Comparative cost-effectiveness of contemporary treatment strategies for stage IIA seminoma

BACKGROUND

The Surgery in Early Metastatic Seminoma (SEMS) trial examined retroperitoneal lymph node dissection as first-line treatment for patients with isolated 1-3 cm retroperitoneal lymphadenopathy. To date, the standard of care for these patients has been either chemotherapy or radiotherapy. Herein, we evaluated the relative cost-effectiveness of these management strategies.

METHODS

A microsimulation model assessed the cost-effectiveness of retroperitoneal lymph node dissection, chemotherapy, and radiotherapy for stage IIA seminoma. Sensitivity analyses were performed to evaluate model robustness. Retroperitoneal lymph node dissection recurrence probabilities were obtained from the SEMS trial. All other probability and utility values were obtained from published literature. Primary outcomes included costs from a commercial insurer's perspective, effectiveness (quality adjusted life-years [QALYs]), and incremental cost-effectiveness ratios using a willingness-to-pay threshold of $100 000/QALY.

RESULTS

At a lifetime horizon, the mean costs per patient for retroperitoneal lymph node dissection, radiotherapy, and chemotherapy were $58 469, $98 783, and $104 096, and the mean QALYs were 40.61, 40.70, and 39.15, respectively. Retroperitoneal lymph node dissection was found to be the most cost-effective approach because of high costs and accrued disutility of chronic toxicities associated with radiotherapy (cost-effectiveness ratios = $433 845/QALY) and chemotherapy (dominated). On 1-way sensitivity analyses, retroperitoneal lymph node dissection was no longer cost-effective if the probabilities of infertility and cardiovascular toxicity after radiotherapy were less than 13% and 16%, respectively, or if the 2-year probability of progression after retroperitoneal lymph node dissection was more than 26%.

CONCLUSIONS

Retroperitoneal lymph node dissection was the most cost-effective treatment approach for stage IIA seminoma. These findings support clinical guideline consideration of including retroperitoneal lymph node dissection as a treatment option for well-selected patients with stage IIA seminoma.

Clinical Outcomes of De Novo Versus Relapsed Early Metastatic Testicular Seminoma Treated With Contemporary Radiation Therapy

PURPOSE

Chemotherapy (CHT) or radiation therapy (RT) are first-line treatments for clinical stage II (CS-II) testicular seminoma. Historically, clinical stage I (CS-I) seminoma was also treated with CHT or RT, but in the past 2 decades practice has shifted toward active surveillance for CS-I with RT or CHT reserved for patients with progression to CS-II. Limited data exist on contemporary RT techniques and patient stratification (ie, de novo [CS-II at orchiectomy] vs relapsed [CS-II diagnosed during surveillance after orchiectomy for CS-I]). We investigated outcomes in CS-II patients treated with RT in the modern era across 2 institutions.

METHODS AND MATERIALS

A retrospective review identified 73 patients treated with RT for CS-II A or B seminoma between 2001 and 2022. Recurrence-free survival (RFS) was calculated by the Kaplan-Meier method and univariate analyses were performed with log-rank or Cox proportional hazard regression. Recurrence was defined as biopsy-proven metastatic seminoma after RT completion. Second malignancies were defined as a biopsy-proven malignancy originating in the prior RT field.

RESULTS

Thirty-eight (52%) patients presented with de novo CS-II and 35 (48%) patients had relapsed CS-II. Median follow-up was 4.8 years (IQR: 2.3-8.1). Five-year RFS was 82% overall (92% in relapsed patients and 73% in de novo patients). Relapsed CS-II disease had lower recurrence rates after RT compared with de novo CS-II disease. All recurrences occurred outside the prior RT field and were salvaged. Disease-specific survival was 100%. Two second malignancies occurred (prostate, colorectal cancer at 67 months and 119 months post-RT, respectively).

CONCLUSIONS

In patients with CS-II seminoma treated with modern RT, there were no in-field recurrences. Presentation with de novo CS-II is associated with out-of-field recurrence. Subject to further larger-scale validation, our results suggest that compared with CS-II at time of relapse, de novo CS-II may portend more aggressive or micrometastatic disease beyond the retroperitoneum, raising the possibility of benefit from CHT after radiation.

