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Stage 1 NSGCT – management

The main prognostic factor on histology for NSGCT is lymphovascular invasion.

Previous EAU guidelines suggested % embryonal (>50%) and proliferative index, but these have been taken away from current edition.

Overall risk of relapse after orchidectomy is about 30 %

Approx 50 % risk of relapse with LVI vs 15 % without LVI

 

Options for management of stage 1 NSGCT:

  1. Surveillance
  2. Adjuvant chemotherapy
  3. Primary RPLND

 

Surveillance

  • Risks of relapse as above – > 90 % of relapses occur in first two years
  • Tumour markers alone are unreliable for detecting relapse
  • Frequent CT and very frequent tumours markers, quite arduous

 

Chemotherapy

  • 1 cycle of BEP has shown to reduce recurrence rates to 2 – 3 %
  • 2008 German RCT showed 2 year RFS 99 % with BEP vs 91 % RPLND
  • Toxicity – lung toxicity, fertility, renal dysfunction, tinnitus
  • Not suitable for teratoma

 

Primary RPLND

  • Was historically the preferred adjuvant option prior to chemotherapy
  • Stronger indications include presence of teratoma on primary, or patients unwilling/unable to undergo chemotherapy now or later
  • 18 – 30 % of patients will have disease, and a third of them may still recur later
    • ? do these patients then get chemo anyway
  • Associated issues with major surgery, as well as retrograde ejaculation and adhesions
  • Nerve sparing and minimally invasive surgery aim to minimise morbidity
  • Less demanding follow up after surgery cf. surveillance

 

 

 

EAU guideline for stage 1 NSGCT:

  • Risk stratify by LVI (differentiates 1a/T1 and 1b/T2+)
  • Offer surveillance for stage 1a; or 1 x BEP for those unwilling/unsuitable for surveillance
  • Offer 1 x BEP for stage 1b; or surveillance for those unwilling; or RPLND for those unsuitable for chemo and unwilling to be surveilled
  • Primary RPLND should be considered if malignant teratoma