Departments of 1 Internal Medicine and 2 Surgical Oncology, University Hospital Groningen, The Netherlands
Received 24 December 2001; revised 22 March 2002; accepted 12 April 2002
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Abstract |
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The routine follow-up of patients with disseminated non-seminomatous testicular cancer (DNSTC) treated with the combination of orchidectomy, polychemotherapy, and if needed, resection of the residual mass, consists of regular physical examinations, chest X-rays (CXR) and tumor marker assessments. Most guidelines for this routine follow-up originate from multi-center trials. In order to estimate the value of CXR in the detection of tumor relapse after complete remission, we reviewed all patients with disseminated testicular cancer treated with chemotherapy at the University Hospital Groningen.
Patients and methods:
Three hundred and fifty-three consecutive patients with DNSTC treated between February 1977 and February 1999 at our institution were reviewed. Two hundred and ninety (82.2%) patients, who were in complete remission after cisplatin-containing chemotherapy followed by, if necessary, resection of the residual mass, entered this analysis. The follow-up schedule consisted of regular physical examinations, tumor marker assessment (lactate dehydrogenase, ß-human chorionic gonadotropin and -FP) and CXR. In all patients the first diagnostic sign of tumor relapse was documented.
Results:
During a median follow-up of 107 months (range 8261) a tumor relapse was documented in 33 patients (11.4%). Median time to relapse was 17 months (range 6179) after the start of chemotherapy. In 27 patients, tumor relapse was first detected by a rise in tumor markers. Two patients presented their relapse with neurological complaints. Both were diagnosed with brain metastasis. In four patients the relapse was detected by both increase in tumor markers and abnormalities in the physical examination. In none of the 33 relapsed patients was routine CXR during follow-up involved in the detection of tumor recurrence. All but one of the relapsed patients had elevated tumor markers before the start of chemotherapy. The total number of CXR made during follow-up in all 290 patients was 10 160; none were diagnostic for the detected relapses.
Conclusions:
These data suggest that routine CXR has no additional value in the detection of tumor relapses during follow-up after chemotherapy in the subset of patients who present their DNSTC with increased tumor markers and are in complete remission after treatment. In order to save valuable resources, CXR can be omitted from the follow-up schedule after chemotherapy for marker-positive non-seminomatous testicular cancer in complete remission.
Key words: chemotherapy, chest X-rays, follow-up, testicular cancer
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Introduction |
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After the first clinical study with cisplatin-based combination chemotherapy for disseminated testicular cancer by Einhorn and Donohue [10], subsequent multi-center studies coordinated by large cooperative groups [Eastern Cooperative Oncology Group (ECOG), South West Oncology Group (SWOG), European Organisation for Research and Treatment of Cancer (EORTC) and Medical Research Council (MRC)] defined the current gold standard in chemotherapy treatment consisting of bleomycin, etoposide and cisplatin (BEP) [1114]. During those studies vigorous follow-up schedules were used after successful chemotherapy treatment with or without retroperitoneal lymph node dissection (RPLND). Although these follow-up schedules for early disease relapse detection are not evidence based, they are still recommended and routinely applied.
This routinely used follow-up schedule of patients with disseminated testicular cancer in complete remission with chemotherapy consists of regular physical examinations, chest X-rays (CXR) and serum tumor marker assessment. There are, however, no firm data on the necessity of performing these CXR.
At our institution we previously investigated follow-up strategies for stage I testicular cancer patients. We demonstrated that the use of CXR is of limited value in detecting a tumor relapse in stage I patients [15]. To estimate the value of CXR in detecting a tumor relapse in patients with disseminated non-seminomatous testicular cancer (DNSTC) in complete remission we reviewed all the patients treated with cisplatin combination chemotherapy at our institution.
