[Integrated treatment for azoospermia caused by radiotherapy after surgical treatment of spermatocytoma: a case report]

OBJECTIVE

To investigate a therapeutic method for male infertility caused by radiotherapy after surgical treatment of spermatocytoma.

METHODS

A case of azoospermia caused by radiotherapy after surgical treatment of spermatocytoma was reported and the Chinese medicine Jiaweishuiluerxiandan was used as a major therapy for 3 years.

RESULTS

The patient's health condition was improved dramatically two years after being treated by the Chinese medicine but no sperm was found in his semen. However, three years after the treatment, his spermatozoon density was recovered from zero to 2.0 x 10(6)/ml with normal morphology. His sperm was subsequently used for intracytoplasmic sperm injection, which made his spouse pregnant successfully, and an healthy male infant was born by caesarean birth.

CONCLUSION

Chinese medicine is a successful try at treating male infertility caused by radiotherapy after surgical treatment of spermatocytoma. For those who have failed to get their sperm frozen before surgery, Chinese medicine is a choice for remediation.

Data required for testicular dose calculation during radiotherapy of seminoma

The purpose of this study was to provide the required data for the direct calculation of testicular dose resulting from radiotherapy in patients with seminoma. Paraortic (PA) treatment fields and dog-leg (DL) portals including paraortic and ipsilateral pelvic nodes were simulated on a male anthropomorphic phantom equipped with an artificial testicle. Anterior and posterior irradiations were performed for five different PA and DL field dimensions. Dose measurements were carried out using a calibrated ionization chamber. The dependence of testicular dose upon the distance separating the testicle from the treatment volume and upon the tissue thickness at the entrance point of the beam was investigated. A clamshell lead shield was used to reduce testicular dose. The scattered dose to testicle was measured in nine patients using thermoluminescent dosimeters. Phantom and patient exposures were generated with a 6 MV x-ray beam. Linear and nonlinear regression analysis was employed to obtain formulas describing the relation between the radiation dose to an unshielded and/or shielded testicle with the field size and the distance from the inferior field edge. Correction factors showing the variation of testicular dose with the patient thickness along beam axis were found. Bland-Altman statistical analysis showed that testicular dose obtained by the proposed calculation method may differ from the measured dose value by less than 25%. The current study presents a method providing reasonable estimations of testicular dose for individual patients undergoing PA or DL radiotherapy.

Surveillance in stage I testicular seminoma

Treatment options in patients with stage I testicular seminoma include adjuvant radiotherapy (RT), surveillance, and adjuvant chemotherapy. RT was the treatment of choice for the past 50 years, but there has been increasing concern in the past decade regarding late complications. Surveillance, reserving treatment for patients who relapse, has been shown to be a safe and effective strategy. It allows >80% of patients to avoid any post-orchidectomy treatment and is the recommended approach for these patients. The possible role of adjuvant chemotherapy is currently being assessed in clinical trials and should not be used outside of a study setting.

Treatment of stage I seminoma: A 15-year review

PURPOSE

To review the treatment and outcomes in patients with stage I seminoma after orchidectomy.

METHODS

A retrospective chart review of all patients with stage I seminoma referred for initial treatment during the last 15 years was performed. Initial treatment approaches and outcomes were analyzed. Comparisons were made between patients treated with adjuvant radiotherapy and those receiving no adjuvant therapy (surveillance group).

RESULTS

A total of 150 patients with stage I seminoma was seen between 1989 and 2003. Median age at diagnosis was 37.5 years (range 19-79), with a median follow-up of 54 months (range 1-162). Of the patients, 71% were treated with adjuvant radiotherapy, and 29% were placed on a surveillance protocol. The 5-year relapse-free survival and overall survival for the entire group were 95% and 100%, respectively. The 5-year relapse-free survival for the adjuvant radiotherapy group was 100% compared with 79% for the surveillance group (P < 0.001). Of the 6 patients who had a relapse, 5 were salvaged with radiation, but 1 required chemotherapy as well. One patient who had a relapse is currently refusing treatment for recurrence.

