Clinical scenario

This protocol addresses patients with clinical stage I NSGCT in whom lymphovascular invasion (LVI) is present on pathology of the primary tumour. LVI marks a high-risk subgroup: relapse risk for LVI-positive tumours reaches 50%, compared with 15% in LVI-negative disease. Because of this elevated risk, adjuvant management is typically undertaken — yet some patients relapse despite it.

Previous line — failure condition

Prior treatment: Adjuvant chemotherapy with one course of BEP (cisplatin, etoposide, bleomycin), or nerve-sparing retroperitoneal lymph node dissection for highly selected patients with a contraindication to adjuvant chemotherapy.

Escalation trigger: Failure to maintain normal serum tumour markers (AFP, hCG, LDH) or evidence of relapse on cross-sectional imaging after the above adjuvant approach.

Approach at relapse

At relapse, the approach centres on cisplatin-based chemotherapy, with regimen selection guided by the patient's IGCCCG prognostic risk group. The treatment goal is normalisation of serum tumour markers (AFP, hCG, LDH) and complete or partial radiological response. The full selection criteria, regimen detail, and sequencing are available in the structured protocol below.

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.
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.

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CS I Non-Seminomatous Germ Cell Tumour with Lymphovascular Invasion: Management After Adjuvant Therapy Fails

References