Advances in radiation therapy for testicular seminoma

PURPOSE

Novel techniques and advances in radiation therapy (RT) have been explored to treat testicular seminoma, a highly radiosensitive and curable histology. We evaluated the historical and current indications for radiation therapy (RT) in testicular seminoma.

METHODS

A narrative literature review was performed. Studies of RT for testicular seminoma were included. Additionally, recent trials testing the use of combination or surgical therapies for clinical stage (CS) II were included. Search parameters included radiation therapy, testicular seminoma, surgery, and chemoradiation. Parameters and outcomes assessed were progression-free survival (PFS), overall survival (OS), acute toxicities, long-term sequelae, and rates of secondary malignancies.

RESULTS

Practice defining and changing studies in the use or omission of radiation therapy for testicular seminoma were identified along with resultant changes in National Comprehensive Cancer Network (NCCN) and European guidelines. Recent trials in combined chemoradiation and upfront surgical approaches to CS II disease were reviewed.

CONCLUSION

RT has historically been used as adjuvant treatment for CS I disease and is highly effective at treating CS II (A/B) testicular seminoma. The drive to maintain therapeutic efficacy and reduce acute and long-term side effects, namely secondary malignancies, is being tested using new radiation technologies, combined modality therapy in the form of chemoradiation and with upfront surgical approaches. Also, as guidelines now "strongly prefer" surveillance instead of adjuvant RT for CS I disease, the current CS II population comprises patients presenting with CS II disease ("de novo") and those who present with CSII after relapsing post orchiectomy for CS I ("relapsed"). Emerging evidence suggests that these two groups have different outcomes with respect to RT and chemoradiation. Consequently, future trials may need to sub-stratify according to these groups.

Dose comparison of robustly optimized intensity modulated proton therapy (IMPT) vs IMRT and VMAT photon plans for testicular seminoma

BACKGROUND

Patients with stage II seminoma have traditionally been treated with photons to the retroperitoneal and iliac space, which leads to a substantial dose bath to abdominal and pelvic organs at risk (OAR). As these patients are young and with excellent prognosis, reducing dose to OAR and thereby the risk of secondary cancer is of utmost importance. We compared IMPT to opposing IMRT fields and VMAT, assessing dose to OAR and both overall and organ-specific secondary cancer risk.

MATERIAL AND METHODS

A comparative treatment planning study was conducted on planning CT-scans from ten patients with stage II seminoma, treated with photons to a 'dog-leg' field with doses ranging from 20 to 25 Gy and a 10 Gy sequential boost to the metastatic lymph node(s). Photon plans were either 3-4 field IMRT (Eclipse) or 1-2 arc VMAT (Pinnacle). Proton plans used robust (5 mm; 3.5%) IMPT (Eclipse), multi field optimization with 3 posterior fields supplemented by 2 anterior fields at the level of the iliac vessels. Thirty plans were generated. Mean doses to OARs were compared for IMRT vs IMPT and VMAT vs IMPT. The risk of secondary cancer was calculated according to the model described by Schneider, using excess absolute risk (EAR, per 10,000 persons per year) for body outline, stomach, duodenum, pancreas, bowel, bladder and spinal cord.

RESULTS

Mean doses to all OARs were significantly lower with IMPT except similar kidney (IMRT) and spinal cord (VMAT) doses. The relative EAR for body outline was 0.59 for IMPT/IMRT (p < .05) and 0.33 for IMPT/VMAT (p < .05). Organ specific secondary cancer risk was also lower for IMPT except for pancreas and duodenum.

CONCLUSION

Proton therapy reduced radiation dose to OAR compared to both IMRT and VMAT plans, and potentially reduce the risk of secondary cancer both overall and for most OAR.

Single-dose carboplatin followed by involved-node radiotherapy for stage IIA and stage IIB seminoma (SAKK 01/10): a single-arm, multicentre, phase 2 trial

BACKGROUND

Standard treatment options for patients with stage IIA or stage IIB seminoma include either para-aortic and pelvic radiotherapy or three to four cycles of cisplatin-based combination chemotherapy. These options result in 3-year progression free survival rates of at least 90%, but bear risks for acute and late toxic effects, including secondary malignancies. We tested a novel approach combining de-escalated chemotherapy with de-escalated involved node radiotherapy, with the aim of reducing toxicity while preserving efficacy.

