Radiotherapy for stage II testicular seminoma

PURPOSE

To compare the outcome of patients with Stage II seminoma treated with prophylactic mediastinal irradiation, without any supradiaphragmatic irradiation, and with prophylactic left supraclavicular irradiation (PLSCI).

METHODS AND MATERIALS

Between 1960 and 1999, 73 men with Stage II seminoma received postorchiectomy radiotherapy. Before 1984, 36 received prophylactic mediastinal irradiation (Series I); between 1984 and 1992, 17 received no supradiaphragmatic irradiation (Series II); and after 1992, 20 received PLSCI (Series III). The outcomes in these series were compared.

RESULTS

The abdominal tumor sizes were as follows: Series I, <or=2 cm, n = 4; >2 and <or=5 cm, n = 12; >5 and <or=10 cm, n = 16; Series II, <or=2 cm, n = 1; >2 and <or=5 cm, n = 12; >5 and <or=10 cm, n = 4; and Series III, <or=2 cm, n = 1; >2 and <or=5 cm, n = 14; >5 and <or=10 cm, n = 5 (p = 0.75). The median duration of follow-up was 14.4, 9.3, and 4.5 years for Series I, II, and III, respectively. The 6-year freedom from relapse was 94%, 71%, and 95% for Series I, II, and III, respectively. The differences between Series I and II (p = 0.014) and between II and III (p = 0.042) were significant. Three patients in Series II had a relapse in their left supraclavicular fossa-a failure pattern abrogated by PLSCI.

CONCLUSIONS

PLSCI significantly diminishes the likelihood of relapse for Stage IIA, IIB, and IIC seminoma (mass <or=10 cm).

Treatment of early stage testicular seminoma

Stage I and IIA/B testicular seminoma represent approximately 45% of all testicular germ cell tumours. Due to the availability of highly efficient salvage treatment, the disease-specific survival in stage I seminoma is approximately 100%, irrespective of the choice of adjuvant treatment. Radiotherapy with 26 Gy to the paraaortic/paracaval lymph nodes yields excellent cure rates of 95 98% with a favourable profile of acute and late toxicity. Likewise, phase-II trials with single-agent carboplatinum systemic treatment have demonstrated a rate of relapse of 3-4% on average. However, carboplatinum chemotherapy has to be regarded as experimental until data of phase-III trials are available. Surveillance in stage I disease is conflicted with a rate of relapse of approximately 20%. However, 80% of the patients will avoid potentially toxic overtreatment by the watch-and-wait policy. In stage IIA/B seminoma, "dogleg" radiotherapy with 30 Gy and 36 Gy, respectively, provides high cure rates of 90-95%. Those patients relapsing will be salvaged in almost 100% of cases. Testicular intraepithelial neoplasia (TIN) is the common precursor lesion of testicular germ cell tumours except for spermatocytic seminoma. In case of TIN in a single testis or bilateral TIN, local radiotherapy with 18 Gy is recommended as standard treatment.

Presentation and revascularization outcomes in patients with radiation-induced renal artery stenosis

This study analyzed the initial presentation and revascularization outcomes of patients with radiation-induced renal artery stenosis, a rare complication of therapeutic irradiation. Of 11 patients with renal artery stenosis after irradiation, 7 patients fulfilled the following criteria: normotension before irradiation, radiation dose greater than 25 grays delivered to the renal arteries, associated perirenal radiation-induced lesions, and absence of arterial disease outside the radiation field. The median age at irradiation was 30 years, and the median local irradiation dose was 40 grays. The median time from irradiation to referral was 13 years. All patients were hypertensive at referral, with a median blood pressure (BP) of 171/102 mm Hg and median treatment score of two. The median glomerular filtration rate was 67 mL/min. Two patients had bilateral stenoses and 1 patient had stenosis affecting a single kidney. Stenoses were proximal in 6 patients and truncal in 1 patient, and all had the appearance of atherosclerotic stenosis. Percutaneous transluminal renal artery angioplasty (PTRA) was successful in 5 patients, but required multiple insufflations. PTRA failed in 1 patient, who subsequently underwent an aortorenal bypass. After a median follow-up of 36 months, 2 patients had died of noncardiovascular causes and 4 patients remained hypertensive, with a median BP of 136/85 mm Hg and median treatment score of two. No restenosis occurred, but aneurysms developed at the site of angioplasty in 1 patient. If hypertension occurs even decades after irradiation, a radiation-induced renal artery stenosis should be sought in patients who have undergone abdominal irradiation.

