title: Patterns of relapse in patients with clinical stage I testicular cancer managed with active surveillance.
abstract: OBJECTIVE
  To evaluate the performance of active surveillance as a management strategy in broad populations and to inform the development of surveillance schedules by individual patient data regarding timing and type of relapse.
  
  
  METHODS
  Retrospective study including data from 2,483 clinical stage I (CSI) patients, 1,139 CSI nonseminoma and 1,344 CSI seminoma managed with active surveillance, with the majority treated between 1998 and 2010. Clinical outcomes including relapse and death, time distribution, extent of relapse and method of relapse detection observed on active surveillance were recorded.
  
  
  RESULTS
  Relapse occurred in 221 (19%) CSI-nonseminoma and 173 (13%) CSI-seminoma patients. Median time to relapse was 4 months (range, 2-61 months), 8 months (range, 2-77 months) and 14 months (range, 2-84 months) for lymphovascular invasion-positive CSI nonseminoma, lymphovascular invasion-negative CSI nonseminoma and CSI seminoma. Most relapses were observed within the first 2 years/3 years after orchiectomy for CSI nonseminoma (90%)/CSI seminoma (92%). Relapses were detected by computed tomography scan/tumor-markers in 87%/3% of seminoma recurrences, in 48%/38% of lymphovascular invasion-negative and 41%/61% of lymphovascular invasion-positive patients, respectively. 90% of CSI-nonseminoma and 99% of CSI-seminoma relapses exhibited International Germ Cell Collaborative Group good-risk features. Three patients with CSI nonseminoma died of disease (0.3%). One patient with CSI seminoma and two patients with CSI nonseminoma died because of treatment-related events. Overall, advanced disease was seen in both early- and late-relapse patients. All late recurrences were cured with standard therapy. Five-year disease-specific survival was 99.7% (95% CI, 99.24% to 99.93%).
  
  
  CONCLUSIONS
  Active surveillance for CSI testis cancer leads to excellent outcomes. The vast majority of relapses occur within 2 years of orchiectomy for CSI nonseminoma and within 3 years for CSI seminoma. Late and advanced stage relapse are rarely seen. These data may inform further refinement of rationally designed surveillance schedules.
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA. ckollmannsberger@bccancer.bc.ca.
authors.forename: Christian
authors.initials: C
authors.lastname: Kollmannsberger
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Torgrim
authors.initials: T
authors.lastname: Tandstad
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Philippe L
authors.initials: PL
authors.lastname: Bedard
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Gabriella
authors.initials: G
authors.lastname: Cohn-Cedermark
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Peter W
authors.initials: PW
authors.lastname: Chung
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Jewett
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Tom
authors.initials: T
authors.lastname: Powles
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Padraig R
authors.initials: PR
authors.lastname: Warde
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Siamak
authors.initials: S
authors.lastname: Daneshmand
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Protheroe
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Scott
authors.initials: S
authors.lastname: Tyldesley
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Black
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Kim
authors.initials: K
authors.lastname: Chi
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Alan I
authors.initials: AI
authors.lastname: So
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Malcom J
authors.initials: MJ
authors.lastname: Moore
authors.affiliation: Peter C. Black and Alan I. So, University of British Columbia, The Vancouver Prostate Centre; Christian Kollmannsberger, Kim Chi, and Scott Tyldesley, British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, British Columbia; Philippe L. Bedard, Michael A. Jewett, Malcom J. Moore, and Peter W. Chung, University Health Network-Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; Torgrim Tandstad, St Olavs University Hospital, Trondheim, Norway; Gabriella Cohn-Cedermark and Padraig R. Warde, Radiumhemmet, Karolinska Institute and University Hospital, Stockholm, Sweden; Tom Powles, Bart's Cancer Institute, St Bartholomew's Hospital, London; Andrew Protheroe, University of Oxford, the Churchill Hospital, Oxford, UK; Siamak Daneshmand, Institute of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA; and Craig R. Nichols, Virginia Mason Medical Center, Section of Hematology/Oncology, Seattle, WA.
authors.forename: Craig R
authors.initials: CR
authors.lastname: Nichols
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D009919:Orchiectomy; D017063:Outcome Assessment, Health Care / Q000379:methods / Q000706:statistics & numerical data; D011379:Prognosis; D012189:Retrospective Studies; D018239:Seminoma / Q000473:pathology* / Q000601:surgery; D013736:Testicular Neoplasms / Q000473:pathology* / Q000601:surgery; D013997:Time Factors; D055815:Young Adult