Introduction and Objectives
It was previously reported that the patients (pts) in clinical stage A (CS-A) nonseminomatous testicular tumors (NSTT) were more likely to relapse if they have >50% embryonal carcinoma (EC) and microvascular tumor invasion (VI+), The aim of this study is to report the value of retroperitoneal lympadenectomy (RPLA) vs cisplatin (CDDP)-based chemotherapy (CT) in high risk (HR) NSTT with normal values of serum tumor markers (STM) postorchiectomy.
Material and Methods
138 pts entered a prospective but nonrandomized study from 1980 to 2005. The pts are divided into 2 groups according to applied primary treatment. Arm A (n = 60): RPLA with 2 cycles of CDDP-based CT in PS-B1/B2 and Arm B (n = 78): only 2 cycles of CDDP-based CT following orchiectomy [PVB (n = 15), PEB (n = 63)]. Pts characteristics were stratified according to primary treatment: 70%, 59% were >50% EC. 45%. 64% were VI+ and 22%, 26% were >50% EC with VI+, respectively.
Results
Arm A – relapses occurred in 10 pts (17%) (7/46 (15%) in PS-A and 3/14 (21%) in PS-B1/B2 within median free interval (MFI) of 8.3 months (m) (range 2–3)(lung5, RPLN 1, only elevated STM 1) and 51.3m (range 8–12o) (RPLN 1, only elevated STM 2) with survival in 95% and 86%, respectively). 21 pts (35%) received postop CDDP-based CT (7 in relapse in PS-A and 14 due to LN metastasis). Overall, alive and free of disease (AFD) are 55 pts (9%) ate median follow-up (MFU) of 14.5 years (y) (range 10.8–16.3) (1 pt died of other malignancy at 90 m). There were 11 surgical complications in 6 pts (10%), 2 minor and 9 major complications. Ejaculatory disturbances occurred in 12 pts (20%) Arm B – 2 pts (2.6%) relapsed within MFI of 8m (9.7) (lung 1, RPLN+lung 1). Both relapsing pts underwent salvage CT+lung sugery with finding of viable GCT, 1 pt died at 18 m. AFD are 77 pts (9%) at MFU of 8.5 y (range 4–17.6). Hemathologic toxicity was mild: 11 G3 and 8 G4 with 4 episodes of febrile neutropenia among 125 treatment cycles according to PEB regimen. 2 G3 and 6 G4 neutropenia ocurred in pts treated by PVB regimens. 2 pts presented tinnitus. The comparison of the results between Arm A and B demonstrated significant difference of RR (p < 0.0036) and DSS (p < 0.0416) in favor of Arm B.
Conclusions
Pts with HR CS-A NSTT are not necessarily helped by initial RPLA, except to secure the RP and make diagnosis and treatment of relapse potentially easier, but at what price? According to our experience 2 cycles of CDDP-based CT following orchiectomy constitute the treatment of choice with acceptable toxicity. However, optimum therapy has not yet been defined, and we are currently evaluating a regimen with only 1 course of CDDP-based CT following orchiectomy.
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Copyright
© 2009 European Association of Urology. Published by Elsevier Inc. All rights reserved.
