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.

Short course para-aortic radiation for stage I seminoma of the testis

PURPOSE

To determine the outcome in men with Stage I seminoma treated with low-dose para-aortic radiation.

MATERIALS AND METHODS

Between January 1988 and December 2000, 431 men with Stage I seminoma were treated with para-aortic radiation to a midplane dose of 20 Gy in 8 fractions over 10 days.

RESULTS

At a median follow-up of 62 months, 15 patients (3.5%) had relapsed, with a median time to relapse of 13 months (range: 9 to 39 months). Nine patients had pelvic nodal relapse; in addition, 1 patient had para-aortic involvement, and 2 had distant disease. Four had metastatic disease only (mediastinum 2, lung 2). One patient had scrotal recurrence, and 1 was treated for progressive rise in human chorionic gonadotrophin without identifiable disease. Initial treatment at relapse was chemotherapy (12), radiation (2), and surgery (1). One patient died from progressive disease. Thirteen men (3%) have developed second malignancies, including 7 contralateral testicular tumors, 5 solid malignancies, and 1 leukemia. The overall 5-year survival was 98%, and the estimated recurrence-free survival at 5 years was 96.3%. On log-rank univariate analysis, lymphovascular invasion, involvement of the tunica, and a preoperative human chorionic gonadotrophin level of greater than 5 were found to be of prognostic significance for recurrence.

CONCLUSIONS

These data support short-duration, limited-field radiation as an optimal safe and effective protocol in the management of Stage I seminoma patients.

Stage I Testicular Seminoma: Para-Aortic and Iliac Irradiation with Reduced Dose after Orchiectomy

BACKGROUND AND PURPOSE

Radiotherapy remains the treatment of choice for patients with stage I seminoma. The aim of this study is to report preliminary results of reduced dose radiotherapy to ipsilateral pelvic and para-aortic lymph nodes.

MATERIALS AND METHODS

Between February 1996 and December 2001, 53 patients with stage I testicular seminoma were treated with adjuvant radiotherapy after orchiectomy. The median age was 34 years (19-59 years). Four (7.5%) patients had a history of cryptorchidism. Eleven (20.8%) patients showed elevated beta-human chorionic gonadotropin. All patients had a radical inguinal orchiectomy and histopathological analysis yielded classic seminoma in 47 (88.7%), spermatocytic in 5 (9.4%) and anaplastic in 1 (1.9%) patients. A total of 19.6-20 Gy in 1.8- to 2-Gy daily fractions was administered to the para-aortic and ipsilateral iliac lymphatics.

RESULTS

Median follow-up time was 42 months (12-77 months). One patient developed para-aortic lymph node recurrence at month 28 of the follow-up. Five-year overall and disease-free survivals were 100 and 98%, respectively. Only grade I-II of the Radiation Therapy Oncology Group acute gastrointestinal complications without any severe late toxicity was detected.

CONCLUSION

Reduced dose radiotherapy seems to be as effective as higher doses in the management of stage I seminoma with an acceptable toxicity.

Two secondary malignancies after radiotherapy for seminoma: case report and review of the literature

We report a case of a 50-year-old man with two synchronous second malignancies 25 years after orchiectomy and adjuvant radiotherapy for seminoma. An annual health examination revealed an elevated prostate-specific antigen level. A biopsy was performed revealing Gleason score 9 adenocarcinoma of the prostate. Computed tomography of the abdomen revealed a 2-cm solid mass in the right kidney consistent with renal cell carcinoma. Both of these lesions were within the nonstandard radiation field for seminoma with which this patient was treated. Second malignancies, including prostate cancer, are a very uncommon occurrence but an important consideration in long-term survivors of seminoma treated with radiotherapy.

[Cancer of the testis: role of radiotherapy in 2003]

Germ-cell tumors of the testis are rare tumors of the young adult. Half of them are seminoma. The majority of patients have disease limited to the testis. Radiotherapy still remains the standard treatment of these patients. Almost all patients are cured by orchidectomy and radiotherapy on the lomboaortic area extended to homolateral iliac area. The dose is 24 to 30 Gy in a standard fractionation. Different studies are ongoing to reduce the irradiation field (omission of the pelvic irradiation), to decrease irradiation dose (to 20 Gy). Other treatment options are strict surveillance and adjuvant carboplatin based chemotherapy. None of these options are standard treatments. A strict attention must be directed on controlateral germ-cell tumors and second cancers.

