Testicular Cancer

Overview Testicular cancer, although an uncommon malignancy, is the most frequently occurring cancer in young men. It is estimated that 8,820 new testicular cancers were diagnosed in the United States in 2014, with approximately 380 deaths. For unknown reasons, the incidence of this cancer has increased since the turn of the century, from 2 cases per 100,000 population in the 1930s, to 3.7 cases per 100,000 population from 1969 to 1971, to 5.4 cases per 100,000 population from 1995 to 1999. Most testicular tumors are of germ cell origin. Approximately 5% of testicular cancers are of Sertoli cell or Leydig cell (non–germ cell) origin. Testicular germ cell cancers are uniquely sensitive to chemotherapy and are considered the model for the treatment of solid tumors. Overall, cure rates exceed 95%, including 80% for patients with metastatic disease. Epidemiology Age Testicular cancer can occur at any age, but it is most common between the ages of 15 and 35 years. Testicular germ cell tumors are the most common solid tumor in this age group. There is a secondary peak in incidence after age 60. Seminoma is the most common histology in the older population. Race Testicular cancer is rare among blacks (1.6/100,000 population), yet black men present with higher-grade disease and have significantly worse survival at 5 and 10 years. The incidence of testicular cancer has increased in whites in the United States and Europe during the past 80 years, whereas the incidence of testicular cancer in African Americans began to increase in the 1990s. Non-Hispanic white patients typically present with disease at early stages when compared with black, Native American, Hawaiian, and Hispanic patients. Body Size A recent systematic review and meta-analysis of North American studies showed that testicular cancer was positively associated with adult height and a trend of inverse association with body mass index. Geography Denmark has the highest reported incidence of testicular cancer with 1% of the male population affected; East Asia has the lowest incidence of this disease. Primary Site Germ cell tumors present most commonly in the testes (90%) and only infrequently in extragonadal sites (10%). The most common extragonadal sites (in decreasing order of frequency) are the retroperitoneum, mediastinum, and pineal gland. Many patients presumed to have a primary retroperitoneal germ cell tumor may have an occult germ cell tumor of the testicle. This possibility should be evaluated with testicular ultrasonography, especially when the retroperitoneal tumor is predominantly one-sided. TABLE 1: Anticipated cure rates in patients with germ cell tumors, according to disease stage Survival rThe 5-year survival rate for all patients with testicular cancer is approximately 95%. Cure rates are highest for early-stage disease, which is treated primarily with surgery or radiation therapy (early seminoma), and lower for advanced disease, for which chemotherapy is the primary therapy (Table 1). Etiology and Risk Factors The specific cause of germ cell tumors is unknown, but various factors have been associated with an increased risk of this malignancy. Prior Testicular Cancer Perhaps the strongest risk factor for germ cell tumors is a history of testicular cancer. Approximately 1% to 2% of patients with testicular cancer will develop a second primary tumor in the contralateral testis over time. This represents a 500-fold increase in incidence over that noted among the normal male population. In addition, there is a 50% risk of developing testicular cancer over 5 years in men with a diagnosis of testicular carcinoma in situ (CIS), otherwise known as intratubular germ cell neoplasia (ITGCN). The risk of contralateral testicular cancer was studied in a large population-based cohort of men with testicular cancer diagnosed before the age of 55. For 29,515 cases reported from 1973 through 2001 to the National Cancer Institute’s (NCI) Surveillance, Epidemiology and End Results (SEER) Program, the 15-year cumulative risk of developing metachronous contralateral testicular cancer was 1.9%, reaffirming the practice of not performing a biopsy on the contralateral testis at initial presentation. Cryptorchidism Patients with cryptorchidism, which occurs in 2% to 5% of boys born at term, have a fourfold to eightfold increased risk of developing germ cell tumors when compared with their normal counterparts. Orchiopexy, even at an early age, appears to reduce the incidence of germ cell tumor. Wood and Elder conducted an extensive review of the data about cryptorchidism as it related to testicular cancer. The relative risk of testicular cancer in cryptorchidism is 2.75 to 8. A relative risk of 2 to 3 has been noted in patients who undergo orchiopexy by age 10 to 12 years. Patients who undergo orchiopexy after age 12 or who have not had orchiopexy are 2 to 6 times as likely to have testicular cancer. For an undescended testis, the most common malignant histology is seminoma. For those who undergo early orchiopexy, the most common malignancy is non-seminoma. Of note, in approximately 10% of patients with cryptorchidism who develop germ cell tumors, the cancer is found in the normally descended testis. Biopsies of nonenlarged cryptorchid testes demonstrate an increased incidence of intratubal germ cell neoplasm, a presumed precursor lesion. Genetics Klinefelter syndrome (47XXY) is associated with a higher incidence of germ cell tumors, particularly primary mediastinal germ cell tumors. For first-degree relatives of individuals affected with 47XXY, approximately a 6- to 10-fold increased risk of germ cell tumors has been observed. In addition, patients with Down syndrome have been reported to be at increased risk for germ cell tumors. Also thought to be at greater risk are patients with testicular feminization, true hermaphroditism, persistent MÃ¼llerian syndrome, and cutaneous ichthyosis. Virtually all adult patients with germ cell tumors have increased copies of isochromosome 12p, usually as i(12p). This is a useful marker in patients with undifferentiated tumors who fit the clinical profile of patients with germ cell malignancy. Although the i12p target genes have not been clearly defined, several candidate genes have been mapped to an amplified region at 12p11 and 12p13. Several other regions of the genome are also imbalanced, at a lower frequency than i12p. 12p is the location of the genes encoding the proteins involved in KITLG-KIT signaling. After KITLG-KIT is aberrantly activated in utero, additional genetic events, including overexpression of transcription factors such as NANOG, SOX17, and OCT3/4, lead to increased proliferation and accumulation of additional mutations. Epigenetic dysregulation also appears to play an important role in subsequent steps leading to the cancer phenotype.Whole-genome sequencing has identified mutations in the tumor suppressor gene CDC27, as well as recurring amplifications at the fibrous sheath interacting protein gene FSIP2, at 2q32.1 and region ar Xq28. A small number of patients may harbor the gene implicated in cisplatin resistance, XRCC2. Family History Of patients with newly diagnosed testicular cancer, approximately 1.4% have a family history of the disease. The risk of testicular cancer is increased 4- to 6-fold and 8- to 10-fold in sons and siblings of patients with testicular cancer, respectively. Environment Numerous industrial occupations and drug exposures have been implicated in the development of testicular cancer. Although exposure to diethylstilbestrol (DES) in utero is associated with cryptorchidism, a direct association between DES and germ cell neoplasm is weak at best. Reports have suggested an increased risk of testicular cancer among individuals exposed to exogenous toxins, such as Agent Orange and solvents used to clean jets. One author has suggested that on the basis of epidemiologic evidence, exposure to ochratoxin A correlated with incidence data for testicular cancer. Prior trauma, elevated scrotal temperature (secondary to the use of thermal underwear, jockey shorts, and electric blankets), and recurrent activities such as horseback riding and motorcycle riding do not appear to be related to the development of testicular cancer. No supporting findings substantiate a