CONCLUSIONS

Our results confirm the excellent prognosis for patients with stage I seminoma and indicate that surveillance does not compromise survival. This result adds to the evidence that surveillance is a good option for many patients and also supports our current approach, which favors surveillance for most patients with stage I seminoma after orchidectomy who are willing to go on our surveillance protocol.

Early intestinal changes following abdominal radiotherapy comparison of endpoints

PURPOSE

To compare tests for intestinal function with clinical scores after abdominal irradiation.

PATIENTS AND METHODS

At the Department of Radiotherapy, Erfurt, Germany, intestinal changes were studied in 91 patients receiving abdominal radiotherapy between 1992 and 1996. Conventional fractionation (1.8-2 Gy per fraction, total doses 30.6-62.5 Gy) was applied. Before and at weekly intervals during radiotherapy, the clinical response was scored according to RTOG/EORTC for the upper and lower gastrointestinal (GI) tract. Resorption tests for vitamin B(12) and D-xylose were performed before the onset and immediately after treatment.

RESULTS

The clinical response displayed a well-defined dose-effect relationship with grade 1 effects in 5% and 50% of the patients at about 10 Gy and 50 Gy, respectively. For grade 2 reactions, 5%- and 50%-effective doses were 20-30 Gy and 60-80 Gy. Effects in the upper and lower GI tract were highly correlated. Changes in body weight did not show a correlation with other clinical symptoms. Changes in resorption also displayed a significant dose effect. However, no correlation was found with the clinical symptoms in the individual patient.

CONCLUSION

In the present study, the clinical manifestation of intestinal side effects according to RTOG/EORTC criteria was reflected by neither the vitamin B(12) nor by the D-xylose resorption test. Hence, these tests cannot be regarded as useful for objective quantitation of intestinal radiation injury.

[Second malignancies after radiotherapy for testicular seminoma: 2 cases]

Orchiectomy with adjuvant radiotherapy of retroperitoneal paraaortic and ipsilateral iliac nodes is the standard treatment for localized testicular seminoma (I, IIA, IIB). Post therapeutic follow-up allows to detect local relapse and radio-induced second cancer. Nevertheless, evaluation of risk of second malignancy still remains difficult. We report 2 cases of rectal cancer after radiotherapy for testicular seminoma.

New Guidelines for Clinical Stage I Testicular Seminoma?

Clinical stage I (CS I) seminoma has been the subject of various studies aimed at finding the ideal treatment. Due to its high radiosensitivity, radiotherapy has been the standard approach for decades. However, the fact that CS I seminoma has a recurrence rate of only 15-20% has prompted many suggestions for better treatment stratification offering surveillance therapy for a subgroup of patients. Moreover, carboplatinum-based monochemotherapy has been the topic of various retrospective studies demonstrating equal effectiveness for adjuvant chemotherapy with one cycle of carboplatin. Since seminoma affects men in their mid-30s, only few reports have been published on long-term survival with reference to radiotoxicity and secondary malignancies. Long-term side effects and secondary malignancies pose an increasing problem for long-term survivors of primary malignancies treated by chemo- or radiotherapy. This becomes evident after a follow-up of 15 years. Since recent studies have disclosed unexpectedly high long-term morbidity and mortality after irradiation, this article critically reviews the value of radiotherapy and carboplatinum-based chemotherapy as equally effective treatment options for CS I seminoma.

Long-term risk of cardiovascular disease in 5-year survivors of testicular cancer

PURPOSE

To evaluate the long-term risk of cardiovascular disease (CVD) in survivors of testicular cancer (TC).

PATIENTS AND METHODS

We compared CVD incidence in 2,512 5-year survivors of TC, who were treated between 1965 and 1995, with general population rates. Treatment effects on CVD risk were quantified in multivariate Cox regression analysis.