METHODS

In the single-arm, multicentre, phase 2 SAKK 01/10 trial, patients with stage IIA or IIB classic seminoma (either at primary diagnosis or at relapse during active surveillance for stage I) were enrolled at ten centres of the Swiss Group for Clinical Cancer Research and ten centres of the German Testicular Cancer Study Group. WHO performance status 0-2, age 18 years or older, and adequate bone marrow and kidney function were required for eligibility. Treatment comprised one cycle of carboplatin (area under the curve 7) followed by involved-node radiotherapy (30 Gy in 15 fractions for stage IIA disease and 36 Gy in 18 fractions for stage IIB disease). The primary endpoint was 3-year progression-free survival. Efficacy analyses were done on the full analysis set, which comprised all patients who signed the informed consent, were registered in the trial, initiated trial treatment, and met all medically relevant inclusion or exclusion criteria. Safety was assessed in all patients who were treated at least once with one of the trial treatments. The study is ongoing but no longer recruiting, and is registered with Clinicaltrials.gov, NCT01593241.

FINDINGS

Between Oct 18, 2012, and June 22, 2018, 120 patients were registered in the study. 116 patients were eligible and started treatment according to the study protocol (46 patients with stage IIA disease and 70 with stage IIB disease). After a median follow-up of 4·5 years (IQR 3·9-6·0), 3-year progression-free survival was 93·7% (90% CI 88·5-96·6). With a target progression-free survival of 95% at 3 years, the primary endpoint was not met. Acute treatment-related adverse events of any grade were noted in 58 (48%) of 116 patients, and grade 3 or 4 treatment-related adverse events occurred in the form of neutropenia in five (4%) patients, thrombocytopenia in three (3%) patients, and vomiting in one (1%) patient. No treatment-related deaths and no late treatment-related adverse events were reported. Serious adverse events were reported in five (4%) of 116 patients (one transient creatinine increase and four second primary tumours).

INTERPRETATION

Despite the fact that the primary endpoint was not met, we observed favourable 3-year progression-free survival with single-dose carboplatin area under the curve 7 and involved-node radiotherapy, with minimal toxic effects. Our findings might warrant discussion with patients about the SAKK 01/10 regimen as an alternative to standard-of-care treatment, but more research on this strategy is needed.

FUNDING

Swiss State Secretariat for Education, Research and Innovation and Rising Tide Foundation for Clinical Cancer Research.

Long-Term Results in Patients Affected by Testicular Seminoma Treated with Radiotherapy: Risk of Second Malignancies

Aims

To report clinical results in patients with testicular seminoma treated with postoperative radiotherapy with regard to survival, acute and late toxicity, and risk of second malignancy.

Materials and methods

176 stage I-II testicular seminoma patients treated with radiotherapy from 1964 to 1994 at the Radiotherapy Division of Pisa University, using 60Co or Linac, were analyzed retrospectively. The follow-up ranged from 0.13 to 32.37 years, with a median of 12.1 years. The observed numbers of second malignancies were compared with those expected, taking into account age, sex, and incidence rates from the Tuscany Tumor Registry.

Results

Overall and specific survival at 10-15 years were 89-82% and 93-92%, respectively. Multivariate analysis revealed a significantly better survival in patients younger than 50 years and in those treated with Linac. Severe late sequelae occurred in 8% of the patients. Sixteen second malignancies were observed (14 solid tumors and 2 leukemias); median latency was 13 years (range, 3-27) and the observed/expected ratio 1.4 ( P not significant). Solid cancers were localized in the bladder (2), kidney (2), skin (2), stomach (1), prostate (1), lung (1), larynx (1), uvea (1) and contralateral testicle (1); 1 patient presented an intestinal carcinoid and 1 a metastasis from an unknown primary. The risk of a second malignancy was higher in the patient group receiving less than 4000 cGy (observed/expected, 2.8; P = 0.015).

Conclusions

The study confirmed the high cure rate in stage III seminomas after postoperative radiotherapy. Incidence of a second malignancy was higher than expected, but the difference was not statistically significant.

