What is the recommended treatment for a 31-year-old male with a history of non-seminomatous germ cell tumor (NSGCT) post-orchiectomy, with a 1.1 cm paraaortic lymph node and normal serum tumor markers and chest X-ray (CXR)?

Management of a 31-year-old Male with pT1 NSGCT and a 1.1 cm Paraaortic Lymph Node

For a 31-year-old male with a 4 cm pT1 non-seminomatous germ cell tumor (NSGCT) after radical orchiectomy, with normal serum tumor markers and a 1.1 cm paraaortic lymph node, the recommended treatment is primary chemotherapy with 3 cycles of BEP (bleomycin, etoposide, cisplatin). 1, 2

Disease Classification and Risk Assessment

• This patient has clinical stage IIA NSGCT based on the presence of a 1.1 cm paraaortic lymph node 1
• The patient falls into the "good prognosis" group according to the International Germ Cell Consensus Classification (IGCCCG) based on normal tumor markers, non-mediastinal primary site, and absence of non-pulmonary visceral metastases 1
• The 1.1 cm lymph node represents a borderline finding that requires careful consideration, as nodes <2 cm can sometimes be equivocal 2

Treatment Options and Rationale

Primary Chemotherapy Approach (Recommended)

• For stage IIA NSGCT with a visible lymph node, primary chemotherapy with 3 cycles of BEP is the preferred treatment according to the most recent guidelines 1, 2
• BEP regimen consists of bleomycin 30,000 IU on days 1,8, and 15; etoposide 100 mg/m² on days 1-5; cisplatin 20 mg/m² on days 1-5 1
• This approach has been associated with improved relapse-free survival (98% vs 79%) compared to primary RPLND in patients with stage IIA/IIB disease 3
• Primary chemotherapy is particularly appropriate when there is radiographic evidence of disease, even with normal markers 2, 4

Alternative Approach: Nerve-Sparing RPLND

• Nerve-sparing retroperitoneal lymph node dissection (RPLND) could be considered as an alternative, particularly if performed by an experienced surgeon at a high-volume center 2, 5
• If RPLND is chosen, it should be a full bilateral template dissection with nerve-sparing technique to preserve ejaculatory function 5
• Post-RPLND management would depend on pathologic findings:
  • If pN0 (no metastasis): surveillance only 1
  • If pN1 (minimal nodal disease): consideration of adjuvant chemotherapy 1, 5

Important Considerations

• Sperm banking should be offered before initiating any treatment that may affect fertility 1
• The patient should be managed by an oncologist with experience in testicular cancer treatment 1
• Treatment decisions should be made in a multidisciplinary setting involving experienced clinicians 2
• The long-term survival rate for stage IIA NSGCT is excellent (>95%) regardless of treatment approach, so consideration of long-term morbidity is important 5

Follow-Up Protocol

• After chemotherapy:

  • Clinical review, chest X-ray, and tumor markers every 2 months for the first year 1, 2
  • Every 3 months for the second year 1
  • Every 6 months for years 3-5, then annually 1
  • Abdominal/pelvic CT scan as clinically indicated 1, 2

• If residual mass remains after chemotherapy:

  • Surgical resection should be considered for masses ≥1 cm 1, 6
  • Even small residual masses may harbor viable tumor or teratoma 6

Common Pitfalls to Avoid

• Failing to obtain adequate baseline tumor markers before orchiectomy, which can make post-surgical interpretation difficult 7
• Not repeating marker tests at appropriate intervals to determine half-life kinetics 7
• Underestimating the significance of small lymph nodes, as even nodes <1.5 cm can harbor residual malignancy or teratoma 6
• Delaying treatment decisions - management should be initiated promptly after staging is complete 1