[Radiotherapy of testicular seminoma: changes over the past 10 years]

Radiotherapy is generally considered as the standard treatment for most testicular seminomas. However, there have been substantial changes in the management of these tumours over the past few years. In early seminoma, there is a trend towards a decrease in treatment intensity or even towards therapeutic abstention (i.e. surveillance); whereas in advanced cases, combination chemotherapy is taking over from radiotherapy. In stage I, where cure rates are almost 100%, the limiting of the lymph node area to be irradiated and decrease of the dose to 20-25 Gy was followed by very low long-term toxicity rates, and a very small risk of infertility, without compromising the overall prognosis. Surveillance is an acceptable alternative to postoperative radiotherapy. However, the risk of nodal relapse is around 18-20%. With surveillance, the frequency and duration of follow-up is increased in comparison to the same with postoperative radiotherapy, with higher cost. In stage IIa, radiotherapy remains the standard but recent studies have shown that limiting the nodal volume to the paraortic area is justified as in stage I. In stage IIb and higher, combination chemotherapy is almost always given. However, the association between carboplatin and radiotherapy represents an efficient and well-tolerated alternative. Late tissue damage and the risk of decrease in fertility are minimized with novel radiotherapeutic approaches. However, the occurrence of second cancers in the long term is a matter of concern. It is possible though, that patients with seminoma have a tendency per se to develop second cancers. The prognosis of cryptorchid seminoma and of HCG-producing seminoma has been the subject of controversy but recent large studies have demonstrated that stage for stage, the cure rates are similar to those of other seminomas.

Retrospective analysis of 74 cases of seminoma treated with radiotherapy

BACKGROUND

Standard post-orchiectomy radiotherapy (RT) is accepted as a standard management option for stage I seminoma.

METHODS

Retrospective evaluation of 74 patients with stage I seminoma was performed according to the Royal Marsden staging system. All of the patients underwent RT in the Radiation Oncology Department of Gülhane Military Medical Academy between 1974 and 1995. The median age of patients was 27 years (range, 20-56). Radiotherapy was applied to all of the patients after orchiectomy for adjuvant purposes. Sixty-nine patients underwent RT while five patients who had recurrence received chemotherapy following radiotherapy.

RESULTS

After a mean follow-up period of 54 months, the 5-year overall survival rate was 98.61%, which complied with the literature. The disease-free survival rate was 90.54%. According to the World Health Organization toxicity scale, acute enteritis was 9.4% for grade I and 5.4% for grade II, while nausea/vomiting was 36.4% for grade I and 5.4% for grade II.

CONCLUSION

To avoid acute toxicity related to RT, prognostic risk factors should be well-known and patients with low risk factors should be monitored carefully after orchiectomy. RT should be directed to the para-aortic +/- ipsilateral pelvic lymph nodes in high risk patients. Although post-orchiectomy RT is a traditional management option for clinical stage I seminoma, the results of RT should be well-known to compare it with other treatment options (e.g. RPLND, adjuvant chemotherapy and surveillance).

Appropriate radiation volume for stage IIA/B testicular seminoma

PURPOSE

Prophylactic left supraclavicular fossa irradiation has been suggested to reduce relapse rates in patients treated for Stage IIA/B testicular seminoma. To address this issue, we reviewed patterns of failure and treatment outcome in patients treated with radiation therapy at our institution.

METHODS AND MATERIALS

Between 1981 and 1999, 79 men with Stage II seminoma (IIA, 49; IIB, 30) were treated with radiation therapy (RT) to the para-aortic and ipsilateral (+/- contralateral) pelvic lymph nodes (dose: 25-35 Gy).

RESULTS

With a median follow-up of 8.5 years, the 5-year relapse-free rate was 91% (standard error: 3%), and 2 patients have died of seminoma, giving a 5-year cause-specific survival of 97%. A total of 7 patients have relapsed with 2 isolated to the left supraclavicular fossa. Five of 7 patients have been successfully salvaged.

