Patient compliance becomes the crucial element in surveillance studies and significantly determines the quality and feasibility of this approach. However, noncompliance is a common finding in a proportion

Localisation of relapse

Localisation of relapse

Non Compliant Patients

Figure 12-1. Localization of relapse in patients with stage I non-seminomatous germ cell tumors.

Figure 12-1. Localization of relapse in patients with stage I non-seminomatous germ cell tumors.

of patients with any illness; it would be surprising if all patients with NSGCT did comply as they are generally young men who are often socially mobile. Noncompliance is also seen with patients who are offered, are receiving, or have had chemotherapy and is a reflection of the complex psychosocial situation in which these young men find themselves.

Patients' preference of surveillance versus adjuvant chemotherapy has been investigated in two studies.52,53 Adjuvant chemotherapy was preferred at projected relapse rates above 50% in the study by Stiggelbout and colleagues.52 In the study by Cullen and col-leagues,53 a group of patients undergoing surveillance preferred to undergo surveillance again if the relapse rate was less than 30 to 40%; the same group preferred chemotherapy if the relapse rate was around 70%. For patients who had been initially treated with adjuvant chemotherapy, the limiting criterion for starting a surveillance program was a relapse rate of less than 10%; there was a preference for adjuvant chemotherapy if the relapse rate was greater than 25%. A high percentage of patients (33-64%) opted for the physician to decide the treatment.

Late Relapse

The phenomenon of late relapse has led critics to state that RPLND is the primary treatment of choice immediately after orchiectomy. As it removes the major risk of relapse at a site that is most difficult and costly to monitor. We do not agree that RPLND is a superior treatment since late relapses also occur in those who have undergone RPLND as the initial treatment. Baniel and colleagues54 reported 81 late relapses (at > 2 years), 35 of which occurred in patients who had originally had clinical stage I disease; of these, 2 were followed with surveillance after orchiectomy, 31 were treated with primary RPLND, 1 was treated with radiotherapy, and 1 was treated with chemotherapy. The other 46 late relapses occurred in patients who had presented with stage II or III disease. The report would suggest that there will be late relapses irrespective of the primary mode of treatment. The first evidence of relapse is most commonly the elevation of serum tumor markers, either alone or in combination with an abnormality seen on abdominal CT. However, the tumor markers are often inconsistent between presentation and relapse. Thus, the measurement of tumor markers is important, irrespective of whether or not they were originally abnormal.

Time to relapse is mentioned in eight stud-ies.7-9,36,47,48,50,55 These studies include 1,169 stage I NSGCT patients on surveillance, with a relapse rate of 28.7%. The majority of the relapses were seen within the first 2 years (95.5%); 1.8% were observed in the third year, 0.6% in the fourth, 0.3% in the fifth, 0.9% in the sixth, and 0.3% in the seventh. There was one relapse (0.3%) after more than 10 years (Figure 12-2). All patients on surveillance are followed for at least 5 years, and 98.5% of the relapses would be diagnosed within this period. Also, in our experience, patients who are re-admitted with relapse after 5 years of follow-up can be cured with chemotherapy. Against this background, it can be concluded that late relapses in patients on surveillance are not a major problem.*

^Editor's note: In many centers, particular concern is held for the phenomenon of late relapse among patients with immature teratoma in the primary tumor; in many of the series cited, late relapses occurred among patients with a dominance of this his-tologic pattern in the primary tumor. At the University of Southern California, we do not believe that it is safe to discharge patients from surveillance within a period of less than 10 years; ideally, patients should be monitored indefinitely, especially if immature teratoma is present in the primary tumor.

Nonseminomatous Germ Cell Tumor
Figure 12-2. Late relapses: the number of relapses after the second year in 1,169 patients with stage I nonseminomatous germ cell tumors.
Germ Cell Tumor Stages
Figure 12-3. The number of clinical controls, including tumor markers, for patients with stage I nonseminomatous germ cell tumors at six centers. (MSKCC = Memorial Sloan-Kettering Cancer Center.)

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