475 PROGRESSION DETECTION OF STAGE I TESTIS CANCER

Because there remains a potential for late progression and an increased risk of a second primary tumor, we currently recommend that followup should be continued beyond 5 years and possibly for life. Although to our knowledge there are no good dat,a on the usefulness of long-term periodic followup by a physician, annual physician examination and possibly tu- mor marker determination should probably be performed in addition to regular patient self-examination. From our study it is diffcult to predict whether followup intervals could be increased while maintaining current morbidity and mortality results. It does not seem that a more rigorous protocol, such as a monthly followup instead of every 2 months, would be beneficial since overall mortality in our study was only 0.610. We did not address the issue of cost efficiency, which is important when determining the optimal protocol from an economic perspective. Munro and Warde examined this issue and found that a protocol that does not include CT is most cost-eficient, resulting in the same 2-year survival.’B A sim- ulation deleting chest x-ray from the protocol was not at- tempted in that study.

CONCLUSIONS

During followup for malignant recurrence it is useful to an- alyze the ability of each diagnostic test to detect disease pro- gression within a panel of investigations. Such an analysis permits the identification of tests that do not contribute addi- tional information and may be deleted from the protocol with- out decreasing the ability to identify relapse. In patients with a clinical stage I nonseminomatous testis tumor who are on sur- veillance we found that history and physical examination, tu- mor marker determination, and CT of the abdomen and pelvis detected some relapses that the other modalities did not. In contrast, chest x-ray did not provide additional data on failure beyond that detectable by the other tests. This finding suggests that chest x-ray is not routinely required in the surveillance protocol. The initial surveillance visit should occur by 2 months after orchiectomy and visits need not be scheduled more often than every 2 months. Beyond 5 years we recommend annual followup visits with physical examination and possibly tumor marker determination in addition to regular self-examination because of the increased risk of a contralateral testis tumor and the potential for late progression. Reports from other centers on the methods of relapse detection would aid in clarifying the role and optimal technique of chest imaging at routine followup, determining whether the intervals between followup visits may be increased without increasing morbidity or mortality and evaluating the cost-effectiveness of various protocols.

REFERENCES

1. Coleman, M. P.. Esteve. J., Damiecki. P., Arslan. A. and Renard, H.: Testis. In: Trends in Cancer Incidence and Mortality. Lyon: Intrrnational Agency for Research on Cancer, chapt. 22, pp. 52 1-542, 1993.

2. Donohuc. J . P.. Thornhill, J. A., Foster, R. S., Rowland, R. G. and Bihrle. R.: Stage I nonseminomatous gem-cell testicular cancc’r-management options and risk-benefit considerations. World J. Urol., 12: 170, 1994.

3. Sturgeon. J . F. G.. Jewett. M. A. S., Alison, R. E., Gospodarowicz. M. K., Blend, R., Heman , S., Richmond, H., Thomas, G.. Duncan. W. and Munro, A.: Surveillance after orchidectomy for patients with clinical stage I nonseminomatous testis tu- mors. J. Clin. Oncol., 1 0 564, 1992.

4. Coils, B. M., Harvey, V. J., Skelton, L., Thompson, P. I., Dady, P. J., Forgeson, G. V. and Perez, D. J.: Results of the surveil- lance policy of stage I nonseminomatous g e m cell testicular tumours. Brit. J. Urol., 7 0 423, 1992.

5. Read, G., Stenning, S. P., Cullen, M. H., Parkinson, M. C., Horwich, A,, Kaye, S. B. and Cook, P. A.: Medical Research

Council prospective study of surveillance for stage I testicular teratoma. Medical Research Council Testicular Tumours Working Party. J. Clin. Oncol., 1 0 1762, 1992.

6. Freedman, L. S., Parlunson, M. C., Jones, W. G., Oliver, R. T. D., Peckham, M. J . , Read, G., Newlands, E. S. and Williams, C. J.: Histopathology in the prediction of relapse of patients with stage I testicular teratoma treated by orchidectomy alone. Lancet, 2: 294, 1987.