CONCLUSIONS

Prophylactic left supraclavicular fossa irradiation might have prevented relapse in 2 of 79 patients in Stage IIA/B seminoma. However, 97% of patients would have received unnecessary left neck RT, so we continue to recommend, as standard treatment, infradiaphragmatic RT only.

Stage I seminoma of the testis: a bi-institutional retrospective analysis of patients treated with radiation therapy only

OBJECTIVE

To analyse relapse patterns, toxicity and second malignancy in patients with stage I pure germ cell testicular tumours, treated in 1970-1999.

PATIENTS AND METHODS

In all, 487 patients received irradiation after surgery to the infra- (407, 83.5%) or infra- and supra-diaphragmatic volumes (80, 16.5%). Treatment-related toxicity was classified according to previous criteria and fertility investigated in 246 men. Second malignancies were identified by retrospective analysis of clinical records or telephone interviews in men who no longer needed a long-term follow-up.

RESULTS

The 10-year overall survival was 97% (98% and 96%, respectively, for the aortic nodes only, or aortic and iliac nodes, i.e. the 'dog leg' field) and disease-free survival was 94%. Twenty-one patients relapsed (five with a true 'in-field' recurrence, nine progressed to the mediastinum, and seven had disseminated disease). Acute toxicity was mainly gastrointestinal, with 7.6% classified as grade II. In all, 73 men achieved paternity after irradiation; nine did not but had normal sperm. Second malignancies were diagnosed in 16 (3.3%) men.

CONCLUSION

Para-aortic irradiation may be used safely in patients with stage I seminoma and undisturbed testicular drainage, with equivalent results to the 'dog-leg' group; these unrandomized data confirm the lower toxicity and equivalent survival rates of this treatment.

Radiotherapy for stages IIA/B testicular seminoma: final report of a prospective multicenter clinical trial

PURPOSE

A prospective multicenter trial was initiated to evaluate the role of modern radiotherapy with reduced treatment portals for stage IIA and IIB testicular seminoma.

PATIENTS AND METHODS

Patients with stages IIA/B disease (Royal Marsden classification) were assessable for the trial. Staging comprised computed tomography of the chest, abdomen, and pelvis as well as analysis of tumor markers alpha-fetoprotein and beta human chorionic gonadotropin. Linac-based radiotherapy was delivered to para-aortic and high ipsilateral iliac lymph nodes. The total doses were 30 Gy for stage IIA and 36 Gy for stage IIB disease.

RESULTS

Between April 1991 and March 1994, 94 patients were enrolled for the trial by 30 participating centers throughout Germany. Seven patients were lost to follow-up. Median time to follow-up of 87 assessable patients was 70 months. There were 66 stage IIA and 21 stage IIB patients. One mediastinal and one field-edge relapse were observed in the stage IIA group. In the stage IIB group, there was one mediastinal and one mediastinal/pulmonary relapse. All patients were treated with a salvage regimen of platinum-based chemotherapy. Actuarial relapse-free survival at 6 years was 95.3% (95% confidence interval [CI], 88.9% to 100%) and 88.9% (95% CI, 74.4% to 100%) for stage IIA and IIB groups, respectively. Maximum acute side effects were 8% grade 3 nausea for stage IIA and 10% grade 3 nausea and diarrhea for stage IIB groups. No late toxicity was observed.

CONCLUSION

Radiotherapy for stages IIA/B seminoma with reduced portals yields excellent tumor control at a low rate of acute toxicity and no late toxicity, which supports the role of radiotherapy as the first treatment choice for these patients.

Do characteristic spermatozoal morphological abnormalities exist in patients who have undergone unilateral orchiectomy and preventive radiotherapy?

DESIGN

We examined 16 men who had been subjected to unilateral orchiectomy owing to seminoma and to preventive radiotherapy, in order to investigate the morphologic abnormalities of the spermatozoa (headless and small-round-headedness) that may contribute to infertility.

RESULTS

The same morphologic abnormalities of the head and neck found in the semen samples of fertile men were also found in the semen samples of the patients, albeit in higher percentages; the morphologic abnormalities of the tail in the semen samples of the patients were similar to those of the fertile men, both qualitatively and quantitatively.

CONCLUSION

No specifically characteristic morphologic abnormalities of the spermatozoa were detected in men who were subjected to unilateral orchiectomy and to preventive radiotherapy in comparison with fertile men. The percentage rate of morphologic tail abnormalities is not affected by preventive radiotherapy.

