Retroperitoneal lymph node dissection versus chemotherapy for stage I testicular nonseminomas
The European Germ Cell Cancer Consensus Group's statement on the diagnosis and treatment of germ cell cancer provides an excellent review of our current state of knowledge and is a welcome addition to the literature [1
]. Nonetheless, I am surprised by the omission of any acknowledgement of the significant cardiovascular morbidity associated with platinum-based chemotherapy in men with germ cell tumors. This is particularly relevant with regard to treatment options for men with clinical stage I nonseminomatous germ cell tumors. When men are deciding between retroperitoneal lymph node dissection (RPLND) and primary chemotherapy, it is essential for them to be educated about the potential for serious long-term toxicity from cisplatin-based chemotherapy. Huddart et al. [2
] conducted a study of cardiovascular events in 992 men with a history of testicular cancer and reported that exposure to platinum-based chemotherapy was associated with a relative risk of cardiovascular events of 2.59 [95% confidence interval (CI) 1.155.84] compared with men treated with orchiectomy alone. Of men receiving chemotherapy, 6.7% experienced cardiovascular events, and radiation therapy was associated with a similarly increased risk. All subjects had been followed for a minimum of 10 years. Meinardi et al. [3
] studied 87 patients treated with cisplatin-based chemotherapy who had been followed for at least 10 years and who were no older than 50 years of age. Two men suffered myocardial infarctions and three more had angina with proven ischemia. These events occurred in men aged 3042 years who had received chemotherapy 916 years previously. The incidence of cardiac events was 6%, representing a relative risk of 7.1 (95% CI 1.918.3) compared with the general Dutch male population.
While the 5% risk of dry ejaculation following RPLND performed by experienced surgeons is significant, the similar risk of cardiovascular morbidity following chemotherapy must also be considered when deciding on treatment of stage I disease. One could wager that most patients would prefer dry ejaculation to cardiovascular disease, and they thus may prefer RPLND to primary chemotherapy. While two cycles of bleomycin, etoposide and cisplatin may well pose a lower risk than the three or more cycles received by most patients in the papers discussed above, little data in that regard are available. Huddart et al. [2
] reported a similar cardiovascular risk in patients receiving either up to four or more than four cycles of chemotherapy. It is also worth emphasizing that cardiovascular disease is a late complication of chemotherapy. Studies with a minimum follow-up of less than 10 years are probably not informative.
T. Gilligan*
Department of Medical Oncology, Dana-Farber Cancer Institute, Department of Medicine, Harvard Medical School, Boston, MA, USA
* Email: timothy_gilligan{at}dfci.harvard.edu
References
1. Schmoll HJ, Souchon R, Krege S et al. European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG). Ann Oncol 2004; 15: 13771399.[Abstract/Free Full Text]
2. Huddart RA, Norman A, Shahidi M et al. Cardiovascular disease as a long-term complication of treatment for testicular cancer. J Clin Oncol 2003; 21: 15131523.[Abstract/Free Full Text]
3. Meinardi MT, Gietema JA, van der Graaf WT et al. Cardiovascular morbidity in long-term survivors of metastatic testicular cancer. J Clin Oncol 2000; 18: 17251732.[Abstract/Free Full Text]