Germ cell tumors: An update of recent data and review of active protocols in stage I and metastatic disease

Germ cell tumors are highly curable malignancies even when metastatic. Investigations currently focus on curtailing toxicity in low-risk patients and improving cure rates in poor-risk individuals. Reduced dose radiation schedules and short-course chemotherapy regimens have been evaluated in stage I disease. In metastatic disease, several new nonplatinum agents offer promise for patients with poor risk or relapsed disease. In addition, high-dose chemotherapy regimens with autologous stem cell transplant provide potential for further improvements in survival. This review will highlight recent developments and currently active clinical trials pertinent to the treatment of patients with germ cell tumors.

An analysis of the long-term therapeutic effect of the integrated therapy of traditional Chinese medicine and radiotherapy on abdominal malignant tumor

To observe the long-term therapeutic effect of the integrated therapy of radiotherapy and Chinese herbal drugs for treatment of abdominal malignant tumor and explore the applied value of differential treatment during radiotherapy. Sixty cases of abdominal malignant tumor with hyperactivity of fire due to yin deficiency or deficiency of both qi and blood were randomly divided into an integrated treatment group of 30 cases and a control group of 30 cases. The integrated treatment group was treated by combination of radiotherapy and Chinese herbal drugs and the control group by simple radiotherapy. The results shows that in the integrated treatment group, the score of physical state was 23.17 +/- 7.18, score of psychological quality 21.23 +/- 4.53 and total score of living quality 44.40 +/- 11.22, and survival rate for three years was 67.55%, which were significantly superior to those of the control group (P < 0.01). It is then concluded that differential treatment of TCM could play a valuable role in treating abdominal malignant tumor during radiotherapy, which can improve the long-term living quality and prolong the survival time of the patients.

Fertility in men after treatment for stage 1 and 2A seminoma

The purpose of this article is to assess the long-term fertility and attitudes towards fecundity in men after radical inguinal orchiectomy and radiation therapy (RT) for seminoma, and also to assess how often sperm cryopreservation is being offered to patients with seminoma prior to treatment. A retrospective review was conducted at 3 institutions (Wilford Hall Air Force Medical Center, Brooke Army Medical Center, and Fitzsimmons Army Medical Center) to identify patients who had undergone treatment of stage 1 or 2A seminoma during the period from 1975 to 1997. Seventy-three of 212 (34%) patients meeting the selection criteria of stage 1 or 2A seminoma provided information for this analysis. This was thought to be a good response rate, given that many of the patients had changed duty stations or had separated from the military by the time this study started. We performed a review of RT and tumor board records of 73 patients who were treated for testicular seminoma at selected treatment facilities from 1975 to 1997. Patients completed questionnaires and phone interviews that focused on prior fertility, the desire to father (more) children, other fertility-affecting factors (varicocele, cryptorchidism, infection, and erectile dysfunction), and incidence of physician counseling with regard to cryopreservation. All patients were asked to obtain a current semen analysis (SA). Eleven (15%) patients reported that they had tried to father children since completion of their RT. Seven of 11 (64%) successfully achieved pregnancy within a mean time of 3.5 years since RT (range: 1 month to 5 years). Of the 4 couples that were not successful, 1 had severe female factor infertility problems and a second had organic erectile dysfunction. A third had a past surgical history remarkable for vasectomy with subsequent vasectomy reversal. Nine patients provided SA. Mean sperm count and motility were 24.2 Mil/mL (range: 5-81 Mil/mL) and 63.1% (range: 30-90%), respectively (normal SA values: count = 20-250 Mil/mL, motility >50%, and volume = 1.5-5.0 mL). No patients were azoospermic. Overall mean time interval from radiation therapy was 7.9 years. Radiation dose and time since RT did not correlate with either SA results or conception. Only 16 of 73 (22%) men had been offered pretreatment sperm cryopreservation by their counseling physician. It is concluded that (1) patients who are treated for early stage seminoma by orchiectomy and RT have greater than a 50% chance of regaining normal semen parameters, and all regain at least some spermatogenesis; 2) recovery of spermatogenesis is not related to therapeutic radiation dose with the use of modern shielding and RT portals; (3) the majority of treated patients who desire children can conceive; and (4) sperm cryopreservation remains an underutilized option for seminoma patients.

Long-Term Results of Radiotherapy for Early-Stage Testicular Seminoma

PURPOSE

We conducted an outcome and complications analysis of patients treated with adjuvant radiotherapy (RT) for early-stage testicular seminoma over a 35-year period at the University of Florida.