RESULTS

After a median follow-up of 18.4 years, 694 cardiovascular events occurred, including 141 acute myocardial infarctions (MIs). The standardized incidence ratio (SIR) for coronary heart disease was 1.17 (95% CI, 1.04 to 1.31), with 14 excess cases per 10,000 person-years. The SIR for MI was significantly increased in nonseminoma survivors with attained ages of less than 45 (SIR = 2.06) and 45 to 54 years (SIR = 1.86) but significantly decreased for survivors with attained ages of 55 years or older (SIR = 0.53). In Cox analysis, mediastinal irradiation was associated with a 3.7-fold (95% CI, 2.2- to 6.2-fold) increased MI risk compared with surgery alone, whereas infradiaphragmatic irradiation was not associated with an increased MI risk. Cisplatin, vinblastine, and bleomycin (PVB) chemotherapy (CT) was associated with a 1.9-fold (95% CI, 1.7- to 2.0-fold) increased MI risk, and bleomycin, etoposide, and cisplatin (BEP) CT was associated with a 1.5-fold (95% CI, 1.0- to 2.2-fold) increased CVD risk and was not associated with increased MI risk (hazard ratio = 1.2; 95% CI, 0.7 to 2.1). Recent smoking was associated with a 2.6-fold (95% CI, 1.8- to 3.9-fold) increased MI risk.

CONCLUSION

Nonseminomatous TC survivors experience a moderately increased MI risk at young ages. Physicians should be aware of excess CVD risk associated with mediastinal radiotherapy, PVB CT, and recent smoking. Intervention in modifiable cardiovascular risk factors is especially important in TC survivors. Whether BEP treatment increases CVD risk should be evaluated after more prolonged follow-up.

Testicular radiation for primary seminoma in a solitary testis

Orchiectomy is the standard of care for patients with a second primary testicular tumor. We report a case of a man, with previous history of stage I left testicular germ cell tumor, who developed a contralateral seminoma and desired preservation of the remaining testis. Partial orchiectomy was not feasible due to tumor size and percutaneous needle biopsy revealed classical seminoma. He was treated with radiotherapy to the testis. Post treatment biopsy revealed no evidence of disease. At 32 months follow-up, he has not required androgen replacement. He has preservation of total testosterone level and libido.

Clinical manifestations of noncoronary atherosclerotic vascular disease after moderate dose irradiation

BACKGROUND

Accelerated atherosclerosis and carotid stenosis are well-established risks occurring after high radiation doses that are used to treat cancers of the head and neck. Noncoronary vascular disease has been observed and may relate to more moderate dose irradiation.

METHODS

A search of patients treated for Hodgkin disease, non-Hodgkin lymphoma, or seminoma was performed to identify cases with noncoronary vascular complications after irradiation. These three groups were chosen because of the use of intermediate dose radiation and prevalence of long-term survivors. Individual patient records were reviewed to document the type and presentation of the stenosis and the clinical factors that may have contributed to this risk.

RESULTS

Twenty-one patients were identified who developed disease in noncoronary arteries after treatment. The median time from irradiation to diagnosis of vascular stenosis was 15 years. Antecedent risk factors for vascular disease were prevalent. Five patients had disease identified by auscultation of bruits before an adverse clinical event occurred. Five patients died from complications related to their vascular disease, which included three deaths after stroke and two after small bowel infarction.

CONCLUSION

Twelve cases arose at an atypically young age for atherosclerotic vascular disease and featured unusual clinical presentations. Nine cases identified occurred at an advanced aged and at a shorter median interval, making a causal relation to irradiation uncertain. Incorporating careful auscultation for bruits in followup evaluation of irradiated patients may identify individuals who are at risk for adverse vascular events. The potential for early vasculopathy in individuals exposed to intermediate dose irradiation suggests a need to manage dyslipidemia and reduce vascular risk factors throughout the posttreatment period.

Time-course of radiation-induced chromosomal aberrations in tumor patients after radiotherapy

PURPOSE

Radiation-induced chromosome aberrations are routinely used in biologic dosimetry to monitor radiation exposure. Translocations are considered stable aberrations with time after exposure. This study was performed to determine the temporal persistence of radiation-induced translocations during a 36-month period in therapeutically irradiated testicular seminoma patients who underwent partial body exposure (>10% of bone marrow).

