Relapse of Nonseminomatous Germ Cell Tumors During Active Surveillance


Key Points

  • Most relapses occurred in the retroperitoneum alone.
  • Most relapses were cured by chemotherapy alone or RPLND alone.

In a single-institution study reported in the Journal of Clinical Oncology, Hamilton et al found that relapses of clinical stage I nonseminomatous germ cell tumors (NSGCT) during postorchiectomy active surveillance most frequently occurred in the retroperitoneum and were cured by single-modality therapy.  

Study Details

The study involved data from 580 patients with clinical stage I NSGCT treated with active surveillance at Princess Margaret Cancer Centre between December 1980 and December 2015. Among these, relapse occurred in 162 (27.9%).

Relapse and Treatment

Among the 162 patients with relapse, median time to relapse was 7.4 months. The most common site of relapse was the retroperitoneum alone (66.0%). After relapse, first-line treatment was chemotherapy in 95 patients (58.6%) and retroperitoneal lymph node dissection (RPLND) in 62 (38.3%), with 5 patients (3.1%) undergoing other therapy. In 103 patients (65.6%), only one modality of treatment was required for cure, consisting of chemotherapy alone in 58 (61.0%) of 95 and RPLND alone in 45 (73.0%) of 62.  

In patients receiving chemotherapy as first-line treatment of relapse, larger nodal size (N2/3 vs N1) was the only significant factor associated with need for more therapy (odds ratio [OR] = 2.68, P = .045). Among 37 patients receiving additional therapy, the most common was postchemotherapy mass resection in 27 (73.0%), consisting of RPLND in 19 (51.4%), mediastinal/lung resection in 6 (16.2%), and other resections in 2 (5.4%).

In patients receiving RPLND as initial relapse therapy, the only factor significantly associated with need for additional therapy was elevated serum tumor markers prior to RPLND (OR = 6.05, P = .008); when RPLND was performed with normal markers, 82% of patients required no further treatment. Of the 17 patients receiving additional therapy, 3 (4.8%) received adjuvant chemotherapy, 12 (19.4%) received chemotherapy after relapse, and 2 (3.2%) underwent other surgery outside the retroperitoneum.

Second relapse occurred in 30 (18.5%) of the 162 patients with initial relapse. With median follow-up of 7.6 years, there were five deaths from NSGCT or treatment complications, representing 3.1% of patients with relapse during active surveillance and 0.8% of the total active surveillance cohort.

The investigators concluded, “The retroperitoneum is the most common site of relapse in clinical stage I NSGCT on [active surveillance]. Most [patients] are cured by single-modality treatment. RPLND should be considered for relapsed patients, especially those with disease limited to the retroperitoneum and normal markers, as an option to avoid chemotherapy.”

Robert J. Hamilton, MD, of Princess Margaret Hospital Cancer Centre, Toronto, is the corresponding author for the Journal of Clinical Oncology article.

Disclosure: For full disclosures of the study authors, visit

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