Stage I: Any adjuvant needed ? N. Mottet Urology department St - - PowerPoint PPT Presentation

Stage I: Any adjuvant needed ?

• N. Mottet

Urology department St Etienne

Disclosure

None

Treating stage 1

> 95% cure rate whatever the attitude Aim: optimizing toxicity and QoL

Stage I definition

After orchidectomy Normal CT scan (NO lymph node > 1 cm) Normalized blood markers (based on half life: AFP: 5-6 days / HCG: 1.5 days) The question: undetectable retroperitoneal metastases ?

Non seminoma GCT. Non risk adapted

Daugaard J Clin Oncol 2014

National cohort N = 1226 NSGCT stade I. Median follow up: 180 months. Specific survival (15 years): 94.4% Relapse: 29,4% (2 years) – 30,6% (5 years) IGCCCG Prognosis: 94.4: good / 4.7%: intermediate / 0.8%: poor Where: Abdomen: 59% - lung: 16% - Lung + RP: 7% Death: N = 87 (7%). 6 TGNS – 4 following treatment 24 second cancer – 15 cardiovascular – 12 alcool / drug - . . .

NS-GCT: non risk adapted

Relapse < 2 years Relapse > 2 years

Daugaard J Clin Oncol 2014

Relapse: where / discovery

NS-GCT. Multicenter cohort

Kollmannsberger J Clin Oncol 2014

Most relapse: < 36 months Relapse linked to LVI Overall OS > 95 % 88% good prognosis N = 1118. Median follow up: 62 months

NS-GCT. Multicenter cohort

Kollmannsberger J Clin Oncol 2014

Relapse: when / risk group at relapse LVI neg LVI pos

N = 1954 median follow up: 15.1 years @ 15 years: specific survival= 99.3% 369 relapse (18.9%). @ a median: 13.7 months.

Seminoma GCT Danish database

Mortensen Eur Urol 2014

72% IIa-b

S-GCT. Multicenter cohort

Kollmannsberger J Clin Oncol 2014

Median follow up: 52 months Most relapse: < 36 months Most diagnosed with abdominal CT Overall OS > 95 % Relapse: 13%

Of note

Stage I: an heterogeneous population cohort: risk factors for relapse Effective alternative exist: adjuvant treatment Therefore shared decision

Risk factors NS-GTC

Vascular invasion

(De Wit J Clin Oncol 2006)

Ia (LVI -) 15- 20% relapse (3 years) Ib (LVI +) 40- 50% relapse (3 years)

Embryonal carcinoma Often associated with VI Thresthold unclear

Difficulty: histology reading Pierorazio Eur Urol 2018

Risk factors NS-GCT

From 1226 patients: relapse risk factors Not only LVI ! Daugaard J Clin Oncol 2014

Risk factors S-GCT

Less clear / discriminant Historical Warde J Clin Oncol 2002 Size > 4 cm / rete testis invaded. Both present: 30% relapse at 5 years Recent: N = 1954 followed (median 15.1 years) Mortensen Eur Urol 2014

Follow up: optimal schedule for NS-GCT

Pierorazio Eur Urol 2018

Overall 4 to 6 abdominal CT

Surveillance: how ?

S-GCT: markers questioned Kollmannsberger J Clin Oncol 2014 IMAGING

Thorax: Chest XR or CT ? Value if RP normal in S-GCT ? Pierorazio Eur Urol 2018 1 CT scan: 14 - 21 mGy (lung, stomach) RR death (radio-induced cancer with 30 CT scan: 1,9 Brenner NEJM 2007 Option: MRI: not standard yet

Therefore optimized imaging needed

Follow up: optimal schedule for S-GCT

• Pierorazio. Eur Urol 2018

Overall 7 to 9 abdominal CT

To summarize: without adjuvant

• Pierorazio. Eur Urol 2018

Strength of evidence: moderate However ALL cohorts pointing in the same direction

Surveillance

COMPLIANCE: major impact Ernst Can J Urol 2005 - Kollmannsberger J Clin Oncol 2014 Most death: poor compliance leading to increased size / risk category at relapse Holland: national recommandation (nationwide guidelines 2002) Centralization if < 5 new cases / year

Alternative: adjuvant treatment

None with NO later relapse (Follow up still needed) If risk adapted strategy LV+: 100% treated (compared to only 30 – 50%) 3 BEP (± RPLND: 1/4 Daugaard J Clin Oncol 2014 compared to 1 Specific side effects of adjuvant Chemo: 1 BEP compared to 3 BEP . . . . a real difference ? Carboplatine: 1 cycle AUC 7: no very long term results RPLND: NOT 0% significant complications EBRT: long term side effects

To conclude

EAU guidelines 2017

Shared decision. Prerequisite: compliance