viral etiology. Fertility An increased risk of infertility exists for men with unilateral testicular cancer successfully treated with orchiectomy. For example, 40% of patients have subnormal sperm counts, and by 1 year, 25% continue to have subnormal sperm counts. Signs and Symptoms Local Disease Scrotal mass The most common complaint of patients on presentation is a painless scrotal mass that on physical examination cannot be separated from the testis. This finding distinguishes the mass from epididymitis. Not infrequently, the mass may be painful and, thus, may mimic epididymitis, orchitis, or testicular torsion. Hydrocele Approximately 20% of patients with germ cell tumors have an associated hydrocele. Inguinal adenopathy Patients generally do not have inguinal adenopathy in the absence of prior scrotal violation. Other symptoms Other symptoms include low back pain (from retroperitoneal adenopathy) and gynecomastia due to elevated Î²-hCG levels. In cases of massive retroperitoneal lymphadenopathy, abdominal pain, nausea, vomiting, and constipation may be reported. Disseminated Disease Patients with disseminated germ cell tumors usually present with symptoms from lymphatic or hematogenous dissemination. Mediastinal adenopathy may be associated with chest pain or cough. Supraclavicular lymphadenopathy may also be present. The cumulative 10-year risk of developing metachronous testicular cancer for patients with extragonadal germ cell tumors is 10.3%. Patients with extragonadal tumors of the retroperitoneum and NSGCTs have a 14.3% 10-year risk of the development of metachronous testicular cancer. Some, however, may have previously undiagnosed occult testicular primary tumors. Hematogenous spread to the lungs may be associated with dyspnea, cough, or hemoptysis. Infrequently, patients with extensive disease may present with signs and symptoms of CNS metastases or bone pain from osseous metastases (most common in patients with seminoma). Metastases to the liver are not uncommon and may manifest as fullness in the upper abdomen or vague abdominal discomfort. More likely, they will be identified on CT scan in an otherwise asymptomatic patient. Primary Mediastinal Germ Cell Tumors Primary mediastinal germ cell tumors are associated with several unique syndromes, including Klinefelter syndrome and acute megakaryocytic leukemia. In addition, mediastinal tumors have a great propensity for the development of non–germ cell malignant histology as a major component of the tumor (eg, embryonal rhabdomyosarcoma, adenocarcinoma, and peripheral neuroectodermal tumor). Screening and Diagnosis Screening Self-examination Testicular self-examination is both simple to learn and safe to perform. The rarity of testicular cancer, however, calls into question the value of routine aggressive screening procedures. Testicular biopsy Testicular biopsy of a suspicious lesion is not recommended. Approximately 95% of patients with a mass within the testicle have a malignancy. Orchiectomy is the preferred treatment for patients with a testicular mass. CIS appears to be the precursor lesion for most testicular germ cell tumors, except spermatocytic seminoma. Most patients harboring CIS can be expected to develop testicular cancer, but with a latency period of a decade or more. The incidence of CIS in infertile men is about 0.6%. In patients with prior testicular cancer, biopsy will reveal CIS in the contralateral testis at a rate of approximately 5% to 6%. Men with a history of cryptorchidism and presumed extragonadal germ cell tumor are at greater risk for CIS. Some investigators suggest routine biopsy of the contralateral testis in men with CIS. Diagnosis Ultrasonography Ultrasonography can reliably identify masses within the testis. In virtually all patients, ultrasonography can distinguish a testicular lesion from an extratesticular mass and may detect lesions that are not palpable on physical examination. Ultrasonographic findings cannot consistently differentiate benign lesions from malignant tumors of the testis (95% of such masses are malignant). Most patients with testicular cancer, and especially those with seminoma, have lesions that are hypoechoic when compared with adjacent tissue. NSGCTs, however, may cause mixed signals, including hyperechoic masses, which are commonly seen with teratoma. Serum markers Serum levels of Î²-subunit human chorionic gonadotropin (Î²-hCG) and Î±-fetoprotein (AFP) are elevated in approximately 80% to 85% of patients with extensive germ cell tumors. Patients with pure seminoma may have elevated levels of Î²-hCG but not of AFP (a significantly elevated AFP level usually indicates the presence of NSGCT elements). False-positive Î²-hCG levels can be seen in patients who have hypogonadism (cross-reactivity with luteinizing hormone) or who use marijuana; AFP levels may be elevated in patients with liver dysfunction or hepatitis. Lactate dehydrogenase (LDH) is a nonspecific marker that is associated with tumor bulk. Inguinal orchiectomy When a testicular mass is discovered, the patient should undergo an orchiectomy through an inguinal incision even when he has undergone initial chemotherapy. Trans-scrotal incisions or biopsies These procedures should not be performed, because they may ultimately lead to aberrant lymphatic drainage from the tumor or scrotal contamination. Staging Evaluation The principal objective of the staging evaluation is to ascertain whether the patient has early-stage disease (which is amenable to local therapy) or disseminated disease (which requires chemotherapy). Chest Radiography A chest radiograph can determine whether or not a patient has gross supradiaphragmatic metastases, which would mandate initial chemotherapy. Chest CT In patients with a normal chest radiograph, chest CT is recommended in both patients with seminoma and those with NSGCT when abdominal adenopathy is found to rule out occult metastases within the lungs or mediastinum. If such metastases are present, the patient should be treated with primary chemotherapy. Abdominopelvic CT This test provides important information about the retroperitoneal lymph nodes. Usually, periaortic adenopathy is noted on the ipsilateral side of the primary tumor. Patients with primary retroperitoneal germ cell tumors often show an enlarged retroperitoneal mass in the midline. Although hepatic metastases are infrequent, CT is the most viable method of determining the presence of these metastatic lesions. Positron Emission Tomography Seminomas are FDG-avid. In some cases, nodal and extranodal metastases not appreciated on CT scans may be noted with FDG-positron emission tomography (PET). The optimal use of FDG-PET is in patients with residual masses following systemic therapy for pure seminoma. In such cases, the scans should be performed at least 3 to 4 weeks after the last course of chemotherapy. Because teratoma is not PET-avid, its usefulness in NSGCTs is limited to patients with late recurrences manifested with marker-only disease. Other Scans In the absence of symptoms or signs, a CT scan (or magnetic resonance imaging) of the head and radionuclide bone scan are unnecessary. PET scans may be useful in patients with residual disease following chemotherapy for seminoma. If a PET scan is positive in such patients, surgical resection of the residual mass is indicated. Otherwise, the residual mass can be simply followed with periodic radiographic evaluation. Pathology Germ cell tumors are classified into two broad histologic categories: seminoma and NSGCT. Patients with seminoma who have increased AFP levels or any focus of NSGCT components (including teratoma) are considered to have NSGCT. Seminoma Seminoma is the most common single histology, accounting for approximately 30% of all germ cell tumors. Up to 10% of seminomas have focal syncytiotrophoblastic cells, which are believed to be the source of Î²-hCG in some cases. Elevated AFP levels connote NSGCT. Seminomas typically stain positively for placental-like alkaline phosphatase (PLAP), c-KIT, OCT 3, and OCT 4 by immunohistochemistry. Spermatocytic seminoma This is a rare subset of germ cell tumors. These tumors often grow to a large size, occur almost exclusively in men older than 50 years of age, and rarely, if ever, metastasize. Unlike classic seminoma, immunohistochemical