Post-orchiectomy radiotherapy for stages I and II testicular seminoma

PURPOSE

In 1984 the following changes were made in the management of testicular seminoma at The University of Texas M.D. Anderson Cancer Center: (1) abdominopelvic computerized tomography replaced the bipedal lymph-angiogram for evaluating retroperitoneal nodes; (2) elective mediastinal radiation was totally abandoned; (3) patients with abdominal adenopathy < 10 cm were classified as having Stage IIA disease. This report evaluates the impact of these management policy changes on disease outcome.

METHODS AND MATERIALS

Between 1960 and 1991, 350 patients with Stages I or II testicular seminoma received post-orchiectomy radiation. The 241 patients treated prior to 1984 constitute our old series, and the 109 patients treated since then are our new series. The outcomes in the new series were compared to those in the old series.

RESULTS

The distribution of patients by stage was Stage I, 282 (old series, 190; new series, 92); Stage IIA, 55 (old series, 39; new series, 16); Stage IIB, 13 (old series, 12; new series, 1). The freedom-from-relapse at 5 years correlated with stage: Stage I, 97%; Stage IIA, 87%; Stage IIB, 69%. Elevated post-orchiectomy chorionic gonadotropin levels or involvement of the spermatic cord were adverse for disease relapse in Stage I but not Stage II disease. Patients with Stage I disease fared extremely well in both series (freedom-from-relapse 97%); the outcome for patients with Stage IIA was significantly worse in the new series (5-year freedom-from-relapse 73% vs. 92%) because of a 20% actuarial incidence of apparently solitary left supraclavicular nodal relapse. Although elective mediastinal radiation in the old series prevented this failure pattern, such treatment appeared to significantly decrease the survival of patients older than 40 years.

CONCLUSIONS

(1) Abdominopelvic computerized tomography scanning is adequate for the evaluation of abdominal lymph nodes in patients with seminoma; (2) Post-orchiectomy radiation to the para-aortic and ipsilateral hemipelvic regions remains the treatment of choice for patients with Stage I disease; (3) Patients with Stage IIA disease experience a 20% relapse rate especially in the left supraclavicular fossa and we recommend elective radiation to this site delivered concomitantly with para-aortic irradiation.

Static and dynamic vascular impact of large artery irradiation

PURPOSE

To evaluate functional post-radiotherapy arterial change in a select patient population.

METHODS AND MATERIALS

Thirty-five seminoma patients were identified in the Radiation Oncology departmental records at Indiana University Medical Center. In this group the ipsilateral pelvis is treated with the contralateral pelvis available for evaluation as a matched control. Additionally, this group is generally young and unlikely to have pre-existing vascular disease, and shows excellent radiocurability with historically standard radiotherapy. Nineteen patients volunteered for a noninvasive vascular evaluation which included: Doppler ultrasound, segmental leg pressures, pulse volume recordings, and post-exercise testing. Average age at treatment was 36 (range 14-68) with an average follow-up of 8.8 years (range 1-20) with five patients now over 15 years post-treatment. The majority of the patients received 2500-2600 cGy.

RESULTS

Three of 19 patients had abnormal vascular evaluations. Of these, two had bilateral abnormalities not felt to be solely associated with irradiation. The remaining patient showed both resting and post-exercise ipsilateral vascular abnormalities. Irradiation was the only identifiable etiologic agent for this patient's vascular abnormality.

CONCLUSION

Subclinical vascular change attributable to low dose radiotherapy was identified in one of 19 patients (5%). Considering the radiocurability of seminoma patients this incidence is acceptable. In light of this slight, yet documented, arterial abnormality occurring with low dose radiotherapy, we recommend additional study of high dose radiotherapy patients to determine the incidence and morbidity of radiation-induced arteriopathy in this group.

Post-orchiectomy management in stage I testicular seminoma: elective irradiation or surveillance?

Fifty-six patients with stage I testicular seminoma were treated at this institute between January 1982 and December 1988. Post-orchiectomy elective radiotherapy to ipsilateral iliac-inguinal and para-aortic lymph nodes was delivered in 54 cases. An overall 3 year survival rate of 96% was observed in this series. Four patients (7%) relapsed (one junctional recurrence in iliac node region, two mediastinal/hilar nodes and one skeletal metastasis). Salvage chemotherapy proved successful in two out of three cases with nodal relapse. No dose limiting acute or late radiation related complications were noticed. No definite correlation was found between the patients who relapsed and various known adverse prognostic factors. We recommend elective irradiation of the draining lymph nodes in stage I seminoma, particularly at centres where surveillance is not feasible.