METHODS AND MATERIALS

Chromosome analyses were carried out in peripheral lymphocytes of 11 patients with testicular seminoma (n = 9), germinoma (n = 1), or follicular non-Hodgkin's lymphoma (n = 1). All patients received radiotherapy with photons from a linear accelerator; in 1 case, additional electron beams were used. Doses ranged from 26 Gy (seminoma) to 45 Gy (non-Hodgkin's lymphoma). None of the patients received chemotherapy. From each patient, blood samples were taken during the 36 months after irradiation at defined points. Chromosomal aberrations were scored after fluorescence in situ hybridization painting of chromosomes 1, 4, and 12 in combination with a pancentromeric probe.

RESULTS

For 9 patients (7 with testicular seminoma, 1 with germinoma, and 1 with non-Hodgkin's lymphoma), a significant temporal decline of translocations, with a mean decline rate of 4.4% +/- 0.4% monthly, could be detected. Two testicular seminoma patients showed no temporal decline of aberration frequencies.

CONCLUSION

Most partial body irradiated patients (9 of 11) showed a significant temporal decline of translocation frequencies during a 36-month period. Thus, reciprocal translocations after partial body irradiation cannot be regarded as stable over time. The temporal decline of aberration frequencies has to be taken into account for retrospective dose estimations.

The management strategies for stage I seminoma

About 80% of men with seminomatous testicular germ-cell cancer are diagnosed with stage I disease. For many years, the standard treatment for this patient group has been radiation to para-aortic and iliacal lymph nodes at the same side as the orchiectomy. However, iliac radiotherapy is unnecessary in patients without prior inguinal or scrotal surgery. Furthermore, in recent years, other treatment modalities for this patient group have evolved. The use of single-agent carboplatin has shown promising results, similar to the effects obtained by radiotherapy. In addition, surveillance after primary orchiectomy with no additional treatment is found to be a safe follow-up for many of these patients. On the basis of new knowledge about primary tumour risk factors, it is now possible to identify patients at a particular high risk of relapse (rete testis invasion, primary tumour size > 4 cm, or both). This will be a helpful tool to identify patients who can be safely included into a surveillance strategy, and those who could have adjuvant treatment. The final decision about treatment will depend on risk factors, capacity of the healthcare service to carry out frequent follow-up examinations and the patient's own preferences. In this paper, we will discuss advantages and disadvantages of the various treatment options in the management of stage I seminoma.

Intracranial Granuloma and Skull Osteolysis: Complication of a Primary Cutaneous Cryptococcosis in a Kidney Transplant Recipient

Cryptococcosis is the third most common invasive fungal infection in organ transplant recipients after candidiasis and aspergillosis. It occurs almost exclusively in the late posttransplantation period (>6 months after the initiation of immunosuppression). Subclinical onset of meningitis is the usual clinical presentation. Despite initiation of therapy, the mortality rate associated with this infection in this patient population remains high. To the best of our knowledge, this report describes one of the first cases of a rare entity: a primary cutaneous cryptococcosis in a renal transplant recipient disclosed by skull osteomyelitis and pseudotumoral intracranial extension. Surgical debridement and azole antifungal therapy were performed. Ten months after the onset of treatment, the patient feels good, clinical examination findings are normal, and no sign of evolutive cryptococcosis is noted.

Germ cell tumors of the testis

Testicular cancer is the most common malignancy in men aged 20 to 35 years and accounts for approximately 1% of all male malignancies. Through the appropriate utilization of clinical trials, effective treatment paradigms have been developed for the management of all stages of testicular cancer. The multidisciplinary approach to the management of germ cell tumors of the testis has resulted in survival rates of > 90% overall. This review summarizes the principal management of germ cell tumors of the testis, highlighting the indications for surgery, controversies surrounding the integration of surgery, and alternative management strategies.

Adverse effects after radiotherapy for early stage (I,IIa,IIb) seminoma

BACKGROUND AND PURPOSE

The evaluation of adverse effects after radiotherapy for early stage (I,IIa,IIb) seminoma.

PATIENTS AND METHODS

A retrospective analysis of 164 patients with stage I, IIa, IIb seminoma treated with post-orchidectomy irradiation, between 1974 and 1990 was performed. Patients had been treated with infradiaphragmatic radiotherapy only (IDRT) in 48%, and prophylactic mediastinal and left supraclavicular irradiation (supradiaphragmatic radiotherapy, SDRT) was performed additionally in the remaining 52% of patients. Median follow-up was 12 years. The incidence of late morbidity was evaluated with respect to treatment-related factors like: PTV, number of fields irradiated each day, beam energy, total dose and dose per fraction. Afterwards, the dose distribution in normal tissues-based on dose per fraction at 3 cm depth and total dose at 3 cm depth, was evaluated in relation to late morbidity.

