This paper is a very nice review of the history of the development of modern urologic surgical procedures for the treatment of testicular germ-cell tumors and their current indications. I agree with virtually everything the authors say. I will emphasize several points that they make and highlight a few small areas of disagreement.
Proper testicular cancer treatment requires compliant patients and experienced doctors. It is not possible to overemphasize the importance of high-quality surgery for testis cancer. I am sure that the authors, being surgeons, were hesitant to stress this issue. However, I, as a medical oncologist, can.
Even in the 1990s, we still see patients who have had inadequate operations elsewhere, making their treatment more toxic and expensive and less likely to be successful. This issue is particularly problematic in patients who require surgery after chemotherapy, but previously untreated patients scheduled for retroperitoneal lymph node dissection (RPLND) will have an easier postoperative course and quicker recovery. In my opinion, it is inexcusable for testicular cancer patients to undergo such surgery performed by individuals who are not experienced in the treatment of this disease. I anticipate that this issue will be aggravated by managed-care organizations, many of which are short-sighted. Skilled treatment centers, in my opinion, treat this disease more effectively and less expensively.
Also important is patient compliance. A patient selected for surveillance for clinical stage A disease or observation after RPLND for pathologic stage B disease must agree to rigorous follow-up.
RPLND vs Surveillance for Clinical Stage A Disease
I believe, as do the authors, that the interests of most patients with clinical stage A disease are best served by RPLND. There are no data to suggest that patients managed with surveillance have a lower cure rate. The issues relate to toxicity and follow-up compliance. Risk of relapse in various prognostic groups ranges from about 15% to 50%. The authors suggest that patients in higher-risk groups not be offered surveillance, but, in my opinion, no group has been identified that cannot be offered either surveillance or RPLND.
I agree with the authors that, currently, the biggest threat to fertility in these patients is chemotherapy, which can be avoided in a few patients (ie, those with positive nodes who elect not to receive adjuvant chemotherapy and do not relapse). However, these patients account for no more than potentially about 15% of the entire patient population. Of these, some will have reduced fertility regardless, and others would have recovered spermatogenesis had they received chemotherapy. Thus, the overall differences in fertility are small.
Choosing Therapy for Patients With Clinical Stage B Disease
The choice of therapy for patients with clinical stage B disease is sometimes difficult. Over the years, our group has lowered the upper limits for the size of nodes appropriate for RPLND; we now feel that about 3 cm is a reasonable cut-off, as do the authors. Patients with clinical disease larger than this likely have a higher risk of relapse after surgery and are less apt to undergo a nerve-sparing procedure.
It is also important to remember that there are not only false-negative abdominal CTs but also false-positive ones. In the Indiana series, 23% of patients with clinical stage B disease actually had negative nodes.
I agree that patients with clinical stage A disease and persistently elevated markers after orchiectomy should be treated with chemotherapy rather than RPLND. In most patients, the elevated marker represents hematogenous spread. This may be particularly relevant for patients with an elevated level of alpha-fetoprotein. In the Indiana series, five of six such patients treated with RPLND ultimately required systemic therapy. Only 6 of 24 patients with elevations of human chorionic gonadotropin alone relapsed after RPLND.