Stéphane Culine1. 1. Département d'Oncologie Médicale, CRIC Val d'Aurelle, Montpellier, France. stculine@valdorel.fnloc.fr
Abstract
BACKGROUND: Stage I nonseminomatous germ cell tumours are characterized by the absence of detectable metastatic extension at the time of diagnosis of the disease. The experience acquired with staging retroperitoneal lymphadenectomy or surveillance cohorts demonstrates that about 30% patients nevertheless present microscopic metastases. Should management after orchidectomy be based on watchful waiting or should complementary treatment be proposed immediately? METHODS: A review of the international literature was designed to: 1) evaluate the contribution to the decision-making process of histological variables able to predict the risk of micro-metastatic dissemination, 2) define the potential advantages and disadvantages of the three approaches usually adopted after orchidectomy (retroperitoneal lymphadenectomy, surveillance and adjuvant chemotherapy), 3) establish guidelines for daily practice. RESULTS: Histological variables are especially reliable for prediction of the absence of micro-metastatic risk. The various approaches adopted after orchidectomy can achieve similar and excellent cure rates. The potential adverse effects are very different. Watchful waiting is preferable in low-risk patients (absence or small proportion of embryonic carcinoma and absence of vascular invasion in the primary tumour). Adjuvant chemotherapy must be strictly reserved to high-risk patients (predominant component of embryonic carcinoma and presence of vascular invasion). Retroperitoneal lymphadenectomy must be performed by specialized teams in patients at low or intermediate risk, especially when watchful waiting cannot be effectively ensured, when serum tumour markers are normal at diagnosis or when the primary tumour presents a predominant component of mature teratoma associated with vascular invasion. CONCLUSION: Histological data derived from the orchidectomy specimen, the urologist's learning curve in relation to retroperitoneal lymphadenectomy and the clinical context (patient's expected compliance with follow-up, expected adverse effects of the various treatment options) are the main decisional parameters to be taken into account by multidisciplinary teams. The optimal individual option can only be determined after discussion with the patient.
BACKGROUND: Stage I nonseminomatous germ cell tumours are characterized by the absence of detectable metastatic extension at the time of diagnosis of the disease. The experience acquired with staging retroperitoneal lymphadenectomy or surveillance cohorts demonstrates that about 30% patients nevertheless present microscopic metastases. Should management after orchidectomy be based on watchful waiting or should complementary treatment be proposed immediately? METHODS: A review of the international literature was designed to: 1) evaluate the contribution to the decision-making process of histological variables able to predict the risk of micro-metastatic dissemination, 2) define the potential advantages and disadvantages of the three approaches usually adopted after orchidectomy (retroperitoneal lymphadenectomy, surveillance and adjuvant chemotherapy), 3) establish guidelines for daily practice. RESULTS: Histological variables are especially reliable for prediction of the absence of micro-metastatic risk. The various approaches adopted after orchidectomy can achieve similar and excellent cure rates. The potential adverse effects are very different. Watchful waiting is preferable in low-risk patients (absence or small proportion of embryonic carcinoma and absence of vascular invasion in the primary tumour). Adjuvant chemotherapy must be strictly reserved to high-risk patients (predominant component of embryonic carcinoma and presence of vascular invasion). Retroperitoneal lymphadenectomy must be performed by specialized teams in patients at low or intermediate risk, especially when watchful waiting cannot be effectively ensured, when serum tumour markers are normal at diagnosis or when the primary tumour presents a predominant component of mature teratoma associated with vascular invasion. CONCLUSION: Histological data derived from the orchidectomy specimen, the urologist's learning curve in relation to retroperitoneal lymphadenectomy and the clinical context (patient's expected compliance with follow-up, expected adverse effects of the various treatment options) are the main decisional parameters to be taken into account by multidisciplinary teams. The optimal individual option can only be determined after discussion with the patient.