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Patients and methods |
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Results |
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Discussion |
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The available literature on the value of CXR in follow-up of treated testicular cancer is scarce. We reported in 1995 that CXR in the follow-up of clinical stage I patients with non-seminomatous testicular cancer have no additional value in detection of disease recurrence [15]. In none of the 42 relapses in 154 stage I patients was CXR the first indication of recurrence.
The lack of value of CXR during post-treatment surveillance after radiation therapy for low early stage seminoma was reported by Buchholz et al. [18]. Rathmell et al. [19] reported relapse patterns of 29 patients who recurred following treatment for metastatic germ-cell tumors of the testis (both seminoma and non-seminoma) [19]. They showed that in two cases (7%) CXR gave first evidence of tumor relapse. However, several of the studied patients had residual masses which were not surgically removed after chemotherapy as is currently considered to be part of standard therapy for DNSTC. This probably influenced the reported data on the value of CXR on relapse patterns and makes comparisons with our data difficult and less valid. Recently the European Society for Medical Oncology (ESMO) released minimum clinical recommendations for diagnosis, treatment and follow-up of mixed or non-seminomatous germ-cell tumors (NSGCT). Recommended follow-up for patients after chemotherapy consists of clinical review, chest X-ray and tumor markers 2 monthly for 1 year, 3 monthly for the second year, than 6 monthly to 5 years, and then annually [20]. If the frequency of ESMO recommended follow-up visits had been applied to our 290 patients instead of the one described in the current paper, this still would have resulted in a little over 6000 CXRs.
For other tumor types, the value of CXR during surveillance after treatment is in several cases somewhat better documented. Studies on follow-up testing for breast cancer, colon cancer and endometrial carcinoma have highlighted the limited usefulness of CXR during follow-up. In a randomized study in breast cancer patients, intensive surveillance including regular CXR after primary treatment did not result in a survival benefit compared with less intensive follow-up regimen during which only clinical indicated tests like CXR were performed [21]. The diagnostic yield of CXR for relapse detection in this study was 24 of 655 patients (3.6%). In patients with colon cancer, the diagnostic yield for potential curative disease with CXR during post-surgical surveillance is also limited and is estimated to be around 1% (12 of 1356 patients) [22]. In a recent report on endometrial cancer recurrence after radiation therapy, routine follow-up CXR showed no value in earlier detection of recurrent disease in 390 patients [23]. For patients with sarcomas of the extremities, however; CXR during surveillance after definitive surgery seems to be effective. In a study by Whooley et al. [24] on follow-up tests after surgery for primary extremity sarcomas 57 of 141 patients (40%) developed distant metastatic disease. In 52% of the cases this distant disease recurrence in the lung was detected by routine follow-up CXR.
Although the current data on routine chest X-rays during follow-up after chemotherapy for DNSTC are just a single-center experience, the conclusion that its use is of limited value seems valid. Because only patients who were in complete response after chemotherapy were eligible for the analysis this subset of patients may have a lower relapse rate which might have underestimated the value of CXR during follow-up.
There is little doubt that the major reason for a patient attending follow-up after treatment is to be assured that his disease has not relapsed. However, this need for reassurance has to be balanced against the anxiety provoked by extensive follow-up testing and the chance of false positive findings, both of which can provoke stress disorders in patients. Therefore from a cost-effectiveness point of view, as well as from a patient psychological well-being perspective, routine chest X-rays can be omitted from routine follow-up. Since there were only a few patients in this study with normal tumor markers before the start of chemotherapy the value of routine CXRs during follow-up in these patients was not sufficiently investigated.
In conclusion, these data demonstrate that routine CXRs have no additional value in the detection of tumor relapses in patients with DNSTC who achieved a complete response after chemotherapy and, if necessary, surgical resection of a residual mass. In order to save valuable resources and improve patient care, CXRs can be omitted from the follow-up schedule after chemotherapy for patients with non-seminomatous testicular cancer who have elevated tumor markers at the start of chemotherapy and who are in complete remission after treatment.
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Acknowledgements |
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Footnotes |
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References |
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