drotocols are still evolving and are justified for Orchidectomv alone in testicular stam I non-seminomatous germ-cell tumours. Lancet, 2 678,1982. some patient;. However, distinguishing patients- at low and
1062
RECURRENCE OF NONSEMINOMATOUS GERM CELL TUMOR
16. Read, G.,Johnson, R. J., W i b n , P. M. and Eddleston, B.: Prospective study of follow up alone in stage I teratoma of the testis. Brit. Med. J., 281: 1503,1983. 17. Thompson, P. I., Nixon, J, and Harvey, V. J.: Disease relapse in patients with stage 1 nonseminomatousgerm cell tumor of the testis on active surveillance. J . Clin. Oncol., 6 1597, 1988. 18. Sogani, P.C. and Fair, W. R.: Surveillance alone in the treatment of clinical stage 1 nonseminomatous germ cell tumor of the testis (NSGCT). Sem. Urol., 6: 53, 1988. 19. Raghavan, D., Colls,B., Levi, J., Fitzharris,B., Tattersall, M. H., Atkinson, C., Woods,R., Coorey, G., Farrell, C. and Wines, R.: Surveillance for stage I non-seminomatousgerm cell tumours
of the testis: the optimal protocol has not yet been defined. Brit. J. Urol., 81: 522, 1988. 20. Colls, B. M.,Harvey, V. J., Skelton, L.,Thompson, P. I., Dady, P. J., Forgeson, G. V. and Perez, D. J.: Results of the surveillance policy of stage I non-seminomatous germ cell testicdar tumours. Brit. J. Urol., 7 0 423,1992. 21. Lowe, B. A.: Surveillance versus nerve-sparing retroperitoneal lymphadeneetomy in stage 1 nonseminomatous germ-cell tumors. Urol. Clin. N. Amer., 2 0 75, 1993. 22. Donohue, J. P.:Options in management of low stage testicular cancer. A.U.A. Update Series. Houston: American Urological Association, Inc., Office of Education, vol. VI,lesson 27,1987.