Indian Journal of Urology
: 2010  |  Volume : 26  |  Issue : 1  |  Page : 150--152

Optimizing the adjuvant therapy in stage I nonseminomatous germ cell tumors

Bhupendra P Singh, Vimal K Choubey, Rahul Pandey 
 Department of Urology, Chhatrapati Shahuji Maharaj Medical University (King George Medical University), Lucknow, U.P, India

Correspondence Address:
Bhupendra P Singh
Department of Urology, Chhatrapati Shahuji Maharaj Medical University (King George Medical University), Lucknow, U.P

How to cite this article:
Singh BP, Choubey VK, Pandey R. Optimizing the adjuvant therapy in stage I nonseminomatous germ cell tumors.Indian J Urol 2010;26:150-152

How to cite this URL:
Singh BP, Choubey VK, Pandey R. Optimizing the adjuvant therapy in stage I nonseminomatous germ cell tumors. Indian J Urol [serial online] 2010 [cited 2020 Sep 20 ];26:150-152
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With an aim to offer minimized risk-adapted adjuvant treatment to clinical stage 1 nonseminomatous germ-cell testicular cancer patients, this study recruited 745 subjects into a prospective, community-based multicenter Swedish and Norwegian Testicular Cancer Project (SWENOTECA) management program over the period from 1998 to 2005. Treatment strategy depended on the presence or absence of vascular tumor invasion. Vascular invasion positive patients were recommended brief adjuvant chemotherapy with bleomycin, etoposide, and cisplatin (BEP), whereas vascular invasion negative patients could choose between ACT and surveillance. Results showed overall 51 relapses at a median follow-up of 4.7 years. In the surveillance group, relapse rate was 41.7% in patients with vascular invasion and 13.7% in patients without vascular invasion. In adjuvant chemotherapy (one course of BEP) group relapse rate was 3.2% in patients with vascular invasion and 1.3% in patients without vascular invasion. Authors concluded that one course of adjuvant BEP reduced the risk of relapse by approximately 90% in all (with or without vascular invasion) CS1 NSGCT and this may be a new option as initial treatment for all CS1 NSGCT. One course of adjuvant BEP for vascular invasion positive CS1 reduces the total burden of chemotherapy compared with surveillance or two courses of BEP. SWENOTECA currently recommends one course of BEP as standard treatment of VASC + CS1 NSGCT, whereas both surveillance and one course of BEP are options for VASC- CS1 NSGCT.


This largest community based study (without randomization) of one BEP cycle in CS1 NSGCT(312 patients), showed the great success of nonsurgical treatment of CS1 NSGCT with very low relapse rates in all categories of patients and a cause-specific survival of nearly 100%. Although there had been some preliminary data on the efficacy of one cycle of adjuvant CT, [1],[2],[3] this study along with the study by Albers et al., [4] might put an end to the surgical approach to management of CS1 NSGCT. There are certain reasons for it: First, Albers et al., showed the RPLND to be inadequate with high abdominal recurrences in broad(community) based setting. In contrast, very low relapse rates were seen with single cycle of BEP (in SWENOTECA study 7/312; in Albers study 2/191), which were successfully managed with salvage standard therapy without any cancer specific death with any treatment approach. Second, concerns regarding compliance of patients on active surveillance/ adjuvant CT were not seen in these as well as other broad based studies, [5] ensuring a cause specific survival of 100%. Third, risks of late recurring unresectable teratoma or late relapsing chemotherapy resistant viable tumor were not seen. Only 37 (out of 745) patients in SWENOTECA study and 1 patient (out of 191 patients given one cycle of BEP) in Albers study required dissection of retroperitoneum any time. The overall late relapses were 5/745 ([ 3],[6] This is in contrast to very late recurrences reported with surveillance. [7] So with nonsurgical management of CS1 NSGCT, only 90% with minimal toxicity. However, there are certain issues related to use of one cycle of CT for all patients. First, it will overburden all patients with mild toxicity to decrease potential complications for a few. Second, although short term side effects of even one cycle of BEP are well known (hair loss, work disruption, anxiety and fear, neutropenia, vascular complications, acute chemotherapy complications and temporary effect on fertility), data regarding subtle long term effects is yet to mature. In this study, short term toxicity of BEP was low (with one cycle; infection 2%, leucopenia 33%, thrombocytopenia 1%, obstipation 1%, Neurological [8] which recommends surveillance for all and the European consensus [9] which recommends surveillance for low risk and 2 BEP cycles for high risk patients. Although further longer data may be desirable to find out the best paradigm providing an optimal therapeutic ratio in long term, one thing is sure; these newer nonsurgical treatment paradigms, providing optimal quality care and survival in community settings, should provide the standard of care for these patients.


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2Klepp OH, Dahl O, Cavallin-Stahl E, Stierner U, Cohn Cedermark G, Wist E, et al. Risk-adapted, brief adjuvant chemotherapy in clinical stage 1 (CS1) nonseminomatous germ cell testicular cancer (NSGCT). Proc Am Soc Clin Oncol 2003;22:399.
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