Controversies in the management of testicular seminoma

Tremendous progress has been made in the treatment of testicular seminoma over the past 25 years. The advent of curative cytotoxic chemotherapy, even for patients with advanced metastatic disease, has led to a paradigm shift toward minimizing additional oncologic therapies and their potential side effects. Despite these advances, controversial issues still exist in managing patients with this disease. Patients with stage I disease can now be managed successfully with close surveillance or postoperative radiotherapy (RT). Although deemed safe, considerable debate persists about surveillance including issues of compliance, cost, and secondary effects of routine RT. Aside from RT, patients with stage I disease also can be managed with one- or 2-dose single-agent carboplatin. Although this appears safe and efficacious, an ongoing randomized study is underway to compare its effectiveness with that of RT. Residual mass after chemotherapy for seminoma is not uncommon and therapeutic options include observation, RT, or retroperitoneal lymphadenectomy. Although most agree that patients with small (<3 cm) or ill-defined masses can be observed, debate persists as to the optimal management of patients with well-defined masses greater than 3 cm. For many years, patients with bulky retroperitoneal disease (>5 cm) were treated with up-front radiotherapy and chemotherapy at relapse. The high failure rate outside the treatment field has now changed this paradigm to one of up-front chemotherapy.

[Urologic treatment of testicular germ cell cancer]

OBJECTIVE

To review the treatment of testicular germ-cell cancer in our series.

METHODS

73 cases with the diagnosis of germ-cell testicular tumours were reviewed. All cases underwent orchiectomy and extension study with abdominal CT-scan and either chest X-ray or Thoracic CT-scan. We reviewed the treatment options employed in our series, analysing different currently recognised risk factors.

RESULTS

34 out of 73 testicular germ-cell tumours were seminomas (46.6%) and 39 non seminomas (54.4%). Clinically 58.9% of the patients had localised, stage I tumours. 85.7% seminomas were stage I at presentation compared to 35.9% (14) non seminomatous tumours. The remainder tumours presented in advanced phases (stages II & III). Inguinal orchiectomy was performed in all cases except 5 patients in whom tumours were incidentally diagnosed (atrophic testis orchiectomy, hydrocelectomy, trauma) and underwent ipsilateral scrotal excision in a second time. Lymphadenectomy was initially performed in 3 patients with non seminomatous tumours. Radiotherapy was used in 23 cases of seminoma (67.6%), although this percentage has been progressively reduced in recent years. 30 patients received chemotherapy after orchiectomy: 3 metastatic seminomas (stage II) (8.8% of seminomas treated with chemotherapy) and 27 non seminomatous tumours (69.2% of them). All metastatic tumours are among the last (25) (Stages II & III) and 2 stage I non seminomatous tumours. All seminomas achieved complete response without later relapse after a median follow-up of 50 months (12-145 months). Median follow-up for non seminomatous tumours was 57 months (1-288 months). 13 non seminomas had relapses (33.3%). Relapses appeared in the retroperitoneum in 11 cases (84.6%), 2 of them concurrent with pulmonary relapse; 1 patient had liver relapse, one lung and another in bone. Median time to relapse was 4 months (2-102). 8 patients died and 2 were lost for follow-up.

CONCLUSIONS

Testicular germ-cell cancer needs a well established multidisciplinary approach, in which the role of the urologist is fundamental. Orchiectomy is the primary treatment and allows determination of the dissemination risk. Radiotherapy is very effective for localised seminomas with poor prognostic factors, and for non seminomas 2 cycles of chemotherapy seem to be an effective approach, as well as of little toxicity. We must know and apply optimised programs for observation of these tumours (stage I), and also use follow-up protocols after chemotherapy or radiotherapy. Some cases need complex surgery for residual masses resection or post chemotherapy salvage surgery in disseminated tumours (Stages II & III). Sterility treatment protocols are applied to preserve fertility.