Reciprocal translocations in patients with testicular seminoma before and after radiotherapy

PURPOSE

The evaluation of radiation-induced chromosomal translocations in peripheral lymphocytes using fluorescent in situ hybridization is a promising method for retrospective dosimetry after a radiation accident. We evaluated the genomic frequency of chromosomal translocations in patients with testicular seminoma who received adjuvant radiotherapy to the retroperitoneal lymph nodes, to evaluate the time-effect relationship of radiation-induced stable aberrations after partial body irradiation.

METHODS

In 13 patients, peripheral lymphocytes could be evaluated before radiotherapy and at several time points after radiotherapy. In 17 additional patients, lymphocyte samples were obtained after radiotherapy. Thirteen healthy men served as age-matched controls for the aberration frequency before radiotherapy. Fluorescent in situ hybridization was performed using whole chromosome probes against chromosomes No. 4, No. 6, and No. 7.

RESULTS

Nearly all patients displayed an increased spontaneous rate of genomic translocations (F(G)) before radiotherapy compared to age-matched, healthy men. The difference was significant in the paired ranks test (p < 0.0001). After adjuvant radiotherapy, the F(G) increased 2- to 8-fold in individual patients. Within 20 months after radiotherapy, the F(G) returned to pretherapeutic levels.

CONCLUSIONS

The frequency of genomic translocations after partial body irradiation is time dependent. A persistence of chromosomal aberrations, which is to be expected after total body irradiation, could not be observed. It is likely that the dose and the volume of the irradiated bone marrow are playing a role in the persistence of stable chromosomal aberrations. Patients with testicular seminoma displayed an increased frequency of spontaneous genomic translocations before the initiation of radiotherapy. This chromosomal instability might be related to the known increased rate of secondary cancers in this patient group.

Long term results and morbidity of paraaortic compared with paraaortic and iliac adjuvant radiation in clinical stage I seminoma

BACKGROUND

Radiotherapy is accepted as standard adjuvant treatment for low-stage seminoma and results in excellent survival rates. The optimal radiation field for stage I seminoma, however, is still being discussed.

PATIENTS AND METHODS

In a retrospective study we evaluated long-term results concerning survival, relapse-pattern, and acute and chronic toxicity in patients receiving adjuvant radiotherapy of the paraaortic and ipsilateral iliac lymph nodes (hockey-stick, HS) versus radiotherapy of the paraaortic lymph nodes only (PA). From 1979-1997, 129 patients (median age 32 years) in clinical stage I received adjuvant radiotherapy. Eighty-seven patients were treated with 36 Gy to the HS field and 42 patients were treated with a median of 28 Gy to the PA field.

RESULTS

With a median follow-up of 7.7 years (HS) and 5.2 years (PA) the relapse rate was 3.4% and 2.4%, respectively. There was no abdominal or pelvic recurrence in either group. Radiotherapy was well tolerated in both groups. No significant difference in acute or chronic toxicity was noted. However, lower gastrointestinal tract toxicities and myelotoxicities appeared less frequent in the PA group. Second malignancies only occurred in the HS group. Overall survival in the HS and PA group was 96.6% and 100%, respectively. No patient died of seminoma.

CONCLUSION

With paraaortic radiotherapy only, long-term disease-specific survival was excellent. Decreased risk of acute toxicity and of second malignancies are potential benefits of the reduced radiation field.