7. Lowe, B. A.: Surveillance versus nerve-sparing retroperitoneal lpphadenectomy in stage I nonseminomatous germ-cell tu- mors. Urol. Clin. N. Amer., 20: 75, 1993.

8. Price, P., Hogan, S. J. , Bliss, J. M. and Horwich, A.: The growth rate of metastatic nonseminomatous germ cell testicular tu- mours measured by marker production doubling time-iI. Prognostic significance in patients treated by chemotherapy. Eur. J . Cancer, 2 6 453, 1990.

9. Montie, J. E.: Follow-up after radical orchiectomy for testicular cancer. Urol. Clin. N. Amer., 21: 757, 1994.

10. Sackett, D. L., Haynes, R. B., Guyatt, G. H. and Tugwell, P.: The selection of diagnostic tests. In: Clinical Epidemiology: A Basic Science for Clinical Medicine 2E. Boston: Little, Brown and Co., chapt. 3, pp. 51-68, 1991.

11. Fossd, S. D., Jacobsen, A. B., Aass, N., Heilo, A.. Stenwig, A. E., Kummen, O., Johannessen, N. B., Waaler, G., Ogreid, P., Borge, L., Umes, T. and Bjerklund-Johansen, T.: How safe is surveillance in patients with histologically low-risk nonsemi- nomatous testicular cancer in a geographically extended coun- try with limited computerised tomographic resources? Brit. J. Cancer, 7 0 1156, 1994.

12. Sogani, P. C., Whitmore, W. F., Jr., Herr, H. W., Bod, G. J., Golbey, R. B., Watson, R. C. and DeCosse, J . J.: Orchiectomy alone in the treatment of clinical stage I nonseminomatous germ cell tumor of the testis. J. Clin. Oncol., 2: 267, 1984.

13. Germa Lluch, J. R., Climent, M. A., Villavicencio, H., Gomez de Segura, G., Blanco, R., Mercedes, A., de Andres, L. and Sole Balcells, F. J.: Treatment of stage I testicular tumours. Brit. J. Urol., 71: 473, 1993.

14. Gels, M. E., Hoekstra, H. J., Sleijfer, D. T., Marrink, J., de Bruijn, H. W. A,, Molenaar, W. M., Freling, N. J. M., Droste, J. H. J. and Schraffordt Koops, H.: Detection of recurrence in patients with clinical stage I nonseminomatous testicular germ cell tumors and consequences for further follow-up: a singlecenter 10-year expe- rience. J. Clin. Oncol., 1 3 1188, 1995.

15. Femandez, E. B., Colon, E., McLeod, D. G. and Mod, J. W.: Efficacy of radiographic chest imaging in patients with testic- ular cancer. Urology, 44: 243, 1994.

16. Baniel, J., Foster, R. S., Gonin, R., Messemer, J. E., Donohue, J. P. and Einhorn. L. H.: Late relapse of testicular cancer. J. Clin. Oncol., 1 3 1170, 1995.

17. Bach, D. W., Weissbach, L. and Hartlapp, J. H.: Bilateral testic- ular tumor. 3. Urol., 1 2 9 989, 1983.

18. Munro, A. J . and Warde, P. R.: The use of a Markov process to simulate and assess follow-up policies for patients with malig- nant disease: surveillance for stage I nonseminornatous tu- mors of the testis. Med. Decision Making, 11: 131, 1991.

EDITORIAL COMMENT

The only purpose of surveillance for testis cancer is to avoid ther- apy in patients whom it will not benefit. For a highly treatable disease such as testis cancer surveillance is only an option if cases of recurrence may safely be salvaged. Our role in treating patients on

NO. pts. ~ ~ ; ~ ~ ~ ~ , ~u~rnonary No. With

Metastasis References

Sogani et al’ 105 Freiha and Torti” 23 Raghavan et al.’ 46 Gelderman et al‘ 54 Nicolai and Pizzocaro’ 85 Rorth et aI6 77 Thompson et a]’ 3 6

Totals 426

27 5 3 1 13 3 11 2 25 9 23 2

5 - 12 - 114 21

476

surveillance for testis cancer is to determine recurrence as early as possible to ensure successful treatment.