METHODS AND MATERIALS

All 73 patients had the classic seminoma histology. No patient received chemotherapy as initial treatment. There were 57, 14, and 2 patients with Royal Marsden stage I, IIA, and IIB disease, respectively. All received RT to the paraaortic (PAN) and pelvic fields. One-third of the patients received prophylactic RT to mediastinal/supraclavicular fields.

RESULTS

Median follow up was 15 years. Median RT dose to PAN and pelvic fields was 25 Gy. Local control and cause-specific survival at 20 years were 95% and 96%, respectively. Of the 3 recurrences, 1 was salvaged with chemotherapy. Subset analysis of 41 patients revealed 1 patient who developed peptic ulcer disease and 11 patients with gastrointestinal reflux symptoms after RT. Thirty-two patients fathered a child before or after RT. Cardiovascular complications were not greater in those treated with prophylactic RT to the mediastinal region. The rate of nontesticular second malignancy for the overall group was 8% at 15 years.

CONCLUSIONS

Patients treated with adjuvant low-dose RT to the paraaortic and pelvic fields for treatment of early-stage seminoma enjoy an excellent long-term cure rate with minimal risk of late RT complications.

Pelvic recurrence in stage I seminoma: A new phenomenon that questions modern protocols for radiotherapy and follow-up

OBJECTIVE

To highlight the increased risk for pelvic relapse in patients with stage 1 seminoma treated with adjuvant radiotherapy limited to para-aortic template alone.

PATIENTS AND METHODS

Over a four-year period, three patients presented with early pelvic recurrence after radical orchidectomy and adjuvant irradiation for stage 1 seminoma. In each case, radiotherapy had been limited to the para-aortic region with omission of the ipsilateral hemi pelvis.

RESULTS

Pelvic recurrences occurred on the ipsilateral tumor side. Durable complete remission was achieved in each case; however, treatment was complex and there was associated morbidity.

CONCLUSION

This significant incidence of pelvic recurrence questions the validity of modern radiotherapy protocol which excludes the ipsilateral pelvis from the radiation field.

Genetic counselling following paternal therapeutic irradiation

We discuss a patient who received adjuvant radiotherapy for stage I seminoma. He was advised to avoid conception for 6 months following treatment. However, his partner became pregnant only shortly after he completed his radiotherapy (i.e. with sperm that had been irradiated). We estimated the dose received by the remaining testis as 30 cGy. Here, we review the information available to advise patients on the risks to the fetus from paternal preconception irradiation. For the population, a doubling dose for hereditary effects of 1 Gy has recently been reaffirmed (United Nations Scientific Committee on the Effects of Atomic Radiation 2001). However, a range of animal studies suggest conception with postmeiotic sperm carries a greater risk of genetic damage than conception with sperm derived from irradiated stem cells. We have attempted to quantify the risks in this particular case. Lead shielding of the testes may reduce radiation received from the primary beam, but internal scatter still produces a risk. In male patients who are potentially fertile, the best advice remains to delay conception after radiotherapy for as long as 6 months. Our case illustrates the need to reinforce such advice.

Long-term results of para-aortic irradiation for patients with Stage I seminoma of the testis

PURPOSE

Adjuvant postoperative para-aortic lymph nodal irradiation is an acceptable alternative to para-aortic and ipsilateral pelvic irradiation postorchiectomy for patients with Stage I seminoma of the testis. In this article, we report the long-term results of our prospective evaluation of para-aortic irradiation only for such patients.

METHODS AND MATERIALS

Between March 1991 and September 2000, 71 patients with Stage I seminoma were treated with adjuvant irradiation to the para-aortic region only after radical inguinal orchiectomy. Radiotherapy was delivered using parallel-opposed fields extending from T11 to L5. A total dose of 25 Gy in 15 fractions was prescribed to midpoint. Follow-up was performed every 3 months for the first year, every 4 months for the second and third years, every 6 months for the fourth and fifth years, and annually thereafter. Chest X-ray, tumor markers, and computed tomography scan of the pelvis were performed routinely as part of the follow-up investigation.

RESULTS

At a median follow-up of 75 months, 68 of 71 patients are alive and free of relapse. Only 1 patient (1.4%) experienced failure in the ipsilateral inguinal nodal region. Two patients (2.8%) died of unrelated causes. The actuarial 10-year relapse free survival is 98.5% and the actuarial 10-year overall survival is 92%. No late toxicity has been encountered.