Management preferences following radical inguinal orchidectomy for Stage I testicular seminoma in Australasia

A survey to evaluate the preferred patterns of management of Stage I seminoma was conducted during March 2001. The questionnaire was distributed by the Royal Australian and New Zealand College of Radiologists to all qualified radiation oncologists, 74 out of 170 responded. All performed a staging CT scan of the abdomen and pelvis. Thoracic imaging consisted of either chest X-ray (29%) or chest CT (38%) while 33% performed both. Fifty-four percent of radiation oncologists discussed surveillance with their patients but estimated that 5% or less would choose this option. The most commonly prescribed dose was 25 Gy in 15 or 20 fractions (79%). Sixty-five percent of respondents treated the para-aortic (PA) nodes alone. Forty-two of 48 clinicians treating the PA field reported a change in practice after publication of the Medical Research Council study in 1999. Of these, 40 and 23% perform CT scans of the pelvis annually and every 6 months. Thirty-one percent did no follow-up CT scan. Compared to a similar survey from North America, we are more likely to use PA fields and less likely to discuss surveillance. As in the USA, and in contrast to Canada, few patients choose surveillance. There is no consensus regarding the frequency of follow-up scans in either North America or Australasia.

Treatment outcome, body image, and sexual functioning after orchiectomy and radiotherapy for Stage I-II testicular seminoma

PURPOSE

Orchiectomy followed by infradiaphragmatic irradiation is the standard treatment for Stage I-II testicular seminoma in The Netherlands. Because body image and sexual functioning can be affected by treatment, a retrospective study was carried out to assess treatment outcome, body image, and changes in sexuality after orchiectomy and radiotherapy.

METHODS AND MATERIALS

The medical charts of 166 patients with Stage I-II testicular seminoma were reviewed. A questionnaire on body image and current sexual functioning regarding the frequency and quality of erections, sexual activity, significance of sex, and changes in sexuality was sent to 157 patients (at a mean of 51 months after treatment).

RESULTS

Seventy-eight percent (n = 123, mean age 42 years) completed the questionnaire. During irradiation, almost half of patients experienced nausea and 19% nausea and vomiting. Only 3 patients had disease relapse. After treatment, about 20% reported less interest and pleasure in sex and less sexual activity. Interest in sex, erectile difficulties, and satisfaction with sexual life did not differ from age-matched healthy controls. At the time of the survey, 17% of patients had erectile difficulties, a figure that was significantly higher than before treatment, but which correlated also with age. Twenty percent expressed concerns about fertility, and 52% found their body had changed after treatment. Cancer treatment had negatively influenced sexual life in 32% of the patients.

CONCLUSIONS

Orchiectomy with radiotherapy is an effective and well-tolerated treatment for Stage I-II testicular seminoma. Treatment-induced changes in body image and concerns about fertility were detected, but the sexual problems encountered did not seem to differ from those of healthy controls, although baseline data are lacking.

The use of preferences to measure the benefit of adjuvant radiation therapy for stage I seminoma

PURPOSE

In Stage I seminoma, treatment with radiation therapy (RT) after radical inguinal orchiectomy reduces the likelihood of relapse by 15%, but does not improve survival, thus making quality of life an important outcome measure. The purpose of this study was to use utilities to assess the quality of life benefits associated with adjuvant RT in this setting.

MATERIALS AND METHODS

One hundred healthy men were interviewed using a utility assessment tool. Utilities for five health states were measured using the standard gamble technique: (A) adjuvant RT with 5% recurrence risk; (B) recurrence after RT, salvaged with chemotherapy; (C) orchiectomy alone with 20% recurrence risk; (D) recurrence after orchiectomy alone, salvaged with RT; and (E) recurrence after orchiectomy alone, salvaged with chemotherapy.

RESULTS

The median age was 25. Utilities were highest for nonrecurrent health states, and lowest for recurrence salvaged with chemotherapy. All differences in utilities between health states were significant, except between states A and C and B and E. Variability in utilities was not explained by the sociodemographic factors examined.

CONCLUSIONS

Our results suggest that healthy males do not value the 15% reduction in recurrence risk achievable with adjuvant RT. However, they do predict that an actual recurrence, especially one requiring salvage chemotherapy, will lead to significant decline in quality of life. We intend to use these utilities to further evaluate the cost-effectiveness of RT in this setting.

