Divrik Rauf Taner, Akdoğan Bülent, Ozen Haluk, Zorlu Ferruh
Department of Urology, SB Tepecik Research and Training Hospital, Izmir, Turkey.
J Urol. 2006 Oct;176(4 Pt 1):1424-29; discussion 1429-30. doi: 10.1016/j.juro.2006.06.012.
We evaluated the potential risk factors for disease relapse in patients with clinical stage I nonseminomatous germ cell tumors treated with surveillance and reevaluated our treatment of these patients.
A total of 211 consecutive patients with clinical stage I nonseminomatous germ cell tumors treated with surveillance after orchiectomy between 1993 and 2005 were included in this retrospective study. Risk factors evaluated were presence of vascular invasion, proportion of embryonal carcinoma, age, tumor size, preoperatively increased serum alpha-fetoprotein and the absence of yolk sac component.
Of the 211 patients 66 (31.3%) had disease relapse. Recurrence ranged from 2 to 32 months after orchiectomy (median 6). A total of 52 (78.8%) cases of relapse were diagnosed in year 1 of followup, 11 (16.7%) during year 2 and only 3 cases were diagnosed thereafter. The first evidence of relapse was most commonly the increase in serum tumor markers alone (28.8%) or in combination with other modalities (66.7%, overall 95.5%). While 40.9% of patients with more than 50% embryonal carcinoma had disease relapse, the relapse rate was 20.8% in patients with less than 50% embryonal carcinoma (p = 0.002). Relapse rates in patients with and without vascular invasion were 75.5% and 17.9%, respectively (p = 0.000). The relapse rates were 6.1% and 75.7% in patients with no risk factors (no vascular invasion and less than 50% embryonal carcinoma) and 2 risk factors (vascular invasion and more than 50% embryonal carcinoma), respectively (p < 0.001). Multivariate analysis revealed that vascular invasion was the most powerful predictor of relapse (OR 16.350, 95% CI 5.582-47.893). Disease-free and disease specific survival rates were 97.6% at a median followup of 75 months.
In light of our results we suggest that all patients with vascular invasion should receive chemotherapy. However, patients with no risk factors and those with more than 50% embryonal carcinoma but without vascular invasion should be on surveillance after orchiectomy since the relapse rate is less than 30%. Although strict followup in the first year is justified, followup schemas may be reassessed for the frequency of radiological investigations.
我们评估了接受监测的临床I期非精原细胞性生殖细胞肿瘤患者疾病复发的潜在风险因素，并重新评估了我们对这些患者的治疗方法。
本回顾性研究纳入了1993年至2005年间共211例接受睾丸切除术后监测的临床I期非精原细胞性生殖细胞肿瘤患者。评估的风险因素包括血管侵犯、胚胎癌比例、年龄、肿瘤大小、术前血清甲胎蛋白升高以及卵黄囊成分缺失。
211例患者中，66例（31.3%）出现疾病复发。复发发生在睾丸切除术后2至32个月（中位时间为6个月）。随访第1年共诊断出52例（78.8%）复发病例，第2年诊断出11例（16.7%），此后仅诊断出3例。复发的首个证据最常见的是仅血清肿瘤标志物升高（28.8%）或与其他检查结果联合出现（66.7%，总体为95.5%）。胚胎癌比例超过50%的患者中40.9%出现疾病复发，而胚胎癌比例低于50%的患者复发率为20.8%（p = 0.002）。有血管侵犯和无血管侵犯患者的复发率分别为75.5%和17.9%（p = 0.000）。无风险因素（无血管侵犯且胚胎癌比例低于50%）和有2个风险因素（血管侵犯且胚胎癌比例超过50%）的患者复发率分别为6.1%和75.7%（p < 0.001）。多因素分析显示血管侵犯是复发的最强预测因素（OR 16.350，95% CI 5.582 - 47.893）。中位随访75个月时，无病生存率和疾病特异性生存率为97.6%。
根据我们的研究结果，我们建议所有有血管侵犯的患者应接受化疗。然而，无风险因素以及胚胎癌比例超过50%但无血管侵犯的患者在睾丸切除术后应接受监测，因为其复发率低于30%。虽然第1年进行严格随访是合理的，但对于影像学检查的频率，随访方案可重新评估。
