Review of relapse detection methods in stage 1 testicular germ cell tumors in patients after orchidectomy managed with active surveillance: is physical examination required?

Background: Active surveillance (AS) is the preferred management for most patients with stage 1 testicular germ cell tumors (GCT) after orchidectomy as it avoids chemotherapy in up to 85% of patients. International guidelines recommend a combination of imaging, serum tumor markers and physical examination. The aim of this review was to analyze the diagnostic yield of physical examination for detecting relapse in these patients. Methods: Systematic review of the literature from 1976 to 2024 detailing method of relapse detection for patients with stage I GCT managed with AS. Studies commencing after 1990 were assigned to the ‘Modern Cohort’ and those prior to this date were assigned to the “Older Cohort.” Descriptive statistical analysis of discrete data was performed to determine recurrence and proportion of patients, where relevant. The chi squared test was used to determine statistical significance. Results: Twenty articles were identified representing 2232 (20%) relapses amongst 11,414 patients managed with AS. Relapses were detected by imaging alone in 60%, tumor markers alone in 24%, imaging and markers in 15%, and physical examination in 1.5%. Comparing the Modern cohort (n = 4771) to the older cohort (n = 6643), there were fewer relapses detected by physical examination (0.3% vs. 2%, P = .01) and more relapses detected by imaging alone (71% vs. 55%, P < .00001). Conclusions: Almost all relapses are detected by routine imaging, serum tumor markers or a combination of these methods. Physical examination alone rarely identified relapses, particularly in the Modern cohort which we hypothesize was driven by improvement in imaging techniques. AS can be conducted safely without mandatory physical examination.