Postsurgical Policy in Stage I Testicular Seminoma: Cost and Benefit of Prophylactic Irradiation in a Long-term Experience

The definitive cure rate for clinical stage I testicular seminoma is very close to 100%, and prophylactic irradiation of the regional lymph nodes is associated with a low morbidity. Nevertheless, in recent years a “wait-and-see” policy has been proposed by some researchers. We analysed the cost/benefit ratio of radiotherapy (RT) by review of the case histories of 299 patients treated at the Department of Radiotherapy of the Istituto Nazionale per lo Studio e la Cura dei Tumori in Milan from January 1968 to December 1989. The 5-year overall survival was 99% (97.5% at 10 years), while the 10-year disease-free survival was 96%. The recurrence rate was 2.3%, but no patient relapsed in the irradiated areas. Acute toxicity was very moderate with only 4 (1.3%) serious radiation sequelae occurring 6 to 27 years after treatment. However, 9 second malignancies (3%) were observed. Lastly, we have calculated the costs for our National Health Service comparing surveillance policy and prophylactic irradiation.

Stage I Seminoma of the Testis: Long Term Results and Toxicity with Adjuvant Radiotherapy

Aims and background

Pure testicular seminoma has historically been treated with post-orchidectomy radiation therapy with excellent results. Recently, several aspects of the treatment of stage I seminoma have been questioned. We assessed long-term results and toxicity of patients with pure testicular seminoma treated at the Department of Radiation Oncology of S. Chiara Hospital, Trento.

Methods

From 1953 to 1987, 102 patients with stage I pure testicular seminoma were given megavoltage irradiation with curative intent. All patients had a minimum follow-up of 3 years (maximum 37 years, median 13 years). They received a mean para-aortic/pelvic dose of 33.07 Gy (range 23.70-45.20 Gy) with different doses and fields reflecting the change in techniques over a long period of time.

Results

The cause-specific actuarial survival at 30 years was 99% and crude survival 67%. One patient had an out-field relapse (inguinal) after a few months and was cured with radiotherapy and chemotherapy. Another patient relapsed with widespared metastases and died after 1 year of progressive disease. Early toxycity was mild and the treatment was well tolerated. Late side effects were reported in 8/102 patients.

Conclusion

In our series adjuvant radiation therapy resulted in cure rates corresponding to those reported in the literature. The 30-year actuarial survival of 99% was extremely good and the toxicity of the treatment was mild. Post-orchidectomy radiation to the para-aortic and ipsilateral pelvic nodes is a safe and effective method of preventing recurrences and is currently to be considered the treatment of choice in stage I testicular seminoma.

Radiation-Induced Sarcoma following Curative Radiotherapy for Testicular Seminoma: Case Report and Brief Review of the Literature

We report a case of radiation-induced retroperitoneal leiomyosarcoma which developed 37 years after the patient received radiation therapy for testicular seminoma. The sarcoma originated within the para-aortic field, extensively involving neighboring organs, soft tissue and muscle tissues, and could be only partially resected. The absolute number of these secondary sarcomas is low, but the risk of developing such neoplasms calls for awareness in the long-term follow-up of cured seminoma patients.

Testicular seminoma: Scattered radiation dose to the contralateral testis in the modern era

PURPOSE

Limited data exist on testicular dose measurements using modern radiation treatment techniques and volumes for testicular seminoma. The aim of this study was to report the testicular dose using in vivo measurements in men with testicular seminoma receiving abdominopelvic radiation therapy (APRT) and a modified dog-leg field with and without gonadal shielding.

METHODS AND MATERIALS

Men with histologically confirmed testicular seminoma, either newly diagnosed stage II disease or isolated retroperitoneal relapse on surveillance for stage I disease, treated with APRT had testicular dose measurements recorded using MOSFET dosimeters. Those patients wishing to preserve fertility underwent radiation treatment with daily gonadal shielding. Factors that may influence testicular dose including field size, distance of the remaining testis from the radiation field, and patient separation, were also measured.

