Encouraging Outcomes Allow Patient-Guided Treatment Strategies for Stage I Pure Testicular Teratoma

Abstract

In their study, ‘‘Retroperitoneal Lymph Node Dissection vs Surveillance for Adult Early-Stage Pure Testicular Teratoma: A Nationwide Analysis,’’ Ali et al. compare and contrast surveillance and retroperitoneal lymph node dissection (RPLND) for patients with early-stage pure teratoma. In broad terms, this study confirms that patients with stage 1 germ cell tumor (GCT), including those with pure teratoma, have an excellent prognosis whether they receive RPLND or surveillance. Although this largely comports with what we already think we know and is incorporated into the guidelines for the management of stage 1 nonseminomatous GCT (NSGCT), use of large nationwide cancer registries such as the National Cancer Database (NCDB) provides further evidence in this otherwise rare malignancy. Although the NCDB has significant advantages over more institutional series in certain aspects, it has important limitations in other aspects that must be acknowledged and considered as caveats for the conclusions drawn about the safety of surveillance. In general, patients with newly diagnosed stage 1 (organ-confined) NSGCT are faced with the decision of how to approach the risk (B 30%) of harboring micro-metastatic disease, most commonly within the retroperitoneum, Their options include surveillance with periodic laboratory examinations and cross-sectional imaging or adjuvant treatment with RPLND or single-cycle chemotherapy comprising bleomycin, etoposide, and cisplatin (BEPx1). Pure teratoma is a unique biologic entity within the broad category of NSGCT, and it is unclear whether in the case of metastatic teratoma, non-teratomatous elements metastasize and transform into teratoma, or whether the teratoma itself can metastasize. Additionally, patients with pure teratoma have narrower options because teratoma typically is chemoand radio-resistant. As Ali et al demonstrate, surveillance is the more commonly used strategy and continues to increase in popularity. Patients who select this strategy appear to have excellent survival outcomes and may avoid potentially unnecessary surgery. The survival rate of nearly 100% for patients receiving RPLND is consistent with that for large series of patients who have stage1 disease, although the survival rate of approximately 90% for patients receiving surveillance is concerning. Unfortunately, no subgroup analysis of stage 1A (T1N0M0S0), stage 1S (TanyN0M0S1), or stage 1B (T2-4N0M0S0) disease is provided. This is critical because surveillance is the preferred management strategy per the American Urological Association (AUA), the European Urology Association (EAU), and the National Comprehensive Cancer Network (NCCN) guidelines for stage 1A disease, with surveillance and adjuvant treatment (RPLND or BEPx1) as the options for 1B patients. Weiner et al. 9 illustrate this point using the same dataset as the current authors, in which 70% of the stage 1A NSGCT patients were managed with surveillance, whereas only 46% of the stage 1B NSGCT patients were managed with surveillance. In the current analysis, it is not clear how many patients were excluded due to unavailable treatment data, which likely was a high proportion of the overall cohort. Society of Surgical Oncology 2021