High risk NSGCT: case for surveillance.

INTRODUCTION: Active surveillance, primary retroperitoneal lymph node dissection and adjuvant chemotherapy are treatment options for high-risk clinical stage (CS) I nonseminomatous germ cell testicular tumors (NSGCT). Since 1981, at Princess Margaret Hospital, Toronto, initial active surveillance with treatment delayed until relapse has been the preferred management option for all CS I NSGCT, regardless of baseline risk of relapse which has allowed us to better define and assess the natural history of high-risk tumors.
MATERIALS AND METHODS: From 1981 to 2005, 371 patients with CS I NSGCT were placed on an active surveillance protocol. Recurrence patterns, predictors of relapse, disease specific (DS) and overall survival (OS) were measured. Outcomes were stratified into two cohorts by their time of diagnosis [initial, 157 patients (1981-1992); recent, 214 patients (1993-2005)].
RESULTS: Median follow-up was 6.3 years. Median time to relapse was 7.1 months. Lympho-vascular invasion (P < 0.0001) and pure embryonal carcinoma (P = 0.02) were independent predictors of relapse. In the initial cohort, 66/157 (42.0%) were high-risk and 36/66 (54.5%) relapsed versus 17/91 (18.7%) low-risk (P < 0.0001). In the recent cohort, 59/214 (27.6%) patients were high-risk and 29/59 (49.2%) recurred, versus 22/155 (14.2%) low-risk (P < 0.0001). The 5-year DSS and OS were 99.2 and 98.2%, respectively.
CONCLUSIONS: Nonrisk adapted active surveillance is the preferred management strategy for all CS I NSGCT patients including those at high-risk, providing near 100% cure rate with reduced overall treatment burden. Approximately half of the high-risk patients will be spared unnecessary treatment with little or no increase risk.