CONCLUSION

Patients with Stage I seminoma of the testis may be safely treated with para-aortic radiotherapy only. Risk of pelvic failure is very low and treatment toxicity minimal.

[Alternatives to the radiotherapy of stage I testicular seminoma]

Adjuvant irradiation is currently the most frequently used standard treatment for the clinical stage I seminoma (CSI) following orchiectomy. There is a potential carcinogenic risk with irradiation that prompted a search for alternative adjuvant treatment approach. The cure in CSI seminoma patients can be achieved with surveillance or chemotherapy. Surveillance takes into account the fact that 80% of patients do not need any adjuvant treatment after orchiectomy and are overtreated by adjuvant irradiation. Recently, one cycle of adjuvant carboplatin has been proven in a prospective randomized trial. Taken together, all three treatment options are acceptable standard strategies for the management of patients with CSI. Finally, the experience with surveillance strategy allowed an in-depth meta analysis of factors predictive for relapse discrimining the patients who are in need of post orchiectomy adjuvant treatment from those who safety can be followed by the surveillance strategy. However, this risk adapted approach is still under prospective evaluation.

Randomized Trial of 30 Versus 20 Gy in the Adjuvant Treatment of Stage I Testicular Seminoma: A Report on Medical Research Council Trial TE18, European Organisation for the Research and Treatment of Cancer Trial 30942 (ISRCTN18525328)

Purpose

To assess the possibility of reducing radiotherapy doses without compromising efficacy in the management of patients with stage I seminoma.

Patients and Methods

Patients were randomly assigned 20 Gy/10 fractions over 2 weeks or 30 Gy/15 fractions during 3 weeks after orchidectomy. They completed a symptom diary card during treatment and quality-of-life forms pre- and post-treatment. The trial was powered to exclude absolute differences in 2-year relapse rates of 3% to 4% (α = .05 [one sided]; 90% power).

Results

From 1995 to 1998, 625 patients were randomly assigned to treatment. Four weeks after starting radiotherapy, significantly more patients receiving 30 Gy reported moderate or severe lethargy (20% v 5%) and an inability to carry out their normal work (46% v 28%). However, by 12 weeks, levels in both groups were similar. With a median follow-up of 61 months, 10 and 11 relapses, respectively, have been reported in the 30- and 20-Gy groups (hazard ratio, 1.11; 90% CI, 0.54 to 2.28). The absolute difference in 2-year relapse rates is 0.7%; the lower 90% confidence limit is 2.9%. Only one patient has died from seminoma (allocated to the 20-Gy treatment group).

Conclusion

Treatment with 20 Gy in 10 fractions is unlikely to produce relapse rates more than 3% higher than for standard 30 Gy radiation therapy, and data on an additional 469 patients randomly assigned in a subsequent trial support and strengthen these results. Reductions in morbidity enable patients to return to work more rapidly. Prolonged follow-up is required before any inference can be made about any impact of allocated treatment on new primary cancer diagnoses.

[Inguinal lymph node metastasis of seminoma 18 years after initial treatment: a case report]

Late relapse of testicular tumor is rare. We report a case of recurrence of seminoma at left inguinal lymph node 18 years after initial treatment. A 63-year-old man had a left orchiectomy for left testicular tumor (T1N0M0) in February 1985, with no past history of scrotal or inguinal surgery. Histological examination revealed seminoma (pT1), and prophylactic radiotherapy (34.2 Gy) to para-aortic and left hemi-pelvic regions was perfomed. In November 2003, the patient presented with left inguinal swelling, and was referred to our hospital with suspicion of metastasis to left inguinal lymph nodes. Serum markers (AFP, hCG, hCGbeta and LDH) were normal. Computerized tomography (CT) showed three masses in the left inguinal region, but no other abnormal mass was detected at chest, abdomen or pelvis. Lymphoidectomy of the left inguinal region was perfomed in January 2004, and the mass revealed to be metastasis of seminoma by histological examination.

