For most patients with early-stage testicular germ cell tumors, surgery is curative and mitigates the risk for long-term toxicities associated with chemotherapy and radiation, according to results presented by Clint Cary, MD, MPH, Associate Professor, Department of Urology, Indiana University School of Medicine, Indianapolis, at the 2020 Genitourinary Cancers Symposium.
Although primary chemotherapy or radiation can also lead to high cure rates in this population of patients, there are potential late adverse effects associated with these approaches, including cardiac disease, hypertension, metabolic syndrome, secondary malignancies, neurotoxicity, cognitive impairment, hypogonadism and fertility problems, and pulmonary complications.
“It’s more than just about survival of cancer; it’s also about survivorship,” Dr Cary noted.
Chemotherapy versus Surgery
An assessment by the Platinum Study Group showed almost 80% of germ cell tumor survivors who received treatment with modern cisplatin-based chemotherapy had at least 1 adverse health outcome, Dr Cary said. In addition, as the number of adverse health outcomes increased, the self-reported perception of health declined.
Current guidelines from the National Comprehensive Cancer Network and the American Urological Association state that either nerve-sparing retroperitoneal lymph node dissection or primary chemotherapy are reasonable approaches for patients with stage IIA non-seminoma with normal levels of postorchiectomy serum alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) and for patients with stage IIB non-seminoma and normal postorchiectomy serum AFP and hCG.
The guidelines support surgery in early-stage disease because the cure rates are high with surgery alone, with the caveat that this outcome is achieved in high-volume centers, explained Dr Cary. In addition, the long-term toxicity with this approach is exceedingly low.
Retroperitoneal lymph node dissection “has stood the test of time as far as its curability,” he said, adding that in studies assessing outcomes with surgery, up to 80% of patients can be cured with this approach and can avoid chemotherapy. He also explained that 10% to 40% of patients with clinical stage II disease enrolled in studies of retroperitoneal lymph node dissection had pathologic stage I disease or negative or reactive lymph nodes.
“Obviously, if we treated all of these patients with chemotherapy, we would be overtreating a number of patients with no real benefit,” Dr Cary said.
The potential downsides of surgery include an approximate 3% risk for ileus ascites and an approximate 1% risk for chylous ascites in the short- term. Longer term issues include retrograde ejaculation, the risk of which is minimal with nerve-sparing approaches, and small bowel obstruction, with an approximate risk of 1%.
Advances in retroperitoneal lymph node dissection have enabled surgical times of 2 to 3 hours, hospital stays of 3 days or less, low rates of complications, minimal long-term toxicity, surgical mortality of 0%, and very low readmission rates, Dr Cary said. “When nerve-sparing approaches are used, most men are going to have normal ejaculation and fertility, assuming their fertility was normal before surgery,” he said.