[Therapy of abdominal and thoracic chylous effusions 18 years after radiation therapy]

Chylothorax and chylascites are rare complications of neoplasm or surgical, but also non-surgical trauma. Extremely rare causes are a subclavian i.v. line, a mesenterical hamartoma, retrosternal goiter, liver cirrhosis, portal vein thrombosis, filariasis, tuberculosis, ruptured aortic aneurysm and radiotherapy. We report on a 60-year-old male with bilateral chylothorax and chylascites resistant to therapy 18 years after irradiation of the iliacal, paraaortal and mediastinal (46 Gray) and the left-sided supraclavicular (40 Gray) lymph nodes for a seminoma (T3N1M0 i.e. IIa, Lugano classification). A fat-free parenteral nutrition was started in order to bring the lymphatic flow down to a minimum. Chyle flow ceased after 3 1/2 weeks of treatment. An oral diet with middle chain triglycerides (MCT-diet), which are transported to the liver via the portal vein instead of the lymphatic system, achieved good control of residual chylous effusions.

Primary retroperitoneal seminoma with utrasonically abnormal testes

Primary retroperitoneal seminomas account for approximately 2% of all seminomas. Differentiating the primary retroperitoneal tumor from a metastatic tumor with an occult testicular primary remains difficult despite the availability of ultrasonic examination. We present a case of primary retroperitoneal seminoma with ultrasonically demonstrated abnormalities in both testes. The patient underwent a unilateral orchiectomy and ultrasound-guided biopsy of the opposite testis. All surgical specimens were negative for testis cancer. Controversial issues in the diagnosis and treatment of primary retroperitoneal germ cell tumors are discussed.

Quality of life after radiotherapy for early-stage testicular seminoma

BACKGROUND AND PURPOSE

Standard therapy in early-stage testicular seminoma (TS) includes inguinal orchiectomy followed by irradiation (XRT) of the pelvic and para-aortic nodes. Since this treatment is highly effective in controlling the disease and leads to many long survivors, the quality of life (QL) may be impaired by treatment-induced side-effects. The aim of this study was to provide a QL evaluation of patients treated with XRT after orchiectomy for TS.

MATERIALS AND METHODS

We used a validated self-completed questionnaire based on a series of 44 items covering all QL fields. The items were grouped into six subscales with standardized scores. The questionnaire was mailed to a consecutive series of 143 patients treated between 1961 and 1995 for TS with no evidence of disease after primary treatment.

RESULTS

Ninety-eight questionnaires (68.5%) were returned and are assessable. The median age of the patients was 48 years (range, 26-85 years) at the time of completing the questionnaire, with a median follow-up after completion of treatment of 123 months (range, 15-432 months). The physical and autonomy subscale standardized scores were > or =1 in 83 and 95% of the cases, respectively. Psychological problems were reported by a small percentage of patients, ranging from 13, who reported a depressive condition, to 16%, who declared feeling tense. Of the patients, 86 and 89% have regularly met relatives and friends. The urinary score was above the central point in 99% of the patients. Only 6% of the patients perceived their body image as worsened by treatment. The patients who were more informed about the disease and therapy had a better physical and psychological adjustment.

CONCLUSIONS

The QL in our patients resulted as satisfactory, with a maintained body image and few side-effects. The information given to the patients about their disease and its treatment influenced the post-treatment QL adjustment.

Combination carboplatin and radiotherapy in the management of stage II testicular seminoma: comparison with radiotherapy treatment alone

PURPOSE

To assess the results of treatment in 33 patients with stage IIA/B seminoma who were treated with carboplatin and radiotherapy (RT) between January 1989 and December 1996.

PATIENTS AND METHODS

Thirty patients received single course single agent carboplatin (400 mg/m2 or area under curve (AUC 7), two patients received two courses carboplatin, and one patient received single course carboplatin and etoposide, all 4-6 weeks prior to infra-diaphragmatic RT. Results were retrospectively compared with those obtained for 80 patients treated from 1970 to 1998 with radiotherapy alone.