Management of clinical stage I testicular pure seminoma. Report on 42 patients and review of the literature

INTRODUCTION

Testis cancer is the most common tumor detected in men aged from 20 to 35 years accounting for 1-2%. About 20-30% of patients presenting with clinical stage I pure seminoma of the testis, which accounts for 45-50% of all germ cell tumors, present with occult metastases in the retroperitoneal lymph nodes. Currently, treatment options for clinical stage I seminoma include adjuvant radiotherapy (RT) as well as surveillance and adjuvant single agent chemotherapy. Herein, we review our experience in the management of 42 patients with clinical stage I pure seminoma of the testis and review the literature concerning this topic.

MATERIALS AND METHODS

Between January 1977 and December 2000, of 56 patients with pure seminoma of the testis 42 (75%) were assessed as clinical stage I disease. Adjuvant RT was performed in 41 patients and surveillance in 1. Radiations fields included the para-aortic and ipsilateral pelvic lymph nodes. A radiation dose of 25 Gy in 20 daily fractions was given. All patients were followed up.

RESULTS

Average age was 41.2 years (range 24-67). Mean follow-up was 85.3 months (range 12-279). Histopathology assessed classic seminoma in 41 cases (98%) and spermatocytic seminoma in 1 (2%). Small vessel invasion was detected in 8 cases (19%). Overall relapse rate was 4.7%. Overall survival rate resulted 97%.

CONCLUSIONS

Adjuvant radiotherapy (RT) is a safe standard of care in controlling microscopic retroperitoneal disease in patients with clinical stage I seminoma. About 3 to 5% of patients undergo relapses, mostly after the first 18 months after orchiectomy. Overall cause-specific survival rates range between 96% to 100%. An alternative optional treatment for compliant patients presenting with low risk factors for relapse is surveillance with recurrences rates ranging between 15% to 20%. Surveillance avoids unnecessary treatment in about 80% of patients, thus it could be offered as a safe alternative option to adjuvant RT since imaging detects relapses at their early stages. Adjuvant chemotherapy with 1 or 2 courses of single-agent carboplatin is being investigated as an alternative adjuvant treatment to RT or surveillance in patients with moderate to high risk factors for relapse. The treatment is well tolerated and recurrence rate is 1%.

Management of testicular seminoma advanced disease. Report on 14 cases and review of the literature

INTRODUCTION

About 25% of testicular seminomas present with advanced clinical stage disease. The retroperitoneal lymph nodes are more likely to be involved (20%) than distant organs (5%). Herein we review our experience in the management of 14 patients with clinical stage II pure seminoma of the testis and review the literature concerning this subject.

MATERIALS AND METHODS

Between January 1977 and December 2000, of 56 patients with pure seminoma of the testis 14 (25%) were assessed as clinical stage II disease. RT was performed for clinical substage IIA-IIB and chemotherapy in for IIC disease. All patients were closely followed up.

RESULTS

Average age was 39.3 years (range 23-47). Mean follow-up was 88.6 months (range 28-232). Clinical stage IIA-IIB was detected in 12 patients (86%) and IIC in 2 (14%). Relapse did not occur in any patient. At the last follow-up evaluation, all patients were alive and disease-free.

CONCLUSIONS

Radiation therapy is the standard of care in managing seminoma small bulk retroperitoneal disease including substages IIA and IIB. Overall toxicity of RT is mild and treatment is well tolerated. After RT, about 20% of patients may undergo relapses. Chemotherapy is the choice treatment for advanced seminoma presenting with clinical stage IIC-III disease; recently, it has also been advocated for stage IIB when presenting with multiple small lymph nodes. Carboplatin and cisplatin are the most effective agents with complete response rates of 89-91%. Patients developing progressive disease after first-line chemotherapy undergo combined salvage chemotherapy with cisplatin, ifosfamide and vinblastine with complete response rate of 83%. Patients presenting salvage chemotherapy failure are treated with high-dose chemotherapy associated with autologous bone marrow transplantation. Residual retroperitoneal masses after chemotherapy for advanced seminoma may be assessed by imaging as poorly or well defined. Surveillance is indicated for residual masses smaller than 3 cm as well as for poorly defined masses equal or greater than 3 cm. Well defined masses equal or larger than 3 cm are treated with surgery or RT. Ongoing clinical trials for testicular germ cell metastatic disease are focused on reducing toxicity without compromising efficacy as well as exploring new salvage strategies and improving the prospect of cures and survival rates.