staining is currently negative for PLAP. Other evidence suggests a different cell of origin for spermatocytic seminoma than for other germ cell tumors. Cure rates approach 100% with orchiectomy alone. NSGCT Embryonal carcinoma This lesion is composed of large pleomorphic cells with different architectural patterns. This tumor may be associated with an elevation in the serum levels of Î²-hCG and/or AFP. Embryonal cancers typically stain positively for PLAP, CD30, OCT 3, and OCT 4 by immunohistochemistry. Endodermal sinus tumor (yolk sac carcinoma) This is the most common testicular tumor seen in infants and young children. Like embryonal carcinoma, the yolk sac tumor has a variety of architectural patterns. This tumor is associated with an elevated serum level of AFP. Yolk sac tumors stain positively for AFP and glypican-3 by immunohistochemistry. Choriocarcinoma As a pure entity, choriocarcinoma is one of the least common germ cell tumors. These tumors have a great propensity for hematogenous spread, often skipping the retroperitoneum. Choriocarcinoma is associated with an increased serum level of Î²-hCG. Choriocarcinomas stain positively for hCG and glycipan-3 by immunohistochemistry. TABLE 2: Staging systems for testicular cancer Teratoma Teratoma is a generally benign tumor with elements from each of the germ layers (ectoderm, mesoderm, and endoderm). Teratoma is uncommonly seen as the sole histology in primary tumors, but it is frequently associated with other histologic elements, including those previously mentioned. Of patients with residual disease following chemotherapy for NSGCT, about 20% to 80% will have evidence of teratoma in resected specimens, depending on whether or not there was evidence of teratoma in the orchiectomy. A subset of teratomas can transform into more malignant tumors, such as primitive neuroectodermal tumor, adenocarcinoma, and sarcoma. These tumors carry a poor prognisis and are generally not curable by chemotherapy, although surgery offers a chance for cure in some patients, if disease remains localized. In addition, late recurrences of both teratoma and carcinoma have been reported in patients with teratoma. Serum markers are normal in patients with pure teratoma. TABLE 3: IGCCCG criteria for good-, intermediate-, and poor-risk testicular cancer patients treated with chemotherapy Pattern of Spread Testicular cancer spreads in a fairly predictable fashion: from the testicle to the retroperitoneal lymph nodes and, later, hematogenously to the lungs or other visceral sites. Only 10% of patients present with hematogenous metastases (usually in the lungs) in the absence of discernible retroperitoneal adenopathy. Staging Systems Clinical staging systems (Royal Marsden and TNM systems) for testicular cancer are outlined in Table 2. These staging systems help define the population for appropriate primary therapy. Good-, Intermediate-, and Poor-Risk Subgroups For patients with NSGCTs who are candidates for chemotherapy, other staging systems (such as those by Indiana University and the Memorial Sloan-Kettering Cancer Center [MSKCC]) were developed to segregate patients into good- and poor-risk categories. More recently, the International Germ-Cell Cancer Collaborative Group (IGCCCG) formulated a classification that more clearly defines good-, intermediate-, and poor-risk disease (Table 3) and is currently being used to stratify patients for appropriate chemotherapy and in ongoing trials. Treatment Treatment of Stage I or II Disease In patients with clinical stage I disease (normal serum markers and normal CT scans of the chest and abdomen), the risk of relapse is 15% to 20% and the majority of relapses occur in the retroperitoneum. Tumor size greater than 4 cm and rete testis involvement have been reported to be the most reliable risk factors for recurrence of seminoma, and lymphovascular invasion is the most reliable risk factor for recurrent of NSGCT. A pooled-analysis of data from the Royal Marsden Hospital, Danish Testicular Cancer Study Group, Princess Margaret Hospital, and the Royal London Hospital (Warde et al: J Clin Oncol 2002) initially suggested risk-based prognostic groups based on tumor size and rete testis invasion may enable a risk-adapted treatment approach for stage I seminoma. However, a study that used an independent data set with 687 patients and median follow-up of 4 years has found that tumor size is the only factor that predicts relapse and that rete testis invasion is not of prognostic importance. The preferred management post-orchiectomy for stage I seminoma is surveillance. Sidebar: The largest study of surveillance in stage I seminoma followed more than 1,900 patients for 15 years. Disease-specific survival at 5, 10, and 15 years was 99.6%, 99.4%, and 99.3%, respectively. The relapse rate was 18.9% after a median time of 13.7 months (Mortensen MS et al: Eur Urol 66:1172-1178, 2014). Alternatively, adjuvant radiotherapy is highly effective for patients who are unable or unwilling to participate in a surveillance program. Adjuvant single-agent carboplatin, given for one or two cycles, has also been investigated. Results of salvage therapy for patients who experience a recurrence while on surveillance are excellent, and this approach achieves about a 100% cure rate with three cycles of BEP (bleomycin, etoposide, cisplatin) or four cycles of EP (etoposide, cisplatin). Surgery Initial intervention for testicular cancer is radical inguinal orchiectomy. Orchiectomy may be deferred temporarily in patients with advanced-stage disease in whom the diagnosis of NSGCT can be made on clinical grounds (elevated markers). In such patients, an orchiectomy must be performed sooner or later, because there is incomplete penetration of chemotherapy into the testes. Further therapy hinges on the pathologic diagnosis. In general, most clinical stage I tumors are typically followed with surveillance (see discussion later in this chapter). In more advanced stages of the disease, patients with pure seminomas are treated with radiotherapy or chemotherapy, whereas patients with NSGCTs are treated with surgery and/or chemotherapy. Inguinal orchiectomy. In addition to removal of the testis, the spermatic cord is dissected high into the retroperitoneum. The vas deferens is isolated from the testicular vessels and ligated separately with a permanent suture. Also, the testicular vessels are freed from the peritoneum and carefully ligated with a permanent suture. Retroperitoneal lymph node dissection (RPLND) for NSGCTs. For patients with NSGCTs and either no evidence or a small volume of disease on CT (stage I [N0] or stage II [N1, N2a, N2b] disease), RPLND was generally indicated because it (1) accurately and definitively defines the presence or absence of retroperitoneal metastases and (2) removes the retroperitoneum as a site of recurrence, thus obviating the need for surveillance with CT. Today, most patients undergo surveillance or primary chemotherapy (see discussion later in this chapter). RPLND can be accomplished transperitoneally or retroperitoneally through a thoracoabdominal approach. The thoracoabdominal approach is more technically difficult but eliminates the risk of postoperative small-bowel obstruction and usually requires a shorter hospital stay. TABLE 4: Follow-up schedule for germ cell tumor TABLE 5: Chemotherapy regimens for testicular cancer • Nerve-sparing surgery-Regardless of the approach, urologic oncologists recommend a unilateral, nerve-sparing procedure. For right-sided tumors, the medial border of the template is the midpoint of the aorta, and for left-sided tumors, the medial border is the midpoint of the inferior vena cava (IVC). The sympathetic trunks responsible for normal bladder neck closure during ejaculation course lateral to the aorta on the left side and behind the IVC on the right side. Below the inferior mesenteric artery, both sympathetic trunks send branches to the region anterior to the aorta. The branches coalesce and then pass to the bladder neck. Critical aspects of nerve-sparing surgery include preservation of the ipsilateral sympathetic nerve trunk and bilateral preservation of branches below the level of the inferior mesenteric artery. In our experience and that of other authors, it is possible to maintain normal