Discontinuous Involvement of the Spermatic Cord by Germ Cell Tumors Should Not Be Considered Pathologic Stage M1

In testicular germ cell tumors (TGCTs), staging is a major determinant of disease-specific outcomes and dictates clinical management. The 8th edition of the American Joint Committee on Cancer (AJCC) staging manual recommends that tumor deposits in the spermatic cord that are discontinuous with the primary tumor be considered pathologic stage M1 (clinical stage [CS] III). This recommendation is controversial because, if patients do not show other metastases, it results in upstaging from CS I to III. This is relevant because CSI patients are candidates for active surveillance, whereas chemotherapy represents the standard treatment of CSIII patients. In this study, we describe the clinicopathologic findings and disease outcomes of TGCT patients presenting with discontinuous cord involvement no other concurrent metastases (ie, otherwise CS I). A total of 19 patients were assessed: 16 nonseminomas and 3 seminomas. When the focus of discontinuous spermatic cord invasion was excluded from staging, 10 tumors were pT3, 8 were pT2, and 1 was pT1. Adjuvant chemotherapy was given to 15 patients, 10 of whom developed disease recurrence (8 of them showing metastases in the retroperitoneum). None of the 4 patients kept on active surveillance showed evidence of recurrence at last follow-up, which is incompatible with the natural history of untreated CS III TGCTs. If the focus of discontinuous cord involvement was excluded from staging, these 4 cases were all pT2. Our data support that discontinuous cord invasion should not be considered pM1, since this practice may result in overtreatment of patients that could be kept on surveillance. We suggest staging these tumors as pT3(disc), considering this finding a risk factor for recurrence.