RESULTS

Measurements were performed for 16 men; 10 with gonadal shielding and 6 without. The mean measured dose to the testis in the patients with gonadal shielding was 2.6 cGy (standard error, 0.75; range, 0-13) compared with 28.6 cGy (standard error, 12.6; range, 0-86) in the unshielded group for a 20-fraction treatment.

CONCLUSIONS

The use of gonadal shielding during APRT with a modified dog-leg technique results in a low testicular dose that is below the likely threshold for impaired spermatogenesis. In those men wishing to preserve fertility, we recommend the use of gonadal shielding, even with the use of modern radiation therapy techniques.

Radiotherapy Alone for Malignant Spinal Cord Compression in Young Men with Seminoma

AIM

Seminomas are very radiosensitive tumors. Therefore, patients with malignant spinal cord compression (MSCC) from seminoma may not require for neurosurgery in addition to radiotherapy. In this study, radiotherapy alone was evaluated in young men with MSCC from seminoma.

PATIENTS AND METHODS

Four young men with MSCC due to vertebral lesions from metastatic seminoma received radiotherapy alone. The impact of radiotherapy on motor function and gait function, local control of MSCC and survival were retrospectively evaluated.

RESULTS

All patients showed improvement of motor function following irradiation. All patients who were not able to walk prior to radiotherapy regained their walking ability. One-year and two-year local control rates were 100% and 100%, respectively. Survival rates at one and two years were 75% and 75%, respectively.

CONCLUSION

Radiotherapy alone resulted in excellent outcomes. If clear indications for neurosurgery are not given, radiotherapy alone can be considered the treatment of choice for patients with MSCC from seminoma.

Adjuvant radiotherapy outcome of stage I testicular seminoma: a single institution study

PURPOSE

To analyze treatment outcome and side effects of adjuvant radiotherapy using radiotherapy fields and doses which have evolved over the last two decades in a single institution.

MATERIALS AND METHODS

Forty-one patients received radiotherapy after orchiectomy from 1996 to 2007. At our institution, the treatment field for stage I seminoma has changed from dog-leg (DL) field prior to 2003 to paraaortic (PA) field after 2003. Fifteen patients were treated with the classic fractionation scheme of 25.5 Gy at 1.5 Gy per fraction. Other patients had been treated with modified schedules of 25.05 Gy at 1.67 Gy per fraction (n=15) and 25.2 Gy at 1.8 Gy per fraction (n=11).

RESULTS

With a median follow-up of 112 months, the 5-year and 10-year survival rates were 100% and 96%, respectively, and 5-year and 10-year relapse-free survival rates were both 97.1%. No in-field recurrence occurred. Contralateral seminoma occurred in one patient 5 years after treatment. No grade III-IV acute toxicity occurred. An increased rate of grade 1-2 acute hematologic toxicity was found in patients with longer overall treatment times due to 1.5 Gy per fraction. The rate of grade 2 acute gastrointestinal toxicity was significantly higher with DL field than with PA field and also higher in the 1.8-Gy group than in the 1.5-Gy and 1.67-Gy groups.

CONCLUSION

Patients with stage I seminoma were safely treated with PA-only radiotherapy with no pelvic failure. Optimal fractionation schedule needs to be explored further in order to minimize treatment-related toxicity.

[Verification of the protective effect of a testicular shield in postoperative radiotherapy for seminoma]

In postoperative radiotherapy for seminoma, control of the testicular absorbed dose is important, since exposure of the testis can lead to temporary or permanent infertility. In this case, instead of using a dog-leg-shaped field, treatment using a field focused near the aorta was provided in several disease stages of seminoma. However, the precise need for testicular shielding during treatment and dose of testis exposure was not clear. We examined these questions by measuring the testicular absorbed dose with and without a testicular shield using two clinical treatment plans and a phantom. The distance from the testis phantom and the lower end of the irradiation field was varied. Where the total dose for the tumor was 20 Gy, the testicular absorbed dose was below 0.1 Gy, the threshold dose for temporary infertility. At this dosage, the distance between the testis phantom and the edge of the irradiation field was 14.6 cm without the shield and 9.99 cm with the shield. Using a testes shield, it was thus possible to reduce the dose by 58.5%.

Seminoma patients treated at a minor oncological department during 1986-2010: treatment and outcome

AIM

To present results for patients with seminoma treated at our University Clinic.