ejaculatory function in virtually all patients using this technique. With a template dissection, there is some risk of disease outside the template. Eggener et al at MSKCC have reported good recovery of ejaculation with bilateral dissection using a nerve-sparing approach. Radiation therapy for stage I seminomas Seminomas of the testes are exquisitely sensitive to irradiation. This characteristic, combined with their predictable lymphatic spread, makes these cancers amenable to radiotherapy. Since low radiation doses are used, acute and late side effects are few, although second primary malignancies in the radiation field and coronary vascular disease (when mediastinal fields have been used) have been reported. Radiotherapy is not indicated in patients with NSGCT, except in the palliative setting. Fields and doses. The radiotherapy portals have traditionally included the retroperitoneal lymph nodes, which are the primary drainage of the testis, from T10 to L5 and the ipsilateral hemipelvis, including the inguinal scar. However, studies that reduced the size of the retroperitoneal field and omitted hemipelvis irradiation in select patients (eg, those who have not undergone prior orchiopexy or other pelvic, inguinal, or scrotal surgery) favor smaller treatment volumes. The T10 study that randomized 478 men with stage I seminomas to receive irradiation of the para-aortics (T11 to L5) and ipsilateral hemipelvis (dogleg) or irradiation of the para-aortics only was recently updated, with a median follow-up of more than 10 years. The actuarial rate of 5-year freedom from relapse was about 96% for both groups. There were four pelvic relapses in patients given retroperitoneal radiation therapy only (two with additional systemic relapse) vs no relapses in the dogleg arm. Otherwise, the few failures observed following radiotherapy most often occurred in the next level of lymph node drainage sites, such as the mediastinum or left supraclavicular fossa. A single seminoma-related death was recorded in the para-aortic radiation-only arm. In the interest of minimizing the field size, together with data from Bruns et al that demonstrates a very low risk of recurrences above T12, the para-aortic field can be further reduced to the bottom of T11 to the bottom of L5. The smaller treatment volume reduces the dose to the remaining testicle and probably the risk of secondary malignancy. The ipsilateral hemipelvis is treated only when there is a history of ipsilateral inguinal surgery. Violation of the inguinal region can alter the testicular lymphatic drainage pathway to the para-aortic region. The hemiscrotum is often treated if the tumor has penetrated the tunica albuginea, a trans-scrotal incision was performed, or orchiopexy was performed for cryptorchidism. This practice has been questioned, however, since the incidence of scrotal failure is low, even in the presence of these risk factors. In fact, some surgeons advocate the use of trans-scrotal exploration to rule out benign lesions. The T18/T19 study randomized 1,094 patients with clinical stage I seminoma to receive adjuvant para-aortic radiation therapy at 30 Gy or 20 Gy. The relapse-free rates at 5 years with these two radiation doses were 95.1% and 96.8%, respectively, and treatment with 20 Gy in 10 daily 2-Gy fractions is preferred. Side effects. The acute side effects of radiotherapy are limited to nausea, vomiting, and infrequently, diarrhea, all of which usually can be readily controlled with medication. Long-term complications reported at The University of Texas MD Anderson Cancer Center demonstrated increased mortality ratios for overall, cardiac-specific, and secondary cancer deaths for men treated with radiation therapy for seminoma between 1951 and 1999. No difference in mortality risk was noted in the first 15 years following treatment; however, over the entire period, the all-cause mortality risk was 1.59. The cardiac-specific mortality rate after 15 years was 1.61, and the secondary cancer mortality rate was 1.91. Permanent infertility from scattered irradiation to the contralateral testis is uncommon, whereas prolonged aspermia for more than 1 year may occur, especially with irradiation of the hemiscrotum. Nevertheless, sperm banking is recommended for patients concerned about childbearing. Follow-up. Relapse following adjuvant radiotherapy occurs in 2% to 5% of patients, and the great majority of recurrences occur within the first 2 to 3 years after treatment. Recurrences are typically found in lymph nodes of the pelvis, abdomen, groin, mediastinum, supraclavicular fossa, and neck. Physical examination of these areas and CT evaluations of the abdomen and pelvis can aid with the detection of recurrence. Owing to increasing concerns about late effects related to radiographic studies, two evidence-based studies have suggested fewer follow-up evaluations than have traditionally been performed. Follow-up with imaging studies two or three times a year during the first 3 to 4 years of follow-up has been suggested. The additional value of chest imaging and tumor markers (AFP, Î²-hCG, and LDH) has been questioned, because few recurrences are detected on the basis of these evaluations alone. However, these studies are routinely done, because solitary pulmonary recurrences can occur and because these tumor markers may also support the suspicion of recurrence indicated on physical examination or imaging. Chest radiography is the preferred method for imaging the chest, because the radiation exposure is lower than that with CT. Late recurrences are well documented, and annual follow-up until at least year 6 has been suggested, a point in time at which the risk of recurrence falls below 0.3% per year. Radiation therapy for stage II seminomas Fields and doses. The radiotherapy fields are similar to those used for stage I disease, except that they are widened to include any retroperitoneal or pelvic adenopathy with a 2- to 3-cm margin. In the past, mediastinal and supraclavicular treatment was standard in patients with stage II disease. However, data from several series revealed only a 3% rate of mediastinal/supraclavicular relapse. In addition, late cardiac toxicity has been reported. Although treatment to supradiaphragmatic sites has largely been abandoned in these cases, one report indicates that the rate of failure in the left supraclavicular fossa is higher than was previously believed. An analysis from another group indicates the opposite, however-that supradiaphragmatic radiotherapy for stage IIA-B seminoma is unnecessary. The overall actuarial rate of freedom from disease at 5 years for patients with retroperitoneal adenopathy less than 2 cm (IIA) is 95%, 2 to 5 cm (IIB) is 90%, and more than 5 and less than 10 cm (IIC) is 85%. Involved areas are usually treated with 30 (IIA) to 36 Gy (IIB), and uninvolved areas are treated with 20 Gy in 10 fractions or alternatively, 25 Gy in 15 fractions. There is no evidence of a dose-response effect above 25 Gy for uninvolved areas and above 36 Gy for involved areas. Failures within the irradiated volume are anecdotal. Chemotherapy Stage I seminomas. Several studies have evaluated the role of chemotherapy, typically carboplatin as adjuvant therapy, for clinical stage I seminoma. Single-cycle carboplatin (area under the curve [AUC] = 7) has been studied as an alternative to adjuvant radiotherapy in a randomized trial conducted by the United Kingdom Medical Research Council (UKMRC)/European Organisation for Research and Treatment of Cancer (EORTC). At a median follow-up of 6.5 years, the 5-year relapse-free survival rate among the 1,477 randomized patients was 96% and 94.7% after radiation therapy and carboplatin, respectively (hazard ratio of relapse = 1.25; 90% confidence interval [CI], 0.83–1.89; 95% CI, 0.77–2.03). First-echelon retroperitoneal nodal recurrences were more common in the chemotherapy group (67% vs < 10%). Retroperitoneal nodal recurrences following radiotherapy are infrequent but typically are marginal misses at the edge of the treatment field. Further questioning the role of single-cycle carboplatin in stage I disease, a pooled analysis of two randomized trials in advanced-stage disease demonstrated that single-agent carboplatin is inferior to cisplatin-based combination therapy. Phase II results