Follow-up strategy of germ cell tumour patients.

We read with interest the 2005 version of the ESMO Minimum Clinical Recommendations (MCR) for diagnosis, treatment and follow-up of germ cell tumour (GCT) patients [1, 2]. Although we are in agreement that MCR are intended to provide just a basic standard of care for all European countries, we would like to express some concerns regarding the recommendations for the follow-up strategy of GCT patients. Despite the fact that patients with advanced GCT in complete remission after chemotherapy have a much more elevated risk of recurrence than patients with stage I non-seminoma, in the MCR the follow-up schedule, including clinical examination, tumour markers, chest X-ray and computerized tomography (CT) scan, appears to be absolutely more intensive in the stage I non-seminoma patients [1]. In these patients, chest X-ray examinations are scheduled monthly in the first year, 2 monthly in the second year, 4 monthly in the third year, then 6 monthly until 5 years [1]. Even in patients with low-stage seminoma and those with GCT in complete remission after chemotherapy, chest X-ray examinations appear coupled with every clinical examination [1, 2]. The recommendations for the use of CT scan are also questionable. The MCR follow-up strategy, based on intensive chest X-ray examinations, is not evidence-based, as suggested by the very low grade of evidence/recommendation reported by authors [1, 2]. Since the introduction of cisplatin in the mid-1970s, GCT has become a highly curable disease. In early 1980s, both the clinical studies with cisplatin-based chemotherapy in patients with advanced GCT and the first trials assessing the utility of surveillance after orchiectomy for stage I disease introduced a very strict follow-up schedule including routine chest X-ray in order to detect ‘low volume’ relapse, which could be potentially cured [3]. These intensive follow-up schedules were introduced in order to assess the efficacy of the treatment, not to define the optimal follow-up schedule, but during the last 20 years remained in the major guidelines (ESMO MCR, PDQ, National Comprehensive Cancer Network) [1, 2, 4, 5]. The literature on this topic is scarce. Nevertheless, in the last decade three large single-centre experiences showed that routine chest X-ray has no additional value in the detection of recurrence in patients with stage I non-seminoma, low stage seminoma and advanced GCT in complete remission after treatment [6–8]. In absence of cost-effective evidence, we also need to take into consideration