title: Management of patients with clinical stage I nonseminomatous testicular germ cell tumours: active surveillance versus primary chemotherapy versus nerve sparing retroperitoneal lymphadenectomy.
abstract: Clinical stage I testicular nonseminomatous germ cell tumours (NSGCT) are highly curable. Following orchidectomy a risk-adapted approach using active surveillance (AS), nerve sparing  retroperitoneal lymph node  dissection (nsRPLND) and primary chemotherapy is recommended by the current guidelines. CS I is defined negative or declining tumour markers to their half-life following orchidectomy and negative imaging studies of the chest, abdomen and retroperitoneum. Low risk CS I NSGCT are defined by the absence of vascular invasion, low percentage of embryonal carcinoma (ECA) and low proliferating Ki-67 index. High risk CS I NSGCT are defined by the presence of VI, high percentage of ECA and a high Ki-67 index.  According to the current guidelines, active surveillance, primary chemotherapy and nerve sparing RPLND represent 3 treatment options with the same high cure rate of about 100% but significantly different long-term  complications.  As demonstrated, active surveillance can be performed in low risk and in high risk NSGCT with an anticipated relapse rate of about 15% and 50%. The majority of  patients will  relapse with good and intermediate prognosis tumours which have to be treated with 3 to 4 cycles chemotherapy. About 25% to 30% of these patients will have to undergo postchemotherapy RPLND for  residual masses.  Primary chemotherapy with 1 -2 cycles PEB is a therapeutic option for high risk clinical stage I NSGCT associated with a recurrence rate of only 2-3% and a minimal acute and long-term toxicity rate. Nerve sparing RPLND, if performed properly,  will cure about 85%  of all high risk patients with clinical stage I NSGCT without the need for chemotherapy. Although armchair calculations of the odds of cure and toxicity associated with the various treatment options can be performed, recommendations about the most optimal  therapy  in clinical stage I NSGCT remain controversial. There seems to be a consensus that active surveillance is the treatment strategy of choice for CS I low risk patients.  However,  there is no clear cut recommendation in high risk patients. Each treatment has its own advantages and disadvantages which have to be discussed thoroughly with the  patient.  If, however, the positive results of 1 cycle of PEB can be validated, it will become the standard cytotoxic approach for clinical stage I NSGCT.
authors.affiliation: Department of Urology, Urologic Oncology, Pediatric Urology and Renal Transplantation, RWTH University Aachen, Germany. aheidenreich@ukaachen.de
authors.forename: Axel
authors.initials: A
authors.lastname: Heidenreich
authors.forename: David
authors.initials: D
authors.lastname: Pfister
mesh_terms: D017024:Chemotherapy, Adjuvant; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008297:Male; D009367:Neoplasm Staging; D009373:Neoplasms, Germ Cell and Embryonal / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D011379:Prognosis; D012307:Risk Factors; D013736:Testicular Neoplasms / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D014057:Tomography, X-Ray Computed; D057832:Watchful Waiting