目的:睾丸生殖细胞癌治疗的最新建议。
方法:全面回顾自2020年以来有关诊断的PubMed文献,睾丸生殖细胞癌(TGCT)的治疗和随访,以及治疗的安全性。评估参考文献的证据水平。
结果:睾丸生殖细胞癌患者的初步检查基于临床检查,生化(AFP,总hCG和LDH血清标志物)和放射学评估(阴囊超声和胸-腹-盆腔[TAP]CT)。腹股沟睾丸切除术是可以进行组织学诊断的第一个治疗步骤,可以确定I期非精原细胞生殖细胞肿瘤(NSGCT)的局部阶段和危险因素。对于纯I期精原细胞瘤患者,进展的风险为15%至20%。因此,依从患者的监测是优选的;卡铂AUC7辅助化疗是一种选择;主动脉旁放疗的适应症有限.对于I期NSGCT患者,监测和风险适应策略之间有多种选择(监测或1个周期的BEP[博来霉素依托泊苷顺铂]取决于肿瘤内是否存在血管栓塞).腹膜后淋巴结清扫术对分期的作用非常有限。转移性TGCT的治疗是BEP化疗,没有博来霉素的任何禁忌症,根据国际生殖细胞癌联盟(IGCCCG)的预后风险组确定周期数。主动脉旁放射治疗仍然是IIA期精原细胞生殖细胞肿瘤(SGCT)的标准。化疗后,应通过NSGCT的TAP扫描评估残余肿块的大小:对于任何超过1厘米的残余肿块,建议进行腹膜后淋巴结清扫,所有其他转移部位都应切除。对于SGCT,需要通过18F-FDGPET重新评估,以指定>3cm残留肿块的手术指征。在这些情况下,手术仍然很少见。
结论:坚持TGCT管理建议,获得了优异的疾病特异性存活率;I期99%,转移期85%以上。
OBJECTIVE: Updated Recommendations for the management of testicular germ cell cancer.
METHODS: Comprehensive review of the literature on PubMed since 2020 concerning the diagnosis, treatment and follow-up of testicular germ cell cancer (TGCT), and the safety of treatments. The level of evidence of the references was evaluated.
RESULTS: The initial work-up for patients with testicular germ cell cancer is based on a clinical examination, biochemical (AFP, total hCG and LDH serum markers) and radiological assessment (scrotal ultrasound and thoracic-abdominal-pelvic [TAP] CT). Inguinal orchiectomy is the first therapeutic step whereby the histological diagnosis can be made, and the local stage and risk factors for stage I non-seminomatous germ cell tumours (NSGCT) can be determined. For patients with pure stage-I seminoma, the risk of progression is 15 to 20%. Therefore, surveillance in compliant patients is preferable; adjuvant chemotherapy with carboplatin AUC 7 is an option; and indications for para-aortic radiotherapy are limited. For patients with stage I NSGCT, there are various options between surveillance and a risk-adapted strategy (surveillance or 1 cycle of BEP [
Bleomycin Etoposide Cisplatin] depending on the absence or presence of vascular emboli within the tumour). Retroperitoneal lymph node dissection for staging has a very limited role. The treatment for metastatic TGCT is BEP chemotherapy in the absence of any contraindication to
bleomycin, for which the number of cycles is determined according to the prognostic risk group of the International Germ Cell Cancer Consortium Group (IGCCCG). Para-aortic radiotherapy is still a standard in stage IIA seminomatous germ cell tumours (SGCT). After chemotherapy, the size of residual masses should be assessed by TAP scan for NSGCT: retroperitoneal lymph node dissection is recommended for any residual mass of more than 1 cm, and all other metastatic sites should be excised. For SGCT, reassessment by 18F-FDG PET is required to specify the surgical indication for residual masses>3cm. Surgery is still rare in these situations.
CONCLUSIONS: By adhering to TGCT management recommendations, excellent disease-specific survival rates are achieved; 99% for stage I and over 85% for metastatic stages.