PATIENTS AND METHODS

All men treated for seminoma in 1986-2010 at the Department of Oncology, University Hospital of North Norway were included (n=232). Treatment was standardized from 2000 as the Swedish and Norwegian Testicular Cancer Project (SWENOTECA) published their first standardised seminoma treatment program (SWENOTECA V).

RESULTS

The percentage of patients administered adjuvant radiotherapy (RT) for clinical stage (CS) I decreased gradually from the late 1990s and was abandoned in 2005. Surveillance was the most common management strategy for CS I after 2000. Overall, disease in 1.9% and 11% of patients relapsed after adjuvant RT and surveillance, respectively. There were no relapses after treatment for metastatic disease. Cancer-specific survival was 100%, and overall survival 95% for the total group.

CONCLUSION

The treatment outcome at our University Clinic is excellent with 100% cancer-specific survival, and is essentially a result of the bi-national SWENOTECA network.

Radiation induced myxoma of superior vena cava origin presenting as a right atrial mass

Myxomas are the most common benign cardiac tumors. Myxomas are more common in the left heart chamber than the right side chamber. An extracardiac origin presenting as a right atrial mass is very rare. Right-sided tumors are considerably less common than left-sided tumors, and however myxoma of great vessels origin presenting as right atrial masses are rare but radiation induced villous myxoma in superior vena cava (SVC) is exceedingly rare tumor. A case of radiation induced myxoma originating in a previously undescribed location and presenting as a right atrial mass is reported.

Second cancer risk and mortality in men treated with radiotherapy for stage I seminoma

BACKGROUND

Patients with stage I testicular seminoma are typically diagnosed at a young age and treatment is associated with low relapse and mortality rates. The long-term risks of adjuvant radiotherapy in this patient group are therefore particularly relevant.

METHODS

We identified patients and obtained treatment details from 12 cancer centres (11 United Kingdom, 1 Norway) and ascertained second cancers and mortality through national registries. Data from 2629 seminoma patients treated with radiotherapy between 1960 and 1992 were available, contributing 51,151 person-years of follow-up.

RESULTS

Four hundred and sixty-eight second cancers (excluding non-melanoma skin cancers) were identified. The standardised incidence ratio (SIR) was 1.61 (95% confidence interval (CI): 1.47-1.76, P<0.0001). The SIR was 1.53 (95% CI: 1.39-1.68, P<0.0001) when the 32 second testicular cancers were also excluded. This increase was largely due to an excess risk to organs in the radiation field; for pelvic-abdominal sites the SIR was 1.62 (95% CI: 1.43-1.83), with no significant elevated risk of cancers in organs elsewhere. There was no overall increase in mortality with a standardised mortality ratio (SMR) of 1.06 (95% CI: 0.98-1.14), despite an increase in the cancer-specific mortality (excluding testicular cancer deaths) SMR of 1.46 (95% CI: 1.30-1.65, P<0.0001).

CONCLUSION

The prognosis of stage I seminoma is excellent and it is important to avoid conferring long-term increased risk of iatrogenic disease such as radiation-associated second cancers.

[Experience with high-dose chemotherapy in patients with testicular diffuse large B-cell lymphoma]

AIM

To evaluate the efficiency of high-dose therapy according to the DLBL-CNS-2007 protocol in patients with testicular diffuse large B-cell lymphoma (DLBL).

SUBJECTS AND METHODS

Out of 408 male patients with non-Hodgkin lymphoma, 8 patients aged 50 to 69 years (median age 55.5 years) with primary testicular (n=3) or with generalized-stage testicular DLBL (n=5) were included in the study. These patients were followed up at the Hematology Research Center, Ministry of Health of the Russian Federation, in 2007 to 2013. Systemic chemotherapy was performed in accordance with the DLBL-CNS-2007 protocol.

