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 Daugaard J Clin Oncol 2014 Relapse: where / discovery Relapse < 2 years Relapse > 2 years

NS-GCT. Multicenter cohort N = 1118. Median follow up: 62 months Kollmannsberger J Clin Oncol 2014 Relapse linked to LVI Most relapse: < 36 months 88% good prognosis Overall OS > 95 %

NS-GCT. Multicenter cohort Relapse: when / risk group at relapse Kollmannsberger J Clin Oncol 2014 LVI neg LVI pos

Seminoma GCT Danish database N = 1954 median follow up: 15.1 years Mortensen Eur Urol 2014 @ 15 years: specific survival= 99.3% 369 relapse (18.9%). @ a median: 13.7 months. 72% IIa-b

S-GCT. Multicenter cohort Kollmannsberger J Clin Oncol 2014 Relapse: 13% Median follow up: 52 months Most relapse: < 36 months Most diagnosed with abdominal CT Overall OS > 95 %

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 Shared decision. Prerequisite: compliance EAU guidelines 2017