RESULTS

Overall 5-year and 10-year survival was 92 and 86%. For IDRT, dose per fraction at midline and dose per fraction from AP field at 3 cm depth were not significantly associated with Gastro-Intestinal morbidity. For SDRT, dose per fraction at 3 cm depth from AP field was significantly associated with cardiac morbidity (mean-1.98 Gy in patients without and 2.27 Gy in patients with cardiac morbidity P=0.006), however total dose at 3 cm was not significantly associated with cardiac morbidity. Dose per fraction at 3 cm depth from AP field significantly (P=0.047) influenced cardiac morbidity probability in multivariate logistic regression, which included patients' age, smoking habits and total dose at 3 cm.

CONCLUSIONS

Excessive dose maximum in normal tissues from each fraction to anterior mediastinum is associated with increased cardiac morbidity.

Towards individualised radiotherapy for Stage I seminoma

BACKGROUND AND PURPOSE

Adjuvant radiotherapy is currently standard treatment of Stage I seminoma (SOS). The use of computerised tomogram (CT) planning is compared with traditional planning for greater treatment individualisation.

MATERIAL AND METHODS

Two plans were generated for each of 10 patients: one using traditional rectangular para-aortic fields, and one using conformal fields. The primary target volume compared was the dosimetric coverage of the inferior vena cava and aorta.

RESULTS

The dosimetric analysis of traditional plans showed that they provided reasonable dosimetric coverage of the CTV. However, if 1cm is used for uncertainty based on nodal coverage then the periphery of the PTV could be significantly under-dosed. The CT based plan delivered improved dosimetry to the vessel PTV compared with the traditional field (CT D 95=24.7 Gy, traditional D 95=23.6 Gy, P=0.002). CT-based plans were significantly wider than traditional plans (CT=11.8 cm, traditional=9 cm, P=0.002). The CT plan tended to irradiate relatively small volumes of the kidneys to higher doses.

CONCLUSIONS

Traditional para-aortic fields may deliver suboptimal dosimetry to an anatomically defined PTV. Our CT-based fields tend to be wider than traditional fields, and provide improved dosimetry to vessels based target volumes. Given that traditional fields are often delivering significantly less than the prescribed dose to the target volume, and that marginal relapses cause a high proportion of treatment failure, there is a suggestion that CT-based plans may avoid under-dosage and geographical miss sometimes seen with traditional plans.

Evaluating changes in stage I seminoma management: a single institution review

PURPOSE

Historically adjuvant radiotherapy has been routinely recommended for stage I seminoma patients but surveillance has become an increasingly popular option over the last decade. We therefore decided to review the approach currently used by the radiation oncologists at our center.

METHODS

A 14-item questionnaire evaluating physician opinions about treatment options for stage I seminoma patients was developed at the Ottawa Hospital Regional Cancer Centre (OHRCC). It was sent to all the radiation oncologists at OHRCC treating genitor-urinary (GU) malignancies for self-completion.

RESULTS

All the GU radiation oncologists completed the survey for a response rate of 100% (7/7). Most (71%) have been treating GU malignancies for at least 5 years with the median being 9 years. At present, all consider surveillance and adjuvant radiotherapy as standard treatment options for stage I seminoma patients, and recommend these to patients. They give patients information about the treatment options but also give their personal recommendations as well. Most have been routinely discussing surveillance as an option since the late 1990's. Clinical data from the OHRCC confirms that there has been a significant increase in the proportion of stage I seminoma patients being managed by surveillance over the past 15 years. Currently almost half of patients are choosing surveillance.

CONCLUSIONS

There appears to be a fairly uniform approach towards the management of stage I seminoma patients at the OHRCC. Radiation oncologists are now routinely offering both surveillance and adjuvant radiotherapy as reasonable option for these patients, and this is consistent with the recently published literature on this topic.