evaluating two cycles of carboplatin (400 mg/m2) for prophylactic treatment of stage I seminomas were more promising. However, acute toxicity (ie, the degree of lethargy and time missed from work) is unlikely to be less than that of a 2-week course of radiotherapy. • Adjuvant radiotherapy vs chemotherapy vs surveillance-On the basis of surveillance data, the overall incidence of disease failure without adjuvant therapy is 15% to 20% in stage I seminoma. This means that adjuvant therapy (radiation or carboplatin) will result in overtreatment in 80% to 85% of patients. A risk-adapted strategy that uses adjuvant treatment rather than surveillance for the highest-risk group (> 4-cm primary tumor and/or rete testes involvement) has been advocated by some clinicians, but it would result in overtreatment for at least 65% of men. In addition, radiation therapy is associated with increased risk of secondary malignancies and cardiovascular disease. Surveillance CT scans of the abdomen are not needed after adjuvant radiation therapy, since retroperitoneal relapses are rare. One cycle of single-agent carboplatin is probably slightly less effective than radiation but appears to be safe with 6.5 years of follow-up (longer follow-up data are awaited). However, surveillance CT scans of the abdomen are still required after adjuvant treatment with carboplatin. Follow-up in patients undergoing surveillance is rigorous and intended to identify disease before tumor is bulky or supradiaphragmatic requiring chemotherapy. Disease progression usually is not associated with symptoms until the tumor burden is large. Surveillance requires abdominopelvic CT scans and chest radiographs at 4-month intervals for 3 to 4 years and then annually for at least an additional 5 years. Late failures beyond 5 years have been observed. Salvage rates reported in patients who relapse while undergoing surveillance are approximately 90% initially, with ultimate salvage rates after relapse of 99% to 100%. Thus, in summary, stage I seminoma is a highly curable disease with a disease-specific survival of 99% to 100%. Surveillance after orchiectomy is preferred, since any adjuvant therapy will result in overtreating the majority of patients who would have been cured with surgery alone. In patients who are poor follow-up candidates or who choose adjuvant therapy, radiation therapy (20 Gy to the para-aortic region) or a single dose of carboplatin (AUC = 7) can be used. Chemotherapy treatment with three cycles of BEP or four cycles of EP is recommended in patients with stage IIC disease and multilevel stage IIB disease. Stage I NSGCT. The risk of relapse after radical orchiectomy is about 30%. The main risk factors are lymphovascular invasion and embryonal carcinoma predominant disease (risk up to 40% to 50%). When patients on surveillance develop recurrent disease, the cure rate is about 100%. Adjuvant RPLND and chemotherapy have been used to decrease the risk of recurrence. In a randomized clinical trial, patients with clinical stage I NSGCT underwent primary RPLND (n = 191) or received one cycle of BEP (n = 191). Only two recurrences occurred in the BEP arm and 15 occurred in the RPLND arm. All patients are currently without evidence of recurrence. Given the excellent cure rate achieved when recurrences are found during surveillance, and to avoid overtreating the majority of patients with stage I NSGCT, surveillance is preferred whenever feasible (Table 4). • Compliance and quality of surveillance-In a study of 75 patients with stage I NSGCTs, compliance with clinical examinations was 61.5% in year 1 and 35.5% in year 2, whereas compliance with abdominal/pelvic CT was only 25% and 11.8% in years 1 and 2, respectively. Careful selection of highly motivated patients for surveillance is indicated. The quality of surveillance for stage I testicular cancer in the community was reported from private insurance claims between 2002 and 2007. Seven hundred men underwent radical orchiectomy and 279 were managed with surveillance. Compliance with surveillance follow-up protocols recommended by referral centers was poor. Nearly 30% of all surveillance patients received no abdominal imaging, chest imaging, or tumor marker tests within the first year of diagnosis. Sidebar: A large retrospective study evaluated 1,034 men with clinical stage I NSGCT managed with active surveillance; 886 had no lymphovascular invasion (LVI–). A total of 221 relapses occurred among 17% of LVI– patients, compared with 50% of the LVI+ patients. At last follow-up, 98% were alive without disease, 1.5% died of other causes, and 7 (0.05%) were alive with disease or dead from their disease (Kollmannsberger CK et al: J Clin Oncol 31[suppl]: abstract 4503, 2013). Stage II NSGCTs. Over the past several years, the threshold for primary surgery in patients with stage II disease on CT scans has changed. At present, masses larger than 3 cm in greatest cross-sectional diameter or those with more extensive longitudinal lymphatic spread are generally handled primarily with chemotherapy. For patients with tumors that are 3 cm or smaller, primary RPLND is considered a standard approach. Up to 25% of patients with enlarged lymph nodes on CT scans will have pathologic stage I (false-positive) disease by RPLND. In patients with serial rising markers (serologic stage II disease), chemotherapy is the standard of treatment. • Adjuvant chemotherapy-Following RPLND, the risk of systemic recurrence is 5% to 10% in patients with pathologic stage I nonseminomas, 15% to 30% in those with completely resected stage IIA (N2a) disease, and 30% to 50% in those with stage IIB (N2b) disease. Recurrence usually occurs in the lungs within the first 24 months after surgery. The risk of retroperitoneal recurrence in patients with stage I, IIA, or IIB disease is less than 1% after a properly performed RPLND. Following RPLND, patients with complete resection of stage II disease can be considered candidates for adjuvant chemotherapy. The decision of whether or not to prescribe adjuvant chemotherapy following lymph node dissection is somewhat arbitrary and often depends on the patient’s social circumstances and likelihood of adhering to close follow-up. A patient with completely resected carcinoma who undergoes RPLND has a 70% chance of cure; thus, the majority of patients will never need chemotherapy. However, these patients must be monitored carefully with chest radiography and serum marker determinations every 2 months for 1 year, every 4 months for an additional year, and then every 6 months for the next 3 years. (CT scanning is not performed routinely unless clinically indicated, such as resection of teratoma.) The 30% of patients followed in such a manner who do develop recurrence will present with a tumor of low volume (eg, small pulmonary metastases or elevated serum markers); nearly 100% of these patients should be cured with appropriate systemic therapy. However, some patients with resected stage II disease elect to receive adjuvant chemotherapy to minimize the risk of cancer recurrence. For such therapy, two cycles of BEP are recommended (Table 5). In a patient who agrees to close follow-up, the chance of dying of cancer should be negligible in either scenario. For patients who have persistently elevated or increasing serum markers following RPLND or who have undergone incomplete lymph node dissection, three cycles of BEP are indicated. Treatment of Stage III Disease Seminomas Chemotherapy is the treatment of choice for patients with stage III seminomas (see Table 5) using either BEP for three cycles or EP for four cycles. The management of patients with bulky disease after chemotherapy (residual mass > 3 cm) is somewhat controversial. Investigators at MSKCC suggested that such patients require consolidation with radiotherapy or surgical removal of radiographically evident disease. Data from the Royal Marsden Hospital and the Centre LÃ©on BÃ©rard showed a relapse rate of 10% to 15% in patients with residual masses with or without postchemotherapy surgery or radiotherapy, supporting the practice of observation in patients with residual masses following chemotherapy. FDG-PET may be helpful in the decision to treat residual masses larger than 3 cm but should be performed 4 to 6 weeks after the last course of