Does decreased skeletal uptake of 99mTc-methylene bisphosphonate in irradiated bone indicate the absence of bone metastases?

Reduced uptake of 99mTc-methylene bisphosphonate (99mTc-MBP) was found in irradiated bone in all of 13 tumour-free patients who had undergone radiotherapy (30-40 Gy) due to seminoma 3-8 years prior to bone scintigraphy. Decreased uptake of 99mTc phosphate compounds can not per se be interpreted as a sign of absence of metastases or reduced tumour burden.

[Is lymphography still relevant in seminoma?]

In the radiotherapist's point of view lymphography and computed tomography scan compete for staging and therapy planning of testicular seminoma. We investigated whether lymphogram can be replaced by computed tomography scan. 114 patients with histologically confirmed seminoma of the testis were treated by radiotherapy at the Nürnberg Community Hospital (n = 65) and the University of Erlangen (n = 49) from 1978 through 1991. Radiological staging included both computed tomography scan and lymphography in all cases. The results of both methods were similar in 79%. Computed tomography scan led to an upstaging in 4% while lymphography was negative. 17% of the patients showed negative results considering computed tomography scan while lymphogram was positive. In accordance with these data treatment portals or doses were altered in 21%. Using the M.D. Anderson Hospital clinical staging system a stage IIa (micrometastasis < 2 cm) is not safely identified by computed tomography scan. Just lymphography can safely identify a stage IIa patient. On the other hand, lymphography shows a very high amount of false positive interpretations. However, two conclusions are made: 1. Using a conventional technic (radiation of para-aortal and ipsilateral iliac region, dose about 30 Gy HD) lymphogram can be superseded by computed tomography scan. 2. In the case of reducing treatment volume and/or dose lymphogram should be added to computed tomography scan.

Radiotherapy and chemotherapy in testis tumors

Testis tumor is rare but interesting tumor as it is a true model of curable solid tumor in adults. The use of chemotherapy constitutes one of its most successful applications. Seminoma are characterized by a great sensitivity to radiation which remains the additional adjuvant treatment for early tumors. For dysgerminoma, the authors discuss the wait and see policy for early tumors and the role of chemotherapy for advanced diseases.

Surveillance in stage I seminoma of the testis

In a health care system with adequate personnel and resources, careful surveillance, rigorously performed, following guidelines set out in the prospective trials is an appropriate alternative to adjuvant irradiation for patients with stage i seminoma of the testis.

Pancreatic insufficiency secondary to abdominal radiotherapy

Delayed post-irradiation steatorrhoea secondary to acute pancreatic insufficiency is rare. We describe a case occurring in a patient 23 years following radical abdominal radiotherapy for testicular seminoma.

Increased incidence of sarcoma in patients treated for testicular seminoma

In a nationwide cancer registry analysis of second primary malignancies in 6187 men with testicular cancer in the period 1943-1987, 13 sarcomas were found, yielding a 4-fold increase of the relative risk (RR). The majority of sarcomas occurred in men with seminoma, and the increased incidence was seen irrespectively of time since the diagnosis of testicular cancer. The interval between the testicular cancer and the sarcoma varied from 5-34 years. After investigation of the hospital records and re-examination of the histological specimens, 3 patients were excluded. In spite of this, the RR was still considerably increased (at least 3-fold). Seven of the 10 sarcomas were found to be located within the field of the radiation treatment administered and three at the periphery. The absolute number of these secondary sarcomas is low, but the risk of developing such neoplasms and other malignancies should, even so, be kept in mind in the follow-up of testicular cancer patients.

[Organ saving therapy of bilateral testicular tumor]

Of 368 patients with unilateral testicular cancer, 12 (3.3%) suffered from a second malignant germ cell tumor; five tumors occurred synchronously, seven were treated by bilateral orchiectomy, five were treated by unilateral organ sparing surgery with enucleation of the germ cell tumor in a pilot study. Enucleation was performed for four seminomas and one embryonal carcinoma; an associated carcinoma was found in situ in three cases. The average follow-up time for patients treated conservatively is 22 months; no local recurrence has been detected. Testosterone synthesis is sufficient to obtain normal serum androgen levels. Organ sparing surgery for testicular cancer is possible if the following prerequisites are met: pT 1-tumor, no infiltration of the rete testis, biopsies of the tumor bed are negative, biopsies from peripheral parenchyma are taken and any associated carcinoma in situ is irradiated with 20 Gy.

[Is organ saving surgery of testicular tumor justified?]