Radiotherapy for early stages testicular seminoma: patterns of care study in Germany

BACKGROUND AND PURPOSE

To evaluate compliance of radiotherapeutic departments with 1997 German consensus guidelines for staging and treatment of testicular cancer patients.

MATERIAL AND METHODS

A questionnaire was mailed to all departments of radiotherapy in Germany as identified by the data-base of the German Society for Radiation Oncology (DEGRO). The questionnaire was analysed with particular respect to institutional characteristics, frequency of seminoma patients treated per year, treatment techniques, and institutional compliance with consensus guidelines.

RESULTS

Fifty-six institutions (39%) returned the questionnaire, 46% of which fully complied with consensus guidelines concerning staging requirements. A minimum workup with computed tomography (CT) of abdomen and pelvis, X-ray or CT of the chest and tumour markers was mandatory in 87.5% of the departments. Compliance with the recommended treatment schedule was high in stage I with less than 5% major violations of recommended dose prescription or target volume definition. In stage IIA/B, however, 22.6 and 10.2% of the departments showed major deviations from either standardised treatment target volumes or total doses of irradiation, respectively.

CONCLUSIONS

Compliance with consensus recommendations in German departments for radiotherapy is satisfactory in many institutions. However, major deviations from treatment guidelines were observed in stage II disease indicating the need for continuous improvement in the quality of testicular cancer patient management.

A rare association between malignant mediastinal seminoma and other malignant neoplasms

Primary malignant mediastinal seminomas (PMMS) are rare tumors accounting for 1-6% of all mediastinal tumors. PMMS mostly affect young men, arising from primordial germ cells that abnormally migrate from the ectoderm of the yolk sac to the gonadal region. They are clinically and biologically distinct from primary testicular tumors and seem to have a worse prognosis. Due to the rarity of the disease, the choice of treatment is a matter of debate. Literature data do not show any association between this kind of tumor and malignant Schwannoma or thyroid carcinoma. In this report we describe the case of a patient affected by PMMS and 12 yr later by a malignant brachial plexus Schwannoma and papillary thyroid carcinoma (PTC). Since both mediastinal seminoma and Schwannoma were treated with surgery followed by local radiotherapy, we were not able to ascertain if either PTC or Schwannoma had been induced by radiotherapy or represented a casual neoplastic association.

Patterns of relapse following radiotherapy for stage I seminoma of the testis: implications for follow-up

A retrospective review was undertaken of 409 consecutive patients treated with adjuvant radiotherapy for Stage I seminoma between 1988 and 1997. A total of 339 men were treated to a volume encompassing the para-aortic nodes and 70 were treated with extended field radiotherapy. The patients were followed up within oncology clinics adhering to a standard protocol of clinical examination, chest radiography and measurement of serum marker levels. No routine computed tomographic (CT) scans were carried out. At a median follow-up of 57 months, 13 patients have relapsed, giving a recurrence-free rate of 97.2% at 3 years and 96.8% at 5 years. Of these, eight (62%) were detected at routine appointments and five (38%) requested early appointments. Chest radiography (2/5) and serum marker levels (3/5) identified disease in asymptomatic patients. Eight patients (62%) had raised markers at relapse, including two with normal serum markers at original presentation. The median size of pelvic node recurrences in the para-aortic-treated group was 7.3 cm (2.8-13 cm). Four patients have developed second testicular primaries: three were detected at routine appointments and one patient had requested an early appointment. We conclude that regular follow-up with serum marker estimations and chest radiography is sufficient to detect recurrence at an early stage and that our policy of no routine CT scanning has been shown to give acceptable results.

[Spermatocytic seminoma. Report of 2 personal cases and review of the literature]

The spermatocytic seminoma is a distinct testicular neoplasm with a low tendency to metastasize. Two own cases with the diagnosis of a spermatocytic seminoma are presented. A third patient is described, where the initial diagnosis of a spermatocytic seminoma was retrospectively changed to classical seminoma after developing retroperitoneal relapse during surveillance. A literature review revealed distinct histopathological characteristics and a remarkably good prognosis for spermatocytic seminoma. With only one case of relapse confirmed in the literature, in these patients postoperative treatment can safely be omitted in favor of surveillance. In case of spermatocytic seminoma diagnosis should be confirmed by a second pathologist.