PROGRESSION DETECTION OF STAGE I TESTIS CANCER

and surveillance protocols must be discussed at a consensus confer- ence on the management of testis cancer.

These authors suggest that chest radiography may be eliminated in the followup of patients on surveillance for nonseminomatms germ cell tumors. In 4 of 48 patients (8.33%) recufience was initially d i a g n d on chest x-ray. All 4 patients had other clinical or radiographic signs of disease. Others have found an approximately 24% rate of pulmonary recurrence (see table).*-' While these studies do not always state that this was the only site of recurrent disease, it was the initial site of diagnosis in many patients. Clearly evaluation of the chest remains an important component of the followup of patients on surveillance for testis cancer.

Until the authors demonstrate that cases of initial recurrence in the chest and then progression to other sites may be salvaged with the same efficacy as those found using other modes of routine Screening, chest x-ray should not be omitted in surveillance for testis cancer. Because stage I testis cancer has an excellent prognosis, failure to perform an effective inexpensive test with minimal morbidity such as a chest x-ray is not yet acceptable. While casteffectiveness and optimiziog testing are laudable goals, our 6rst priority must remain to find recurrence promptly.

The authors also continue to include patients with stage I disease in their surveillance protmol who have venous or lymphatic invasion despite their previous report that 60% with invasion had progression versus 23% with progression but without invasion (reference 3 in article). At other centers, such as Memorial Sloan-Kettering and Oregon, vascular invasion is used as an exclusion criterion for entry into a surveillance protocol. This article updates patient accrual and outcomes, and their surveillance protocol is now presented in a helpful tabular form.

Surveillance remains a controversial treatment option in a highly seled group of patients with stage I nonseminomatous germ cell tumor. Serial reports from this and other groups with long-term experience managing such cases are needed. Better agreement among these groups to standardize such issues as exclusion criteria

James M. Holland and Michael S. McGuire Department of Urology Northwestern University Medical School Evanston Hospital Evanston, Illinois

1. Sogani, P. C., Perrotti, M., Herr, H. W., Fair, W. R., "haler, H. T. and Bosl, G.: Clinical stage I testis cancer: long-term outcome of patients on surveillance. J. Urol., 159: 855, 1998.

2. Freiha, F. and Torti, F.: Orchiectomy only for clinical stage I nonseminomatous germ cell testis tumors: comparisons with pathologic stage I disease. Urology, 34. 347, 1989.

3. Raghavan, D., Colls, B., Levi, J., Fitzharris, B., Tattersall, M. H. N., Atkinson, C., Woods, R., Coorey, G., Farrell, C. and Wines, R.: Surveillance for stage I nonseminomatous germ cell tumors of the testis: the optimal protocol has not yet been detined. Brit. J. Urol., 61: 522, 1988.

4. Gelderman, W. A. H., Koops, H. S., Sleijfer, D. T., Oosterhuis, J. W., Mamnk, J., De Bruijn, H. W. A. and Oldhoff, J.: Orchi- dectomy alone in stage I nonseminomatous testicular germ cell tumors. Cancer, 69 578,1987.

5. Nicolai, N. and Pizzocaro, G.: A surveillance study of clinical stage I nonseminomatous germ cell tumors of the testis: 10- year followup. J. Urol., lbl: 1045, 1995.

6. Rorth, M., Jacobsen, G. K., von der Maase, H., Madsen, E. L., Nielsen, 0. S., Pedersen, M. and Schultz, H.: Surveillance alone versus radiotherapy a h r orchiectomy for clinical stage I nonseminomatous testicular cancer. J. Clin. Oncol., 9 1543, 1991.

7. Thompson, P. I., Nixon, J. and Harvey, V. J.: Disease relapse in patients with stage I nonseminomatous germ cell tumor of the testis on active surveillance. J. Clin. Oncol., 6 1597, 1988.