chemotherapy. Thus, resection is recommended for patients with residual masses larger than 3 cm and an abnormal PET scan. NSGCTs As mentioned previously, patients with NSGCTs being treated with chemotherapy can be classified as having good-, intermediate-, or poor-risk disease (see Table 3). Approximately 60% of patients presenting with disseminated disease are categorized as good risk, 26% are intermediate risk, and 14% are poor risk. Good-risk disease. Three cycles of BEP given every 3 weeks or, alternatively, four cycles of EP at the same dosages appear to yield equivalent results. More than 90% of good-risk patients should be cured with these therapies. Two prospective randomized trials comparing cisplatin with carboplatin in good-risk patients with disseminated germ cell tumors have demonstrated inferior results for carboplatin-containing regimens. • Postchemotherapy resection-Patients who have persistent radiographic disease with normal serum markers 4 to 6 weeks following chemotherapy for an NSGCT should undergo surgical resection of the residual mass and bilateral template RPLND when possible. Histologic examination of residual disease will reveal necrotic fibrous tissue in approximately 45% of such cases, benign teratoma in about 45%, and persistent carcinoma in about 10% to 15%. • Postresection chemotherapy-If persistent carcinoma is detected in the resected specimen, two additional cycles of EP should be administered. For patients with complete resection of mature and immature teratoma or necrosis, no additional therapy is needed. Intermediate-risk disease. The optimal management of patients with intermediate-risk disease is not well defined. Most patients with intermediate-risk disease receive the same treatment as those with poor-risk disease (BEP for four cycles or VIP [VP-16, ifosfamide, cisplatin] for four cycles). Intermediate-risk disease, however, encompasses a heterogeneous group of patients, including those with very elevated levels of Î²-hCG (> 5,000 but 1,000 but < 10,000) or patients with seminoma who have non-pulmonary visceral metastses (including bone, brain, or liver). DeWit et al reported results of a phase III trial of intermediate-risk patients randomized to receive standard BEP for four cycles or Taxol plus BEP (T-BEP) for four cycles. There was no statistical difference in progression-free survival on an intent-to-treat basis, although there was a numerical advantage in progression-free survival favoring T-BEP when considering only the eligible patients (82.7% vs 70.1%). There was no difference in overall survival, however. Poor-risk disease. A cohort of patients with disseminated germ cell tumors presents with advanced or poor-risk disease. “Poor risk” has been variously defined (see Table 3) but represents a patient population with a cure rate of 50% or less with standard cisplatin-based combination chemotherapy. Irradiation is useful in the treatment of metastatic NSGCTs to the brain. • Chemotherapy-During the past few years, several trials have evaluated a variety of combination regimens in patients with poor-risk disease (Table 5). The regimen VIP for four cycles appears to be therapeutically equivalent to BEP for four cycles; however, for most patients with advanced disease, BEP is the preferred regimen because it produces less myelosuppression. In patients with underlying pulmonary dysfunction or primary mediastinal non-seminomatous germ cell tumor, VIP is preferred. • High-dose chemotherapy with stem cell transplant (SCT) up-front-A North American intergroup trial randomized 219 previously untreated patients with intermediate- or poor-risk testicular germ cell tumors (TGCTs) to four cycles of BEP or two cycles of BEP followed by two tandem courses of high-dose chemotherapy plus SCT. No difference in the outcome between the two arms was seen, but greater toxicity was seen in the high-dose arm. Recently, a European trial randomized 137 patients with poor-risk disease to four cycles of BEP or one cycle of VIP followed by three cycles of high-dose VIP with SCT. The 2-year failure-free survival rates were 44.8% and 58.2% in the standard and high-dose arms, respectively. The difference was not statistically significant. Overall survival did not differ and toxicity was higher in the high-dose arm. Thus, four cycles of BEP remain the standard of care for poor-risk patients. Sidebar: Dose-Dense Chemotherapy. In the phase III Genitourinary Tumor Group’s GETUG 13 study, 263 patients with poor-prognosis germ cell tumors were treated with one cycle of BEP. After 3 weeks, 51 patients with favorable tumor marker decline continued to receive four cycles of BEP, but 203 patients with unfavorable decline were randomly assigned to receive dose-dense chemotherapy (105 patients) or continued to receive three further cycles of BEP (98 patients). The dose-dense regimen consisted of two cycles of paclitaxel, oxaliplatin, and BEP, followed by two cycles of cisplatin, ifosfamide, and continuous-infusion bleomycin. In patients with unfavorable tumor marker decline, dose-dense chemotherapy reduced the risk of progression or death by 34%. The primary endpoint of progression-free survival rate at 3 years was 59% in the dose-dense arm, compared with 48% for BEP (HR = 0.66; 95% CI, 0.44–1;P= .05). For the secondary endpoint, the 3-year overall survival rate was 73% for the dose-dense arm vs 65% for the BEP arm (P= .34). Adverse events were generally similar between the two arms, however patients receiving dose-dense therapy were more likely to get greater than grade 2 neurotoxicity, with a rate of 23% for patients randomized to the dose-dense regimen vs 4% for patients receiving BEP (Fizazi K et al: J Clin Oncol 31[18 suppl]: abstract LBA4500, 2013). • Postchemotherapy resection-The ultimate goal of combination chemotherapy in these patients is the resolution of all radiographically visible disease and the normalization of tumor markers. If residual radiographic abnormalities persist in the lungs and/or abdomen, surgical resection of residual disease is indicated. Postchemotherapy RPLND must clear the region of residual disease. In general, postchemotherapy resections are extremely difficult, and incomplete resections are unacceptable. After the retroperitoneum is cleared of persistent radiographic disease, persistent pulmonary lesions are resected. In cases with residual disease in the retroperitoneum and thorax, RPLND should be performed first. If necrosis is found, the disease within the chest can be observed. If teratoma or cancer is noted, the supradiaphragmatic disease should be resected. Complicating factors associated with postchemotherapy resection include the risk of oxygen toxicity secondary to bleomycin as well as intense fibrosis and adherence of residual disease to the aorta and other vital retroperitoneal organs. Inspired oxygen levels must remain below 35% to prevent bleomycin-related acute respiratory distress syndrome, which has a fatality rate of 50% or more. After successful resection, the only visible structures remaining should include the back muscles, nerves, anterior spinous ligament, aorta, IVC, renal vessels, kidneys, and ureters. Up to 20% of patients with advanced abdominal disease may require resection of a kidney or even the IVC. Operative mortality in centers with experience performing resection of these advanced-stage tumors should be less than 2%. Although intraoperative, postoperative, and late complication rates were higher between groups receiving open primary or postchemotherapeutic RPLND, they were not significantly different when the procedure was performed by fellowship-trained urologists. A more thorough RPLND increases the 2-year relapse-free probability from 90% (10 nodes removed) to 97% (50 nodes removed). Additional procedures may be required in as many as 25% of post-chemotherapy RPLND patients, with retroperitoneal (RP) mass size, elevated markers, and RP pathology as risk factors. • Post–complete remission RPLND-patients who achieve complete remission (normal tumor markers and no residual radiographic abnormalities > 1 cm) with first-line cisplatin-based combination chemotherapy can be monitored safely without additional treatment (RPLND). This was demonstrated in a retrospective review of 141 patients in complete remission. Median follow-up was 