[Coverage an irradiated wound of the lower lumbar area with a latissimus dorsi musculocutaneous free flap by lengthening the vascular pedicle with interpositional vein grafts]

Reconstruction of radionecrosis of the lower lumbar area is a challenging problem because of the difficulty of mobilization of the irradiated local tissues, absence of a reliable locoregional procedures and prolongation of the receiving vessels of the free flaps. The ideal treatment is a wide excision of the irradiated tissues and an immediate reconstruction in one step, which is better to be done by using a musculocutaneous flap. The latissimus dorsi musculocutaneous flap is ideal for this indication. The authors prefer to do the revascularization of the latissimus dorsi flap by its'thoracodorsal pedicle because of the possibility to have a high pressure blood flow which allow to use long venous bypass, the exposure of the recipient vessels at the same time of dissecting the flap and to have the anastamosis site away from the irradiated tissue. The authors are presenting their experience in treating a case of radionecrosis in the lower lumbar region with exposed vertebrae by a latissimus dorsi musculocutaneous free flap with exposed vertebrae by a latissimus dorsi musculocutaneous free flap with the lengthening of its'pedicle by two 30 cm interposition saphenous vein grafts.

Radiotherapy-induced malignant peripheral nerve sheath tumor of the cauda equina

STUDY DESIGN

Case report.

OBJECTIVES

To report a rare case of radiation-induced malignant peripheral nerve sheath tumor of the cauda equina 10 years after treatment for testicular seminoma.

SUMMARY OF BACKGROUND DATA

Development of malignant peripheral nerve sheath tumor after irradiation is well recognized and often associated with a dismal prognosis. There have been isolated reports of malignant peripheral nerve sheath tumor developing in sites of previous irradiation for testicular seminoma.

METHODS

Retrospective review of case records and imaging.

RESULTS

A 38-year-old man presented with signs of cauda equina syndrome. Ten years previously, he had undergone right radical inguinal orchidectomy and adjuvant para-aortic radiotherapy as treatment for Stage I testicular seminoma. Magnetic resonance imaging demonstrated an inoperable intra- and extradural tumor leading to significant cauda equina compression. CT-guided biopsy revealed a diagnosis of malignant peripheral nerve sheath tumor, most likely due to previous radiotherapy. His clinical condition did not improve, and he underwent a course of palliative chemotherapy.

CONCLUSIONS

Postirradiation malignant peripheral nerve sheath tumors are rare and occur in a population at high risk of developing second malignancies. The authors report the fourth case resulting from adjuvant radiotherapy for testicular seminoma, with the present report being the first report of extensive intradural tumor leading to cauda equina syndrome.

Late recurrence of clinical stage I seminoma of the testis after 12 years despite adjuvant infradiaphragmatic irradiation

A patient treated with prophylactic infradiaphragmatic radiation therapy for clinical stage I left testicular pure seminoma developed a large mass of the chest wall 12 years after primary treatment. An incisional biopsy confirmed pure seminoma. After chemotherapy, surgical removal of the residual mass and second-line chemoradiation therapy for persistent seminoma, the patient had a vertebral relapse. He died of progression 24 months after the first relapse despite further therapy.

Solitary skull recurrence from stage I seminomatous germ cell tumor of testis

We describe a 35-year-old man who was initially treated with standard inguinal orchiectomy and prophylactic radiotherapy for Stage I seminomatous germ cell tumor of the testis. We report the case because of the unique nature of the later disease recurrence, which was a solitary cranial bony recurrence that extended both intracranially and extracranially. The patient had complete remission after combined cisplatin-based chemotherapy.

Para-aortic irradiation for stage I testicular seminoma: results of a prospective study in 675 patients. A trial of the German testicular cancer study group (GTCSG)

A prospective nonrandomised trial was performed in order to evaluate tumour control and toxicity of low-dose adjuvant radiotherapy in stage I seminoma with treatment portals confined to the para-aortic lymph nodes. Between April 1991 and March 1994, 721 patients were enrolled for the trial by 48 centres in Germany. Patients with pure seminoma and no evidence of lymph node involvement or distant metastases received 26 Gy prophylactic limited para-aortic radiotherapy. Disease-free survival at 5 years was the primary end point. With a median follow-up of 61 months, 675 patients with follow-up investigations were evaluable for this analysis. Kaplan–Meier estimates of disease-free and disease-specific survival were 95.8% (95% CI: 94.2–97.4) and 99.6% (95% CI: 99.2–100%) at 5 years and 94.9% (95% CI: 92.5–97.4%) and 99.6% (95% CI: 99.2–100%) at 8 years, respectively. A total of 26 patients relapsed. All except two were salvaged from relapse. In all, 21 recurrences were located in infradiaphragmatic lymph nodes without any ‘in-field’ relapse. Nausea and diarrhoea grade 3 were observed in 4.0 and 1.0% of the patients, respectively. Grade 3 late effects have not been observed so far. The results of our trial lend further support to the concept of limited para-aortic irradiation as the recently defined new standard of radiotherapy in stage I seminoma. There is no obvious compromise in disease-specific or disease-free survival compared to more extensive hockey-stick portals, which were used as standard portals at the time this study was initiated.