RESULTS

There was minimal toxicity associated with the use of carboplatin prior to RT. With a median follow-up of 4 years (range 2-70 months) 2/33 patients treated with chemotherapy and RT have relapsed, 5-year relapse free survival (RFS) = 96.9% (95% confidence interval (CI) 72.9-99.4%), and one patient has died of progressive disease, 5-year overall survival (OS) = 96.7%. With a median follow-up of 11.2 years (range 6 months to 25.8 years) 15/80 patients treated with RT alone have relapsed, 5-year RFS = 80.7% (95% CI 70.1-87.9%), including 13/61 patients treated with infra-diaphragmatic RT, 5-year RFS = 77.9%, and 2/19 treated with additional supra-diaphragmatic RT, 5-year RFS = 89.5% (P = 0.277). Eleven out of 80 patients have died, 5-year OS = 94.7%. For stage IIA, 1/14 patients treated with chemotherapy and RT have relapsed, 5-year RFS = 92.3%, compared with 5/34 treated with infra-diaphragmatic RT alone 5-year, RFS = 84.9% (P = 0.527). For stage IIB, 1/19 patients relapsed (at 69 months) following chemotherapy and RT (5-year RFS = 100%), whereas 8/27 relapsed following infra-diaphragmatic RT alone, 5-year RFS = 69.4% (P = 0.0595).

CONCLUSION

Infradiaphragmatic RT alone cures the majority of patients with stage II seminoma, but the relapse rate remains high particularly for patients with stage IIB disease. As compared with historical controls, carboplatin with RT appears to reduce the relapse rate in stage II seminoma with minimal additional toxicity and the results approach statistical significance for stage IIB patients. Confirmation would require a phase III randomized comparison.

The effect of radiotherapy treatment changes on sites of relapse in stage I testicular seminoma

AIM

To evaluate relapse patterns in stage I testicular seminoma related to changes in radiotherapy practice.

METHOD

Four hundred and six patients with stage I testicular seminoma were treated with adjuvant radiotherapy following orchidectomy: 338 patients received para-aortic radiotherapy only and 68 patients with added risk factors had radiotherapy extended to include the pelvis. Computed tomograms of relapsed patients were reviewed and sites of relapse were documented with correlation to the radiotherapy field.

RESULTS

Thirteen relapses were identified; 10 occurring in the para-aortic radiotherapy group (3.0% relapse rate) and three in the extended radiotherapy field group (4.4% relapse rate). Sites of relapse were; five pelvis, three mediastinum, one lung, one scapula, one scrotum, while one patient had multiple relapse sites including the pelvis and one had a tumour marker relapse with no site identified. All the pelvic relapses occurred in the para-aortic radiotherapy group.

CONCLUSION

Pelvic relapse only occurred when radiotherapy had been confined to the para-aortic region. Since para-aortic radiotherapy achieves equivalent outcome to wider field radiotherapy with reduced toxicity, it is likely to become standard practice in stage I seminoma and pelvic relapses will therefore increase in frequency. It is therefore important to include pelvic imaging when relapse is suspected.

[Primitive seminoma of the mediastinum: a case report]

In this study, the case has been reported of a 36-year old male who was treated at the Ibn Rochd Oncology Center in Casablanca for a primary mediastinal seminoma revealed by a symptomatology including cough, dyspnea, laterocervical swelling, rachidial pain and gait disorder. The preliminary investigation showed significant mediastinal enlargement with a right pleuritis and vertebral metastases; tumor markers were normal. The diagnosis of seminoma was confirmed by pathological and immunohistochemical analysis of the cervical adenopathy. Disease management consisted of BEP/cisplatin type chemotherapy and lumbar, mediastinal, and supraclavicular radiotherapy. The response after four courses of combined chemo-/radiotherapy was estimated at 25%, but the patient died from respiratory failure five months after the initiation of treatment.

Malignant peritoneal mesothelioma associated with deep vein thrombosis following radiotherapy for seminoma of the testis

A 52-year-old man developed malignant peritoneal mesothelioma 17 years after radiotherapy for seminoma of the testis. Although asbestos exposure is considered to be the major risk factor for the development of malignant mesothelioma, prior therapeutic radiation has also been postulated as a causative factor. The unexplained appearance of ascites or pleural effusion within a previously irradiated area should be considered suggestive of malignant mesothelioma in any long-term survivor of cancer. In addition, the patient suffered a deep vein thrombosis four years before the diagnosis of mesothelioma. Deep vein thrombosis is a common complication of malignant disease, and is often the first clue to occult malignancy.

