John Libbey Eurotext

Bulletin du Cancer


Systematic review 2007 : Primary treatments of testicular germ cell tumors after radical orchydectomy Volume 95, issue 2, février 2008

Urologue, Clinique chirurgicale mutualiste, Saint-Étienne, Méthodologiste, FNCLCC, Paris, Oncologue médical, Centre Val d’Aurelle, Montpellier

Background : The “Standards, Options and Recommendations” (SOR) program in oncology, has been initiated in 1993 by the Federation of French Cancer Centres and is realised in collaboration with public and private clinicians, professional federations, scientific societies and since 2005 with National cancer institute. Its aims are to develop clinical practice guidelines (CPG), health technologic assessment reports and systematic reviews. By preparing the latter, it provides support to the scientific societies for the update of their CPG. In this context, the SOR, in collaboration with the French Association of Urology (AFU), has developed a systematic review on the management of nonseminomatous (NSTGC) or seminomatous (STGC) testicular germ cell cancer treated with primary radiotherapy (RT), chemotherapy (CT) or surveillance (SV) after radical orchidectomy. Today, 80 % of patients with testicular germ cell cancer, including metastatic stage, can be cured. Actual challenges are to limit morbidity and late sequels of treatments while maintaining their therapeutic efficacy. Following this goal, surveillance, considered as a therapeutic option, is being broadly developed particularly for localised tumours. Objective : To synthesize outcomes of patients with NSTGC or STGC treated with primary RT, CT or SV after radical orchidectomy. Search strategy : A systematic literature search has been performed on Medline® between 01/2004 and 08/2007 and completed by the consultation of evidence based medicine websites, experts citations and further relevant references identified from trials revealed by electronic searches. Selection criteria : Randomised controlled trial (RCT), systematic reviews, and observational studies (prospective or retrospective cohorts) in patients with locally or advanced NSTGC or STGC treated with primary RT, CT or SV after radical orchidectomy have been included. Data analysis : Studies have been assessed for eligibility and quality by three independents reviewers. Authors were contacted to provide details of outstanding clinical trials. No quantitative analy sis was initially planned because of the heterogeneity of experimental designs researched Bibliographical results : Twenty-nine trials have been included : 1 meta-analysis, 1 pooled analysis of 2 RCT, 4 non-inferiority RCT, 6 comparative studies (1 prospective, 5 retrospective) and 17 observational studies (7 prospective, 10 retrospective). Nineteen references were for NSTGC and 10 for STGC. Conclusions : The choice of risk-adapted treatment for patients with locally NSTGC of the testis seems to be appropriate : SV for low risk patients and CT for others. For advanced stage, the suppression of bleomycine remains questionable. For local STGC, the choice of SV or CT versus RT needs to be confirmed by RCT with prolonged follow-up according to promising results in term of toxicity obtained with carboplatine or lower irradiation dose (20 Gy instead of 30 Gy). Finally, for advanced STGC, the utility of carboplatine single agent treatment versus cisplatin-based combination chemotherapy has not been proved.