Eight patients with malignant germ cell tumours of residual testes had organ-conserving surgery. The largest diameters of the tumours were 9-32 mm. In seven patients conservation of the organ was successful without local or systemic progression (n = 5), two patients needed chemotherapy for concurrent or subsequent metastatic spread. In one case the testis had to be removed because of functional loss. Improved surgical techniques and increased knowledge of the importance and treatment of testicular intraepithelial neoplasm (carcinoma in situ) made this approach of enucleating resection possible; it permits the maintenance of endogenous androgen production in a small group of patients. The generally good prognosis of malignant testicular tumours means that in certain circumstances surgical treatment of the primary tumour can be limited.

Radiotherapy of germinomas involving the basal ganglia and thalamus

Nine patients with histologically confirmed germinomas of the basal ganglia and thalamus (GBT) were treated by radiotherapy. The average dose of 52.5 Gy was delivered to the tumor bed, 37 Gy to the whole brain and 24.8 Gy to the CNS axis. The local control, which was verified by CT scan, was achieved in all patients. All patients are alive 11 to 96 months after radiotherapy. As with other intracranial germinomas, geminomas of the basal ganglia and thalamus respond well to radiotherapy and the prognosis is good after treatment.

[Surveillance after orchiectomy for stage I testicular seminoma]

The results of treatment by orchiectomy and radiotherapy for stage I testicular seminoma are excellent with cure rates exceeding 95% and relapse rates less than 5%. However, after the development of successful surveillance programs for stage I nonseminomatous testicular cancers, the role of radiotherapy has been questioned by some authors and they proposed a "surveillance policy" for these patients. The purpose of this study was to determine the percentage of patients cured by orchiectomy alone, percentage who ultimately required therapy for occult metastases, site of recurrence, and over-all cure rate and treatment morbidity. And these data were compared with those of adjuvant radiotherapy group retrospectively. Twenty seven patients were treated with adjuvant radiotherapy (RT group). Since 1986, 23 patients with stage I testicular seminoma entered the "surveillance only" protocol at our institution (S group) with a follow-up between 14 and 70 months (median 43 months). Informed consent for the policy of surveillance was obtained. Follow up consisted of physical examination, determination of serum tumor markers and chest X-ray bimonthly for 2 years, every 3 months for 1 year, every 6 months for 2 years and annually thereafter to 10 years. CT scans were performed every 4 months for 3 years, every 6 months for 2 years. Two patients in S group (8.7%) relapsed at 4 and 7 months after orchiectomy with nonbulky retroperitoneal disease (less than 5 cm in diameter), whereas only 1 (3.7%) irradiated patients did so after 4 months.

Orchidectomy followed by radiotherapy in 176 stage I and II testicular seminoma patients: benefits of a 10-year follow-up study

Results are presented for 176 patients with stage I and II primary testicular seminoma treated at the Dr. Daniel den Hoed Cancer Center (DDHCC) between 1975 and 1985. The median follow-up time was 7 years and 4 months. One-hundred and seventy-four (99%) of these patients were treated primarily with radiotherapy after extensive staging. According to the Royal Marsden Staging Classification, 132 patients (75%) were stage I, 8 (5%) were stage IIA, 21 (12%) were stage IIB, 9 (5%) were stage IIC and for 6 stage II patients a further subdivision was not possible. At 5 years the actuarial relapse-free survival and the actuarial survival were 95 and 99%, respectively, for stage I, and 77 and 91% for stage II. Prophylactic irradiation of the mediastinum has not been performed for stage II patients. Five stage II patients relapsed in the mediastinum. Four out of these five relapses were cured with chemotherapy, and in one case, in combination with radiotherapy, at the time of relapse. These results indicated that prophylactic irradiation of the mediastinum appeared to be unnecessary for stage II patients. Tumour markers were not useful in the discovery of metastases. Five years after treatment no relapses were seen. Therefore, it is proposed that a maximum follow-up of 5 years is sufficient to measure disease-free survival.

Humoral hypercalcemia associated with a dysgerminoma

A 16-year-old girl sought medical attention at the Mayo Clinic because of a 4.5-kg weight loss, hypercalcemia, and a pelvic mass. Preoperatively, the level of the beta-subunit of human chorionic gonadotropin was 147 IU/liter. After a brief period for observation and hydration, abdominal exploration revealed a stage III dysgerminoma; total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Within the dysgerminoma, syncytial giant cells expressed human chorionic gonadotropin-positive immunostaining in the cytoplasm. Postoperatively, the value of the beta-subunit of human chorionic gonadotropin decreased rapidly. The patient received whole-abdomen irradiation 4 weeks postoperatively, after which the level of calcium returned to normal. The patient has been free of disease for more than 7 years.

