Figure. The authors at the 2023 Confederación Americana de Urología Annual Congress. Left to right, Rodrigo Riveri, Cristian Rodríguez, Francisco Osorio, Ana Chávez, Gustavo Carvalhal, Juan Astigueta, and Luis Ebel.

A case based on a 31-year-old patient with nonseminoma germ cell testicular cancer (NSGCT) pT2N2M1aS0 group IIIA at high risk per International Germ Cell Consensus Classification treated with 4 cycles of cisplatin, etoposide, and ifosfamide, and operated on for a postchemotherapy retroperitoneal residual mass (pCTRM), was carried out at one of the instructional courses from the recent Confederación Americana de Urología (American Confederation of Urology) 2023 Congress held in Santiago, Chile October 4 to 7, 2023.

In relation to the evaluation of fertility, most men at the time of diagnosis are in the middle of their reproductive stage, and more than half of them present deterioration in semen quality prior to diagnosis¹ or their reproductive potential will be affected by associated treatments, including orchiectomy. Most clinical guidelines recommend active fertility counseling for all patients before starting treatment, but it is carried out in less than 50% of cases.² It is the urologist who must evaluate with the patient the gonadotoxic effects of all treatments for testicular cancer (TC), offer available alternatives for fertility preservation, and advise them during the monitoring on aspects of sexual and reproductive well-being.

Regarding an alternative of conservative surgery, with the purpose of preserving testicular function, avoiding overtreatment of potentially benign lesions, or resecting only the tumor in bilateral TC cases, it is emphasized that the discovery of small testicular tumors is increasing, and that only 25% of those smaller than 20 mm are malignant³ and practically all of those smaller than 5 mm are benign.⁴ Therefore, the indication for tumorectomy is increasing, even in patients with a healthy contralateral testicle, and it is always necessary to perform a contemporary histological study of the tumor to know its histology and surgical margins.

The use of artificial intelligence to support the management of TC has had great development and its application in medicine is varied, through big data processing and the use of large language models, machine learning, and deep learning. In TC, deep learning models support histopathological diagnosis with precision to detect lymphovascular invasion; the evaluation is performed in a fraction of the time and would represent a significant advance in the efficiency of histopathological diagnosis.⁵ In the imaging evaluation of NSGCT pCTRM, radiomics detects viable tumor tissue with greater precision than conventional imaging, allowing retroperitoneal lymph node dissection to be avoided in many cases to rescue nontumor residual masses,⁶ and machine learning allows predicting the evolution toward an M1b stage with the need for more aggressive management in these patients.⁷ Artificial intelligence has great development potential, and with adequate medical validation it will contribute greatly to improving the understanding and management of TC.

In the management of retroperitoneal pCTRM the behaviors are different depending on the histological type of the tumor. For seminoma germ cell testicular cancer (SGCT), residual masses smaller than 3 cm generally do not have active tumors and can be monitored. In NSGCT, residual masses larger than 1 cm are most likely active and should be operated on. A significant aspect is the role of positron emission tomography–CT in differentiating residual masses from SGCT: hyperenhancement lesions are generally active and require treatment. There are doubts about template extension in residual masses and about the use of robotic surgery since pneumoperitoneum may be associated with tumor recurrences in unusual places due to the dissemination of cells in the peritoneum during robotic retroperitoneal lymph node dissection.

Patients with metastatic NSGCT have a 5-year progression-free survival of 54% and a 5-year overall survival of 67%, and restaging must be done 4 to 6 weeks after the beginning of the last cycle of chemotherapy with tumor markers (TMs) and TC scan or MRI. If the mass postchemotherapy is over 1 cm, surgery is indicated, as stated. For intermediate- to high-risk metastatic cancer per International Germ Cell Consensus Classification with complete response to chemotherapy only 18% of patients relapse. The most frequent sites for relapse are retroperitoneum. The recommended minimal follow-up (FU) schedule after adjuvant treatment or complete remission for advanced disease is doctor visits and TMs every 3 months, and abdominopelvic scan/MRI and thoracic scan every 6 to 12 months during the first year; during second year, doctor visits and TMs, keeping the same schedule and images at month 24; and during years 3 to 5, doctor visits and TMs twice a year with images at months 36 and 60. After 5 years, further FU is according to the survivorship plan. Nevertheless, poor prognostic patients and those with no remission can have tailored schedules for proper FU on special conditions.⁸ Cancer diagnosis implies diagnostic procedures, treatment, and FU that affects quality of life. Patients must be informed of the potential long-term effects of the treatment (metabolic syndrome, cardiovascular events, secondary malignancies, as psychological and reproductive issues), emphasizing the importance of recognizing psychological distress and poor social support, to give them adequate management by the psychological and social staff, while anxiety, depression, and fear of recurrence of the disease are more frequent in oncologic patients and affect their quality of life. Many studies show that returning to daily activities reduces stress and depression, and that patients in a relationship tend to have better emotional adaptation than those who don’t have one.⁹

Finally, 95% of patients successfully treated relapse in the first 2 years of FU, especially those with risk factors, where lymphovascular invasion in the case of NSGCT is the most powerful predictive and reproducible factor. The chemotherapy of choice is 4 cycles of a 3-drug combination that includes cisplatin and ifosfamide as a base, plus a third agent which can be etoposide, paclitaxel, or gemcitabine. The use of high-dose chemotherapy is an alternative rescue treatment, with sequential cycles of high doses of carboplatin and etoposide being preferred, because it is associated with lower mortality due to toxicity. The comparison of both alternatives is currently awaiting the results of the TIGER study.¹⁰ Finally, referring to late relapses (more than 2 years after the end of treatment), chemotherapy and radiotherapy are management alternatives for SGCT, while surgery is recommended, when possible, for NSGCT, alone or in combination with chemotherapy.