Treatment of Clinical Stage I NSGCT with Lymphovascular Invasion
In non-seminomatous germ cell tumour (NSGCT) at clinical stage I, the pathological presence of lymphovascular invasion (LVI) is a well-established high-risk feature that substantially changes the post-orchiectomy management decision.
Clinical Scenario
Non-seminomatous germ cell tumour, clinical stage I, with lymphovascular invasion confirmed on pathology. LVI has long been strongly associated with the risk of relapse: the relapse risk in LVI-positive disease is approximately 50%, compared with around 15% in LVI-negative tumours.
High relapse risk — LVI positive
Treatment Approach
Given the markedly elevated relapse risk associated with LVI, adjuvant chemotherapy is the preferred management strategy for eligible patients in this setting. A surgical approach is available as an alternative for a highly selected subset unable to receive adjuvant chemotherapy.
Full regimen details, eligibility criteria, and the complete structured protocol are available via the link below.
Treatment Goals
Successful management targets normalisation of serum tumour markers (AFP, hCG, LDH) and no evidence of relapse on cross-sectional imaging.
References
- For CS I NSGCT, invasion of the primary tumour into blood or lymphatic vessels, i.e. LVI, has long been described to be strongly associated with the risk of relapse.
- Vascular invasion present: high risk.
- Relapse risk for patients with LVI-positive tumours was 50% versus 15% in patients with LVI-negative tumours.
- Offer adjuvant chemotherapy with one course of BEP, or surveillance and discuss the advantages and disadvantages.
- Those with LVI should have their high risk of relapse (up to 50%) highlighted and be guided to consider adjuvant management, and chemotherapy with single-cycle BEP as the "preferred" option.
- Offer nerve-sparing retroperitoneal lymph node dissection to highly selected patients only; those with contraindication to adjuvant chemotherapy and unwilling to accept surveillance.
- The relapse rate in patients who receive adjuvant chemotherapy with BEP single-cycle is up to 3%.
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