Minisatellite mutation frequency in human sperm following radiotherapy

Screening pedigrees for inherited minisatellite length changes provides an efficient means of monitoring repeat DNA instability but has given rise to apparently contradictory results regarding the effects of radiation on the human germline. To explore this further in individuals with known radiation doses and to potentially gain information on the timing of mutation induction, we have used an extremely sensitive single molecule approach to quantify the frequencies of mutation at the hypervariable minisatellites B6.7 and CEB1 in the sperm of three seminoma patients following hemipelvic radiotherapy. Scattered radiation doses to the testicles were monitored and pre-treatment sperm DNA was compared with sperm derived from irradiated pre-meiotic, meiotic and post-meiotic cells. We show no evidence for mutation induction in any of the patients and discuss this finding in the context of previous population studies using minisatellites as reporter systems, one of which provided evidence for radiation-induced germline mutation.

Chromosomal changes in somatic cells in seminoma patients after treatment with ionizing radiation or cytostatics

Seminomas are sensitive to both ionizing radiation and cytostatic drugs. The study's objective was to find out the effects of cytostatics or ionizing radiation by comparing the results of genome testing before treatment and immediately afterwards. Repeat cytogenetic testing six months after completion of treatment was used to find out changes resulting from reparatory processes after various types of treatment and the degree of elimination of defective lymphocytes from circulation. Three cytogenetic tests were used in our study to find out structural changes in chromosomes (percentage of aberrations), sister chromatid exchanges (SCE) and the number of micronuclei in binuclear lymphocytes (MN). In patients treated with ionizing radiation, strong inhibition of the mitotic activity of lymphocytes occurred after irradiation of para-aortal and ipsilateral inguinal lymph nodes. However, it is difficult to make a connection between the mitotic activity of lymphocytes and their total number, which was found to be within a normal range throughout the study. There is, therefore, another possibility, i.e. that this process actually involves impairment of intracellular enzymes and blockage of the synthesis of macromolecules in lymphocytes which have suffered a large degree of genome damage. Six months after a completed course of irradiation, mitotic activity was found to be mostly normal; however, there was still a very high percentage of aberrations compared with group II (patients treated with a cytostatic, paraplatin) or with respect to the control group, in which the average percentage of aberrations was 1.42 (excluding dicentrics and rings, which are found in all irradiated patients). From the cytological-mutagenetic point of view, chemotherapy proved to be less aggressive to patients. The results of recovery were visible earlier and the elimination of damaged cells was quicker.

[Radiotherapy for the treatment of testicular seminomas]

OBJECTIVE

Conventional treatment of testicular seminoma has been orchiectomy followed by adjuvant lymph node irradiation. Over the last 10 years the role of postoperative elective radiotherapy has been questioned. This paper reviews the role of radiotherapy in the treatment of seminoma of the testis.

METHODS

The literature is reviewed with special reference to the results achieved in the treatment of testicular seminoma with and without radiotherapy. The advantages and disadvantages of postoperative radiotherapy, the techniques and dose administered are discussed.

RESULTS/CONCLUSIONS

The results obtained with radiotherapy postorchidectomy in stage I seminoma of the testis are excellent, with a disease free survival of 95%-100%. The use of more limited fields of irradiation and lower dose has reduced the radiation-induced toxicity. Currently, many centers have opted for clinical surveillance after orchiectomy. Their experience have permitted identification of the risk factors and there have been attempts to identify the group of patients that benefit from adjuvant therapy. The low incidence of stage II tumors has not permitted performing randomized studies to determine the benefits of adjuvant therapy and its comparison with chemotherapy. Consolidation radiotherapy for bulky stage II and stage III and IV tumors continues to be a controversy, although its potential value in carefully selected patients is recognized.