15.5 years. Six patients (4%) relapsed and two died as a result of disease progression. Five patients had late relapse and all were rendered disease-free with subsequent treatment. The 15-year disease-specific survival was 97%. • Postresection chemotherapy-As mentioned, two additional cycles of chemotherapy are indicated for patients with persistent viable carcinoma in the resected specimen. For patients with resected teratoma of nonviable necrotic tissue, no additional chemotherapy is warranted. Refractory or Recurrent Disease Approximately 20% to 30% of patients with disseminated germ cell tumors do not attain complete remission with induction chemotherapy or relapse after such therapy. Occasional patients may be erroneously classified as having recurrent disease on the basis of false-positive markers or abnormal radiographic findings. Some of these false-positive results may be due to a growing teratoma; pseudonodules from bleomycin-induced pulmonary disease; or elevated markers from other causes, such as an elevated Î²-hCG level from marijuana use, cross-reactivity with luteinizing hormone, or an elevated AFP level associated with hepatitis or liver dysfunction. Another cause of persistently elevated markers is a tumor sanctuary site (eg, in the testes or brain). Assuming that false disease progression has been ruled out, several approaches to salvage therapy can be used. Prognosis The International Prognostic Factors Study Group collected data on 1,594 patients from 38 centers worldwide who progressed after first-line cisplatin-based chemotherapy. Histology, primary tumor location, response, and progression-free interval after first-line treatment, as well as levels of AFP, Î²-hCG, and the presence of liver, bone, or brain metastases at salvage were identified as independent prognostic variables. The patients were divided into five prognostic categories, with 2-year progression-free survival ranging from 6% to 75%. Surgery Salvage surgery may have a role in certain settings. Surgery in this setting would classified as a complex RPLND, as Foster and Donohue have discussed. Such procedures would include surgery after second-line chemotherapy, re-do RPLND, RPLND for late relapse, or in the setting termed “desperation RPLND” (chemotherapy-resistant patients with rising or elevated tumor markers). These operations are technically more demanding and may require adjuvant procedures such as nephrectomy or resection of the inferior vena cava. After second-line chemotherapy, residual masses should be resected because the histology of these masses is more frequently viable GCT or teratoma. In contrast, in resected masses after first-line chemotherapy, as Daneshmand et al have described, complete resection offers patients long-term freedom from relapse. Re-do RPLND is a resection of localized recurrence in the retroperitoneal field after previous treatment or surgery. These patients should usually receive upfront chemotherapy before surgery, especially if there are elevated markers-unless there is convincing evidence of the relapse being teratoma, in which case chemotherapy would be ineffectual and surgery alone potentially curative. Late relapse is a recurrence of cancer 2 years or longer after initial therapy. These recurrences are often with viable GCT or teratoma. The teratomatous recurrence may also be associated with somatic malignancy. These recurrences, too, should be resected. Desperation RPLND performed in the setting of a residual mass with persistently elevated markers should be considered in select settings. Newer salvage chemotherapy regimens, such as TICE, have offered improved survival benefits. When desperation RPLND is being considered, an assessment of resectability should be weighed against risks of complications and cancer benefit. However, as Beck et al have reported, in select settings 30% to 70% of patients may have long-term cure, including up to 30% of patients with viable GCT in the resected mass. Salvage chemotherapy Ifosfamide is one of a few drugs (including etoposide, gemcitabine [Gemzar], and paclitaxel) that have clinical activity in patients with cisplatin-refractory disease. As second-line therapy, VeIP (vinblastine, 0.11 mg/kg on days 1 and 2 [total dose = 0.22 mg/kg]; plus ifosfamide, 1.2 g/m2 [plus mesna (Mesnex)]; plus cisplatin [Platinol], 20 mg/m2, both on days 1 to 5) produces durable complete remissions in approximately 30% of NSGCT patients and 50% of seminoma patients previously treated with BEP chemotherapy (Table 5). Toxicity, which is primarily hematologic, can be minimized with the use of a colony-stimulating growth factor. TIP (paclitaxel [Taxol], 175 mg/m2 on day 1; plus ifosfamide, 1.2 g/m2 [plus mesna (Mesnex)]; plus Platinol, 20 mg/m2-both on days 1 to 5) is another salvage regimen that has been used in patients with good-risk relapsed TGCT (gonadal origin, response to cisplatin-based first-line chemotherapy and a progression-free interval of at least 6 months) with a 63% durable complete remission rate. Seminoma. Patients with recurrent seminoma appear to be more sensitive to salvage therapy. In a study by Miller et al (J Clin Oncol 1997), 24 patients with seminoma were treated with VeIP as second-line therapy (following relapse after cisplatin-etoposide combination therapy). Of the 24 patients, 20 patients (83%) achieved a complete response, and 13 patients (54%) are long-term survivors, including 4 of 6 with extragonadal primary sites. As previously stated, patients with seminoma tend to be older than those with nonseminoma. As a result, some patients with relapsed seminoma may be older than 50 or 60 years and may have more comorbidities than their younger counterparts. For these patients, treatment with VeIP for four cycles should be considered. Other patients with relapsed seminoma should be considered for high-dose chemotherapy with stem cell rescue (see below). High-dose chemotherapy with stem cell rescue. High-dose chemotherapy with tandem courses of carboplatin and etoposide plus autologous stem cell rescue produces durable complete remission in patients with relapsed germ cell tumors. When this approach is used in patients with recurrent, but not cisplatin-refractory, disease, improved response rates are observed; more than 60% of all patients with recurrence of testicular cancer (excluding extragonadal recurrence) will be cured. Approximately 70% of patients treated with second-line therapy are curable with this approach. A retrospective review by Einhorn et al evaluated 184 patients who had progressed on initial platinum-based therapy. They were treated with two consecutive courses of high-dose chemotherapy with carboplatin and etoposide followed by infusion of autologous peripheral-blood hematopoietic stem cells. Of the 135 patients who received this treatment as second-line therapy, 94 were disease-free; 22 of 49 patients who received this treatment as third-line therapy or later were disease-free; and 18 of 40 platinum-refractory patients were disease-free. With respect to relapsed seminoma, 74% are continuously with no evidence of disease with high-dose therapy, including 14 of 15 patients with seminoma in whom high-dose therapy was given in the second line. Investigators at MSKCC have also reported on their experience with the TICE regimen. TICE consists of one cycle of Taxol plus ifosfamide followed by three cycles of high-dose carboplatin plus etoposide with stem cell rescue. One hundred seven patients were treated between 1993 and 2006. The 5-year disease-free survival was reported to be 47%, with an overall 5-year survival rate of 52%. Of special note, 5 of 21 patients with primary mediastinal NSGCT are reported to have no evidence of recurrent disease. A retrospective review of 1,594 patients in 38 centers worldwide treated with either high-dose or conventional-dose chemotherapy as first salvage treatment showed better progression-free and overall survival with high-dose chemotherapy.The number of high-dose treatments is controversial. Indirect comparison reveals better outcomes with tandem transplants as opposed to a single transplant. In addition, the only randomized trial in patients with relapsed germ cell tumors after first-line cisplatin-based chemotherapy showed that four cycles of ifosfamide-based salvage chemotherapy