RESULTS

The DLBL-CNS-2007 protocol was implemented in first-line therapy in 7 patients. At the first diagnostic stage, one patient was found to have anaplastic seminoma; in this connection right orchifuniculectomy was carried out, followed by radiotherapy applied to the scrotal region in a total focal dose of 34 Gy. This patient with disease recurrence was included in the DLBL-CNS-2007 treatment protocol. The number of polychemotherapy (PCT) cycles (n=4 or 6) was determined by the time to achieve complete remission. After completion of DLBL-CNS-2007 PCT, 6 patients achieved complete remission; the primary resistant disease was noted in 2 cases. At this moment 6 patients are alive in first complete remission during the median follow-up of 50 months (10-54 months).

CONCLUSION

The findings suggest that high-dose therapy according to the DLBL-CNS-2007 protocol in patients with testicular DLBL can achieve complete remission and increase overall and event-free survival rates. This fact should be borne out by a large number of observations.

Stage I testicular seminoma: a SEER analysis of contemporary adjuvant radiotherapy trends

PURPOSE

Patients with clinical stage I testicular seminoma have historically been treated with adjuvant radiotherapy in the United States. However, nearly 80% of patients on surveillance will not experience relapse and even with relapse, salvage rates approach 100%. It remains unclear how practice patterns have changed with recently accumulating evidence and changes in guidelines. In a population based setting we evaluated contemporary trends and factors that may affect the use of adjuvant radiotherapy.

MATERIALS AND METHODS

A total of 8,151 men diagnosed with stage I testicular seminoma from 2000 to 2009 were identified in the national SEER (Surveillance, Epidemiology, and End Results) registry. A multivariate regression model was constructed to analyze the association of year, age, race, socioeconomic status, SEER region, pathological stage and tumor size with the administration of adjuvant radiotherapy.

RESULTS

The use of adjuvant radiotherapy decreased significantly from 2000 to 2009. In 2000, 74.7% of patients received radiation, compared with only 37.7% of patients in 2009 (p <0.0001). Later year of diagnosis was significantly associated with decreased odds of receiving adjuvant radiotherapy (p <0.0001, 2000 to 2005 vs 2006 to 2009, OR 0.40, 95% CI 0.36-0.44). Men age 35 years or older (p <0.0002, OR 1.20, 95% CI 1.09-1.32) and men in the highest socioeconomic index quartile (p <0.0001, OR 1.34, 95% CI 1.16-1.54) were more likely to receive adjuvant radiotherapy.

CONCLUSIONS

The use of adjuvant radiotherapy for clinical stage I testicular seminoma has decreased significantly in the last decade. Older age and higher socioeconomic status are associated with higher rates of adjuvant radiotherapy.

Barriers to the implementation of surveillance for stage I testicular seminoma

PURPOSE

Postorchiectomy adjuvant radiotherapy (RT) for Stage I seminoma can be associated with long-term toxicity, and management strategies with a lower treatment burden achieve the same excellent cure rate. Because studies suggest that radiation oncologists in the United States continue to recommend RT for these patients, we sought to identify factors associated with management recommendations.

METHODS AND MATERIALS

We conducted a one-time internet-based survey among 491 randomly selected American radiation oncologists self-described as specializing in genitourinary oncology.

RESULTS

Response rate was 53% (n = 261). Forty-nine percent of respondents worked in university-affiliated practices. Sixty-two percent of respondents always/usually recommended adjuvant RT for patients with Stage I seminoma, whereas 21% always/usually recommended surveillance and 3% always/usually recommended chemotherapy. One third (33%) expressed concerns that patients who experienced relapse during surveillance could not be salvaged. Although 88% of physicians were aware of an increased risk of second malignant neoplasms (SMN) after adjuvant RT, 85% underestimated its magnitude. Compared with physicians not typically recommending RT, physicians who always/usually recommended RT were more likely to believe that patients might not be salvaged at relapse during surveillance (p = 0.008) and were less aware of the association between RT and SMN (p = 0.04).

CONCLUSIONS

Respondents who always/usually recommend postorchiectomy RT for patients with Stage I seminoma are more likely to underestimate late RT morbidity and to believe that surveillance is associated with increased mortality. Given the equivalent efficacy and reduced morbidity of surveillance compared with RT, our findings underscore the need for ongoing physician education to increase appropriate clinical implementation of surveillance strategies.

