Outcomes of surveillance protocol of clinical stage I nonseminomatous germ cell tumors -: Is shift to risk adapted policy justified?
Outcomes of surveillance protocol of clinical stage I nonseminomatous germ cell tumors -: Is shift to risk adapted policy justified?
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DOI：
10.1016/j.juro.2006.06.012
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发表时间：
2006-10-01
影响因子：
6.6
通讯作者：
Zorlu, Ferruh
中科院分区：
文献类型：
--
作者：
Divrik, Rauf Taner;Akdogan, Buelent;Zorlu, Ferruh
目的：我们评估监测治疗的临床I期非精原细胞肿瘤患者疾病复发的潜在危险因素，并重新评估我们对这些患者的治疗。材料和方法：对1993-2005年间连续211例临床I期非精原细胞肿瘤患者进行切除术后的监测。评估的危险因素有血管侵犯、胚胎癌比例、年龄、肿瘤大小、术前血清甲胎蛋白升高和卵黄囊成分缺失。结果：211例患者中有66例(31.3%)复发。术后复发时间为2~32个月(中位数6个月)。术后第1年复发者52例(78.8%)，第2年复发者11例(16.7%)，术后复发者仅3例。复发的第一个证据最常见的是血清肿瘤标志物的增加(28.8%)或与其他方式联合(66.7%，总体95.5%)。胚胎性癌>50%的患者复发率为40.9%，低于50%的复发率为20.8%(P=0.002)。有血管侵犯和无血管侵犯患者的复发率分别为75.5%和17.9%(P=0.000)。无危险因素(无血管侵犯且胚胎性癌<50%)和2个危险因素(血管侵犯及胚胎性癌>50%)患者的复发率分别为6.1%和75.7%(p<；0.001)。多因素分析显示血管侵犯是预测复发的最有力因素(OR 16.350，95%CI 5.582~47.893)。中位随访75个月，无病生存率和疾病特异性生存率为97.6%。结论：根据我们的结果，我们建议所有有血管侵犯的患者都应该接受化疗。然而，无危险因素的患者和那些胚胎癌超过50%但没有血管侵犯的患者应该在切除术后监测，因为复发率不到30%。虽然第一年严格的随访是合理的，但根据放射学检查的频率，后续方案可能会被重新评估。
Purpose: We evaluated the potential risk factors for disease relapse in patients with clinical stage I nonseminomatous germ cell tumors treated with surveillance and reevaluated our treatment of these patients.Materials and Methods: A total of 211 consecutive patients with clinical stage I nonseminomatous germ cell tumors treated with surveillance after orchiectomy between 1993 and 2005 were included in this retrospective study. Risk factors evaluated were presence of vascular invasion, proportion of embryonal carcinoma, age, tumor size, preoperatively increased serum a-fetoprotein and the absence of yolk sac component.Results: Of the 211 patients 66 (31.3%) had disease relapse. Recurrence ranged from 2 to 32 months after orchiectomy (median 6). A total of 52 (78.8%) cases of relapse were diagnosed in year 1 of followup, 11 (16.7%) during year 2 and only 3 cases were diagnosed thereafter. The first evidence of relapse was most commonly the increase in serum tumor markers alone (28.8%) or in combination with other modalities (66.7%, overall 95.5%). While 40.9% of patients with more than 50% embryonal carcinoma had disease relapse, the relapse rate was 20.8% in patients with less than 50% embryonal carcinoma (p = 0.002). Relapse rates in patients with and without vascular invasion were 75.5% and 17.9%, respectively (p = 0.000). The relapse rates were 6.1% and 75.7% in patients with no risk factors (no vascular invasion and less than 50% embryonal carcinoma) and 2 risk factors (vascular invasion and more than 50% embryonal carcinoma), respectively (p < 0.001). Multivariate analysis revealed that vascular invasion was the most powerful predictor of relapse (OR 16.350, 95% CI 5.582-47.893). Disease-free and disease specific survival rates were 97.6% at a median followup of 75 months.Conclusions: In light of our results we suggest that all patients with vascular invasion should receive chemotherapy. However, patients with no risk factors and those with more than 50% embryonal carcinoma but without vascular invasion should be on surveillance after orchiectomy since the relapse rate is less than 30%. Although strict followup in the first year is justified, followup schemas may be reassessed for the frequency of radiological investigations.