was equivalent to three cycles of ifosfamide-based salvage chemotherapy plus one cycle of high-dose chemotherapy. Lorch et al initiated a randomized trial to compare a single cycle with three sequential cycles of high-dose chemotherapy in patients with relapsed germ cell tumors. That study was stopped early because of excess mortality in the sequential arm. Patients with relapsed mediastinal germ cell tumors have a poor prognosis with a 2-year disease-free rate of 0% to 11% after high-dose chemotherapy. Other agents. Few drugs besides etoposide and ifosfamide have activity in patients with cisplatin-refractory disease. Oral etoposide given according to a long-term schedule (50 mg/m/d for 21 days) has produced objective responses in approximately 20% of patients who were previously treated with intravenous etoposide. Paclitaxel has a similar response rate in minimally pretreated patients (fewer than six cycles). Gemcitabine produces a response rate of approximately 15% in patients with cisplatin-refractory disease. The Eastern Cooperative Oncology Group (ECOG) conducted a phase II trial of gemcitabine (1,000 mg/m2) plus paclitaxel (110 mg/m2) given on days 1, 8, and 15 of a 4-week cycle for a maximum of six cycles in patients with recurrent germ cell tumors not thought to be curable with standard chemotherapy or surgery. (All were previously treated with high-dose chemotherapy.) Of 28 evaluable patients, six responded, including three who had complete responses (two of whom were free of disease at 15+ and 25+ months). In a group of patients not considered to be curable with standard salvage chemotherapy, cisplatin plus epirubicin produced durable complete remissions in seven of 30 patients. Survivorship Issues Delayed Toxicity From Systemic Therapy Delayed toxicity from systemic therapy for germ cell tumors has been well characterized. In the absence of signs and symptoms, specific monitoring for these late effects is not generally warranted. A number of late effects have been observed. Fertility problems and fetal malformation Fertility problems, manifested by azoospermia or oligospermia at or beyond 2 years, occur in 45% to 55% of treated patients. No increased risk of fetal malformation has been observed in the offspring of men previously treated with chemotherapy for testicular cancer. Cardiovascular disease Several reports have documented an increase in prevalence of cardiovascular risk factors and cardiovascular disease in patients with a history of testicular germ cell tumors who were treated with chemotherapy or radiotherapy (even infra-diaphragmatic is associated with increased risk of cardiovascular disease). Haugnes et al reported on cardiovascular risk factors and morbidity in survivors of testicular cancer. Median follow-up was 19 years. Treatment with chemotherapy was associated with increased prevalence of antihypertensive medication use. Radiation therapy was associated with a higher prevalence of diabetes. Cardiovascular disease was increased in patients who received chemotherapy or radiotherapy, and was especially prevalent in patients who received both modalities. Raynaud phenomenon also occurs at a rate directly proportional to the number of cycles of cisplatin-based chemotherapy. Renal and pulmonary toxicities Although renal and pulmonary dysfunction can occur acutely during therapy, long-term consequences from therapy are uncommon. Of special note is the concern about bleomycin-related pulmonary toxicity. Overall risk is associated with cumulative doses of bleomycin; this was found in 8.5% of patients who received more than 300 units. Pulmonary toxicity may manifest as bronchiolitis obliterans with organizing pneumonia, eosinophilic hypersensitivity, or interstitial pneumonia. Secondary Malignancies Perhaps of greatest concern is the development of late recurrences or secondary malignancies. Late recurrence The incidence of late recurrence is estimated at 3.2% in NSGCT and 1.4% in seminoma. These late recurrences typically occur beyond 5 years (with latest reported recurrences occurring at 32+ years) from primary therapy, frequently present with an elevated serum level of AFP, and are particularly resistant to salvage chemotherapy. Thus, surgical resection of disease is the primary treatment strategy. Sharp et al reported on 75 patients with late recurrence, noting that the 5-year cancer-specific survival (CSS) was 79% vs 36% for men who underwent complete or incomplete surgical resection, respectively. The 5-year CSS for chemotherapy-naive patients was 93% compared with 49% for men who had a history of chemotherapy in their initial management. Testicular cancer Approximately 1% to 2% of patients may develop a second primary testicular cancer. At diagnosis the contralateral testicle should always be throughly evaluated with physical examination and ultrasound. Other cancers In a large series of 40,000 men reported by Travis et al, the relative risk for developing secondary tumors was 1.9 for 10-year survivors of testicular cancer, and it remained 1.7 for 35-year survivors. The greatest elevated risk was for cancers of the pleura, pancreas, bladder, and stomach. In another large retrospective analysis of 635 patients with extragonadal germ cell tumors treated from 1975 to 1996, only an increased number of hematologic and skin malignancies were observed. The contribution of chemotherapy and/or radiation therapy to the development of these other malignancies, as opposed to a natural propensity toward their development, is unknown. Theoretically, radiation exposure during follow-up CT scans might contribute to the increased risk of cancer. Etoposide has been shown to pose an increased risk for the development of secondary leukemia (dose-related). At higher dosages (> 2 g/m2 cumulative), etoposide has been associated with a greater incidence of acute leukemia (associated with 11q23 chromosomal abnormality). Very high dosages of etoposide with stem cell rescue do not appear to be linked to a higher risk than standard-dose chemotherapy. In one article by Travis et al, both increased dosages of radiation therapy and cisplatin were associated with an increased risk for acute leukemia. Although these risks are real, they still are low compared with the risk of death caused by testicular cancer. Nonetheless, indiscriminate use of chemotherapy for early-stage (stage I) disease should be tempered by recognition of the long-term hazards of therapy. Currently, there are no data to suggest that additional screening beyond standard guidelines for the general population is beneficial. Follow-Up for Relapse Because the relapse rate for testicular cancer is low, patients with pathologically confirmed stage I NSGCTs require no further therapy, and follow-up can be accomplished easily with chest radiography, tumor markers, and physical examination. Similarly, for patients who have stage II disease and receive adjuvant chemotherapy, the risk of relapse is low. For patients with either of these two clinical scenarios, follow-up tests (chest radiography, serum markers) should be performed every 2 months for 1 year, every 4 months for the second year, every 6 months for years 3 through 5, and annually thereafter. In patients with resected stage II NSGCTs who do not receive adjuvant chemotherapy, the follow-up tests are the same as those listed above. However, in these patients, follow-up tests are performed every month for 1 year, every 2 months for 2 years, every 6 months for years 3 through 5, and then annually. van Walraven et al retrospectively reviewed data sets of 2,569 patients treated for testicular cancer between 1991 and 2004. After a median of 10 CT scans and 11.2 years of follow-up, non–germ cell malignancy was diagnosed in 14 patients (5 per 10,000 patient-years). The risk of cancer was not associated with the amount of diagnostic radiation exposure. Suggested Reading Albers P, Seiner R, Krege S, et al: Randomized phase III trial comparing retroperitoneal lymph node dissection with one course of bleomycin and etoposide plus cisplatin chemotherapy in the adjuvant treatment of clinical stage I nonseminomatous testicular germ cell tumors: AUO Trial AH 01/94 by the German Testicular Cancer Study Group. J Clin Oncol 26:2966–2972, 2008. 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