A single institution, retrospective study of treatment experience in primary mediastinal germ cell tumors: elucidating the significance of systemic chemotherapy

BACKGROUND

Primary malignant germ cell tumors (GCTs) of mediastinum are rare neoplasms. We introduce our institutional experience in managing patients with primary malignant GCTs of the mediastinum, focusing on the analysis of therapeutic modalities.

METHODS

A retrospective review was done in 39 consecutive patients with mediastinal malignant GCTs treated in our institution between 1991 and 2007.

RESULTS

A total of 39 patients were enrolled in this study with a median age of 27 years. The 5-year overall survival (OS) and progression-free survival (PFS) rates of the whole population were 60.2% and 57.7%, respectively. Stratified by the histology, 18 patients (46.2%) had seminoma and 21 patients (53.8%) had nonseminomatous germ cell tumors (NSGCTs). The 5-year OS rate of patients with seminoma was 87.4% as compared with 36.7% in patients with NSGCTs (P = 0.0004). The 5-year PFS rate was also significantly higher in seminoma patients (87.4% vs. 31.6%, P = 0.003). For 19 patients with NSGCTs managed with multi-modality treatment, chemotherapy exposure appeared to impact the prognosis. The 5-year OS rate was 44.9% in patients with chemotherapy exposure as compared with 20.0% in patients without it (P = 0.43).

CONCLUSION

Our study confirmed the significance of systemic chemotherapy in the treatment of primary mediastinal GCTs.

Treatment of Stage I Seminoma testis with extended field adjuvant radiation

With an aim to analyze and document the outcome of Stage I Seminoma patients we undertook a retrospective analysis of patients treated between January 1990 and December 1998. The treatment charts of patients treated between January 1990 and December 1998 were reviewed. Patient and tumor characteristics, treatment details, relapse rates, late toxicities, or occurrence of second primary was noted. Royal Marsden Staging System was utilized because of its simplicity and wide-use in the above period. Out of 137 patients, 41 (30%) patients did not receive any further treatment, 96 (70%) patients received prophylactic radiotherapy to para-aortic and pelvic nodes. The observation group patients had a median follow-up 20 months, 9 patients had nodal relapse with 7 in retroperitoneal nodes and 2 patients in inguinal nodes. Of these, 7 patients received BEP chemotherapy and 2 patients Chemoradiation. Four patients had complete remission while remaining 5 patients had partial response. The histopathologies of all the 5 patients with partial response were reviewed to reconfirm the diagnosis. Patients of prophylactic radiotherapy group had a follow-up of 33 months, 6 patients relapsed, RP nodal disease in 5 patients and distant metastasis in 1 patient. All these patients received BEP chemotherapy. One had complete response and remaining 5 patients had partial response. The group of patients under observation had a significantly higher relapse rate and lower disease free compared to the adjuvant radiotherapy group (73.5% vs. 91% at five years, p value 0.004). Disease specific survivals for the two groups were however similar (89% vs. 93%) at five years, p value 0.18). We conclude that Stage I Seminoma patients treated with prophylactic radiation to paraaortic and pelvic region had better outcome.

[Tolerance of adjuvant radiotherapy in the treatment of stage I seminoma]

OBJECTIVE

To assess the tolerance of adjuvant radiotherapy in the treatment of stage I seminoma post-orchiectomy.

MATERIAL AND METHODS

Between 2001 and 2006, 21 men with stage I seminoma underwent 3D conformal radiotherapy 3 to 4 weeks post-orchiectomy. The total radiation dose was 2490 cGy divided into 15 sessions. Radiation was delivered by 2 antero-posterior fields using X-ray photons of 18 MV. Two types of radiation fields were used : para-aortic and ipsilateral iliac (dog leg) or para-aortic only. The average followup was 2 years 4 months with an interval of 4 to 58 months. Tolerance of treatment was evaluated according to criteria of the RTOG.

RESULTS

Median follow-up time is 30 months. Disease-free survival was 100%. The most frequently encountered acute toxicity was gastrointestinal; mainly nausea and vomiting. Tolerance to treatment was better in the group receiving para-aortic radiotherapy alone (37% of grade II gastrointestinal toxicity vs 62%)

CONCLUSION

The para-aortic irradiation for stage I seminoma gave satisfactory results with a better toxicity profile than the dogleg irradiation.