Erroneous diagnosis of pancreatic cancer after radiotherapy of testicular cancer

BACKGROUND

After radiotherapy with or without chemotherapy radiation-induced normal tissue alteration may mimic cancer and may cause major morbidity.

RESULTS

Two patients irradiated for seminoma, in one case combined with cisplatin-based chemotherapy, developed clinical symptoms and radiological signs comparable to pancreatic cancer (stenosis of the ductus choledochus). The non-malignant diagnosis was finally established by revision of the histological specimen (case 1) and per-operatively (case 2). In both patients by-pass operations for biliary tract stenosis resulted in excellent palliation.

CONCLUSION

Radiation-induced fibrosis within the upper retroperitoneal space is an important differential diagnosis versus pancreatic cancer in patients with prior radiotherapy for seminoma. Diagnosis based only on clinical and radiological findings may lead to incorrect patient information and registration errors in Cancer Registries.

[Does radiotherapy still have a place in the treatment of stage I seminoma?]

For the last 60 years, radiotherapy delivering 30 Gy to homolateral iliac and paraaortic lymph nodes has been the standard treatment for clinical stage I seminoma. Adjuvant radiotherapy after orchidectomy is associated with a potential carcinogenic risk. The risk depends on the irradiation field and the dose delivered. The risk appears to be low with low-dose (20 Gy) irradiation techniques. However, the late effects of radiotherapy have led to the search for alternative adjuvant approaches, including surveillance and carboplatin chemotherapy. Finally, experience with surveillance strategies in patients with stage I seminoma have allowed a meta-analysis of predictive factors for relapse, distinguishing patients requiring post-orchidectomy adjuvant therapy from those who can be easily followed by a surveillance strategy. Although this attitude can constitute a reasonable alternative for low-risk patients and appears to be acceptable for patients who find the carcinogenic risk of radiotherapy unacceptable, its disadvantage is the need for long-term surveillance.

Practice patterns of Canadian urologists in the management of stage I testicular seminoma

OBJECTIVE

To evaluate the practice patterns of Canadian urologists in the management of stage I testicular seminoma.

METHODS

A survey was conducted with a three-page questionnaire among Canadian urologists between July and November 2002.

RESULTS

The overall response rate was 48%. The total number of completed and partially completed questionnaires was 198 and 212, respectively. Ninety-four responders described their practice as university-affiliated teaching centre, while 118 reported community-based or private practice. All ordered CT abdomen/pelvis with either chest x-ray or CT scan of chest for staging investigation. Only 1% would order a lymphangiogram. About one third would not offer surveillance as a management option for stage I testicular seminoma. When asked to rank, in order of preference, three management options (surveillance, adjuvant radiotherapy, and adjuvant chemotherapy) under four different clinical scenarios varying in perceived relapse risk and the presence/absence of fertility preservation concern, the majority selected adjuvant radiotherapy as the treatment of choice for a patient with high relapse risk or no fertility concern. When a patient had desire to preserve fertility as well as low relapse risk, surveillance was chosen as the preferred management strategy. There was no significant response difference between academic and community urologists.

CONCLUSION

There was some variation among Canadian urologists in the management of stage I testicular seminoma. The issue of fertility preservation and perceived relapse risk were important factors influencing management decisions. There was no significant difference between academic and community-based urologists with respect to patient volume and management approaches.

Effects of adjuvant radiotherapy for testicular cancer on CD4+ cell count in HIV-positive patients: a case report

The occurrence of testicular seminoma is more frequent in HIV-positive than in HIV-negative men. Management involves orchiectomy and radiotherapy for early-stage seminoma. Radiotherapy is typically well tolerated, with minimal side effects. This Case Report presents an HIV-positive patient who experienced a decrease in CD4+ cell count and an alteration of his clinical HIV disease course following radiotherapy for seminoma.

[Radiotherapy in stage I testicular seminoma: retrospective study and review of literature]

INTRODUCTION

Seminoma accounts for about 40% of germ cell tumours of the testicle. In this retrospective analysis, we review literature concerning management of stage I seminoma.