Value of retroperitoneal lymph node dissection in advanced testicular seminoma

Seven patients with advanced seminoma of the testis (stages II C and III) were treated with 3 induction cycles of VAB-6 chemotherapy. Three patients had complete remission after chemotherapy and are alive disease free at 32, 38, and 40 months with no additional treatment. Four patients were subjected to retroperitoneal lymph node dissection for residual retroperitoneal masses measuring 2-4 cm after chemotherapy, which revealed fibrosis in 2 patients and metastatic seminoma in the other 2. Patients with metastatic residual masses were given postoperative radiation therapy to the retroperitoneum and are alive disease free at 33 and 34 months, while those with fibrosis are alive disease free at 30 and 52 months, respectively, with no additional treatment.

Stage I seminoma of the testis: is post-orchidectomy surveillance a safe alternative to routine postoperative radiotherapy?

Experience with the management of 128 patients with Stage I testicular seminoma over a 10-year period, 1980-1989, is presented. Fifty-six patients were treated with post-orchidectomy radiation therapy and 72 patients were put on surveillance. Patients thought to be at higher risk of relapse were generally treated with radiotherapy. There have been no tumour related deaths in this series; 5.4% of the irradiated group and 18% of patients on surveillance have relapsed to date. All relapses have been salvaged with further therapy and are currently in complete remission. In this interim analysis, surveillance appears to be a safe alternative to adjuvant radiation therapy provided regular, prolonged follow-up can be ensured. Surveillance is, however, time consuming and resource demanding, and should be undertaken only as part of a formal clinical study. Adjuvant post-orchidectomy radiotherapy should be considered the treatment of choice until further long-term data are available.

The role of radiotherapy in the treatment of primary mediastinal seminoma

Nine patients with primary mediastinal seminoma were treated with radiotherapy. All patients achieved complete response on chest radiography. None of the three patients treated with whole mediastinal irradiation relapsed. Four of the six patients with involved-field irradiation had marginal relapses, suggesting the efficacy of the whole mediastinal irradiation.

The role of radiotherapy in patients with advanced seminomatous germ cell tumors. Controversies in management. Part 2

The role of radiotherapy in the management of advanced seminomatous germ cell tumors remains controversial. The authors review the available literature, and recommend radiotherapy for stage II seminoma with bulky abdominal metastases (greater than 10 cm) under the following circumstances: As primary therapy only if the patient cannot or will not be treated with chemotherapy; as an adjuvant following chemotherapy in patients with residual masses of any size. Similar recommendations are made regarding the role of radiotherapy in the management of extragonadal seminoma outside the central nervous system.

The recurrence of primary intracranial germinomas. Special reference to germinoma with STGC (syncytiotrophoblastic giant cell)

Twenty three cases of primary intracranial germinomas including five cases of germinomas with syncytiotrophoblastic giant cells are studied and analyzed, with special reference to the recurrence under radiotherapy. The follow-up period for all cases was 7 months to 12 years (average: 5.8 years) with that for pure germinomas ranging from 8 months to 12 years (average: 5.7 years) and that for germinomas with syncytiotrophoblastic giant cells ranging from 7 months to 11 years (average: 6.3 years). Late recurrence was observed in three cases (3/23, 13%), developing outside of the initial irradiation field. With regard to recurrence, significant correlation to radiation fields was evident, while it was not to radiation doses. Furthermore, germinoma with syncytiotrophoblastic giant cells showed a more significant tendency to recur than pure germinoma. The radiotherapy of germinomas is discussed and the clinical features of germinoma with syncytiotrophoblastic giant cells are presented.

Post radiation monomelic amyotrophy

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[Radiation therapy of intracranial germinoma]

The appropriate radiation dose and field for the treatment of intracranial germinoma were investigated in 33 patients. Recurrences were observed in 4 cases treated with local field irradiation only, and all of them were recognized at the margin of the radiation field or under the dose (less than 25 Gy) area. This suggests that whole cranial irradiation (dose of 25 to 30 Gy) should be added even if the tumor is solitary. The effective dose for cerebrospinal dissemination appears to be 25-35 Gy, but prophylactic CNS irradiation seems unnecessary for patients who have not undergone surgical procedures. Changes in mental status were seen in 5 patients (26.3%). Doses of over 59 Gy may be related to this complication.

Radiation therapy for testicular seminoma: controversies in the management of early-stage disease

Subdiaphragmatic irradiation remains the standard treatment for patients with stage I and IIA testicular seminoma. Elective mediastinal irradiation is not indicated. In well-selected patients with stage I disease, aggressive surveillance may be a reasonable alternative to elective irradiation. We believe that bipedal lymphangiography is useful in staging, radiation field design, and follow-up. Other controversies in the radiotherapeutic management include the optimal radiation dose and appropriate target volume.