1Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
2The University of Toronto, Toronto, Ontario, Canada.
J Clin Oncol. 2019 Aug 1;37(22):1919-1926. doi: 10.1200/JCO.18.01250. Epub 2019 Feb 25.
Active surveillance (AS) for testicular nonseminomatous germ cell tumors (NSGCT) is widely used. Although there is no consensus for optimal treatment at relapse on surveillance, globally patients typically receive chemotherapy. We describe treatment of relapses in our non-risk-adapted NSGCT AS cohort and highlight selective use of primary retroperitoneal lymph node dissection (RPLND).
From December 1980 to December 2015, 580 patients with clinical stage I NSGCT were treated with AS, and 162 subsequently relapsed. First-line treatment was based on relapse site and extent. Logistic regression was used to explore factors associated with need for multimodal therapy on AS relapse.
Median time to relapse was 7.4 months. The majority of relapses were confined to the retroperitoneum (66%). After relapse, first-line treatment was chemotherapy for 95 (58.6%) and RPLND for 62 (38.3%), and five patients (3.1%) underwent other therapy. In 103 (65.6%), only one modality of treatment was required: chemotherapy only in 58 of 95 (61%) and RPLND only in 45 of 62 (73%). Factors associated with multimodal relapse therapy were larger node size (odds ratio, 2.68; = .045) in patients undergoing chemotherapy and elevated tumor markers (odds ratio, 6.05; = .008) in patients undergoing RPLND. When RPLND was performed with normal markers, 82% required no further treatment. Second relapse occurred in 30 of 162 patients (18.5%). With median follow-up of 7.6 years, there were five deaths (3.1% of AS relapses, but 0.8% of whole AS cohort) from NSGCT or treatment complications.
The retroperitoneum is the most common site of relapse in clinical stage I NSGCT on AS. Most are cured by single-modality treatment. RPLND should be considered for relapsed patients, especially those with disease limited to the retroperitoneum and normal markers, as an option to avoid chemotherapy.
主动监测（AS）在睾丸非精原细胞瘤生殖细胞肿瘤（NSGCT）中的应用非常广泛。尽管在监测时复发的最佳治疗方法尚无共识，但全球患者通常接受化疗。我们描述了非风险适应 NSGCT AS 队列中复发的治疗方法，并强调选择性使用原发性腹膜后淋巴结清扫术（RPLND）。
从 1980 年 12 月至 2015 年 12 月，580 例临床 I 期 NSGCT 患者接受 AS 治疗，其中 162 例随后复发。一线治疗基于复发部位和程度。Logistic 回归用于探讨与 AS 复发时需要多模式治疗相关的因素。
中位复发时间为 7.4 个月。大多数复发局限于腹膜后（66%）。复发后，一线治疗为化疗 95 例（58.6%），RPLND 62 例（38.3%），5 例（3.1%）患者采用其他治疗方法。在 103 例（65.6%）患者中，仅需一种治疗方法：化疗仅 95 例中的 58 例（61%），RPLND 仅 62 例中的 45 例（73%）。接受化疗的患者中，肿瘤标志物升高（比值比，2.68； =.045）和接受 RPLND 的患者中肿瘤标志物升高（比值比，6.05； =.008）与多模式复发治疗相关。当 RPLND 标志物正常时，82%的患者无需进一步治疗。162 例患者中有 30 例（18.5%）发生二次复发。中位随访 7.6 年后，有 5 例（3.1%的 AS 复发，但 0.8%的整个 AS 队列）死于 NSGCT 或治疗相关并发症。
AS 中临床 I 期 NSGCT 最常见的复发部位是腹膜后。大多数患者通过单一模式治疗即可治愈。对于复发患者，尤其是腹膜后疾病局限且标志物正常的患者，应考虑使用 RPLND，以避免化疗。