MATERIALS AND METHODS

Between March 1987 and April 2001, 65 patients with stage I pure testicular seminoma received adjuvant radiotherapy with a 25 MV linear accelerator.

RESULTS

Median age was 33 years. Testicular tumour has been found on the right testis in 39 patients and on the left one in 24 patients. Patients have been treated using an anterior-posterior parallel pair and have received 20-25 Gy in 10-14 fractions. The target volume consisted of paraaortic, and paraaortic + homolateral iliac lymph nodes in 17 and 46 patients, respectively. Acute toxicity was mainly digestive, 38% of patients presenting nausea and vomiting. Median follow-up time was 37 months. All patients are alive in complete remission.

DISCUSSION

Because of good radio-sensitivity of seminoma, radiotherapy is regarded as standard adjuvant treatment (5 years relapse rate: 3-5%). Acute toxicity is dominated by moderate gastro-intestinal side effects. Secondary neoplasia represents one of the worst possible long-term complications of therapy. Waiting for ongoing randomised trials, the modern literature for seminoma reflects a trend toward lower radiation doses (20-25 Gy) and smaller treatment volumes (paraaortic field). Adjuvant chemotherapy with two courses of carboplatin, might be equivalent to radiotherapy but must be investigated in randomised trials. A surveillance policy is one of the other management options less recommended.

Mortality after cure of testicular seminoma

PURPOSE

To determine the incidence of potentially treatment-related mortality in long-term survivors of testicular seminoma treated by orchiectomy and radiation therapy (XRT).

PATIENTS AND METHODS

From all 477 men with stage I or II testicular seminoma treated at The University of Texas M.D. Anderson Cancer Center (Houston, TX) with post-orchiectomy megavoltage XRT between 1951 and 1999, 453 never sustained relapse of their disease. Long-term survival for these 453 men was evaluated with the person-years method to determine the standardized mortality ratio (SMR). SMRs were calculated for all causes of death, cardiac deaths, and cancer deaths using standard US data for males.

RESULTS

After a median follow-up of 13.3 years, the 10-, 20-, 30-, and 40-year actuarial survival rates were 93%, 79%, 59%, and 26%, respectively. The all-cause SMR over the entire observation interval was 1.59 (99% CI, 1.21 to 2.04). The SMR was not excessive for the first 15 years of follow-up: SMR, 1.30 (95% CI, 0.93 to 1.77); but beyond 15 years the SMR was 1.85 (99% CI, 1.30 to 2.55). The overall cardiac-specific SMR was 1.61 (95% CI, 1.21 to 2.24). The cardiac SMR was significantly elevated only beyond 15 years (P <.01). The overall cancer-specific SMR was 1.91 (99% CI, 1.14 to 2.98). The cancer SMR was also significant only after 15 years of follow-up (P <.01). An increased mortality was evident in patients treated with and without mediastinal XRT.

CONCLUSION

Long-term survivors of seminoma treated with post-orchiectomy XRT are at significant excess risk of death as a result of cardiac disease or second cancer. Management strategies that minimize these risks but maintain the excellent hitherto observed cure rates need to be actively pursued.

Fertility after testicular cancer treatments

BACKGROUND

Patients with testicular cancer have an excellent survival rate, and fertility is one of the main concerns of survivors. The authors investigated fertility status after treatment for testis cancer in long-term survivors.

METHODS

Four hundred fifty-one consecutive patients with testicular cancer (1979-1999) from health facilities in the French Midi-Pyrenees region were enrolled. Testis tumors were classified according to the Royal Marsden Hospital Classification. Fertility status was assessed by means of a mailed, standardized questionnaire focused on reproductive events that occurred before and after treatment. Of 451 patients with germ-cell tumors, information concerning fertility was obtained in 446 patients (98.9%). The follow-up was at least 3 years.

RESULTS

Before they were diagnosed with testicular cancer, 91.2% of patients who had tried to get their partners pregnant had succeeded, compared with 67.1% of patients after treatment. Radiotherapy had a much more deleterious effect on fertility compared with chemotherapy alone. Furthermore, cumulative conception rates (log-rank test) for patients who received radiotherapy were significantly lower compared with the rates for patients who received chemotherapy.

CONCLUSIONS

The outcome of this study, which included the largest series reported to date, showed that fertility in patients with testicular cancer decreased by 30% after treatments and that radiotherapy seemed to have the most deleterious effect on fertility.