Soluble levels of CD-95, CD 95-L and various cytokines after exposing human leukocytes to ionizing radiation

BACKGROUND

Local radiotherapy induces systemic effects and influences the immune system. Some of these effects can hardly be explained by direct cellular reactions, but might be triggered by humoral factors.

MATERIALS AND METHODS

In seminoma patients we measured the influence of radiotherapy on various lymphocyte subsets by FACS-analysis. We analysed the release of cytokines, CD95 (Apo-1/Fas) and CD 95-L (Fas-Ligand) of human blood cells after exposure to ionizing radiation in vitro and in vivo by ELISA-technique.

RESULTS

Although radiation leads to a differential and sustained reduction of all lymphocytes subsets in vivo no increase of cytokine levels, or of levels of CD95 or CD 95-L could be detected by ELISA in vivo or in vitro. On the contrary mitogen-induced cytokine production in vitro was inhibited by radiation.

CONCLUSIONS

Local radiation induced a significant systemic decrease of all lymphocyte subsets, but neither a systemic release of cell death mediators like CD95 or various cytokines, nor a release in the extracellular space in vitro were detectable.

Prognosis of primary testicular seminoma: a report on 57 new cases

Most urologists perform adjuvant radiation therapy for stage 1 (TxN0M0) testicular seminoma after orchiectomy, although the majority of patients with clinical stage 1 seminoma do not have occult metastases and therefore do not require elective nodal irradiation. However, there are currently no clinical or histological parameters that can be used to distinguish patients who need radiation therapy from those who do not. We reported previously that estimates of volume-weighted mean nuclear volume (MNV) were a better predictor of the prognosis of prostate cancer and renal cell carcinoma than subjective histological grading. Here, we examined the usefulness of estimation of MNV for predicting the prognosis of primary testicular seminoma. A retrospective study of 57 patients with testicular seminoma diagnosed between April 1981 and March 1997 at Kobe City General Hospital was performed. Unbiased estimates of MNV data were compared for prognostic value with the level of beta-human chorionic gonadotropin (beta-HCG), alpha-fetoprotein (AFP), alkaline phosphatase (ALP), and lactate dehydrogenase (LDH). Fifty patients were stage 1 (TxNoMo), and 7 patients were stage 2 (TxN1-2M0). All patients received orchiectomy, followed by radiation therapy. Estimates of MNV of stage 2 patients were significantly larger than that of stage 1 patients (P = 0.0142). Although the LDH level was also significantly higher in stage 2 (P = 0.001), there were no significant differences between stages 1 and 2 with respect to beta-HCG (P = 0.997), ALP (P = 0.226), and AFP (P = 0.467). Multivariate logistic regression analysis revealed that the estimate of MNV was the only variable predicting lymph node metastasis (P = 0.0315). In stage 1 patients, only the estimate of MNV was significantly correlated with progression-free survival (P = 0.0118). These findings indicate that the estimate of MNV may be an important prognostic indicator for testicular seminoma. Estimates of MNV may also be useful for excluding patients from surveillance protocols.

Postirradiation aortic sarcoma demonstrated by magnetic resonance angiography

This is the first ever reported case of a radiation-induced aortic sarcoma. This patient had symptoms and signs initially interpreted as a pulmonary embolus. The extent of the disease was demonstrated with magnetic resonance imaging and magnetic resonance angiography, in particular, allowing rapid surgical intervention.

Second malignancies following pure seminoma

PURPOSE

Second malignancies in patients with pure testicular seminoma were studied in order to look for adverse late effects of treatment and to study the significance of second malignancies during follow-up.

PATIENTS, METHODS

In a multicentric investigation, 839 consecutive patients with pure testicular seminoma were observed for a median follow-up of 3.9 years. Thirty-seven patients had been excluded from the study because they already had had either a contralateral testicular germ cell tumor or another malignancy. 758 patients received radiotherapy, 76 underwent chemotherapy, 5 had surveillance only. The expected rate of second cancers was calculated according to the data of the cancer registry of Saarland, Germany.

RESULTS

Twenty-two second cancers (13 contralateral testicular tumors, 9 extratesticular malignancies) were recorded. The overall risk of having a second cancer was RR = 4.8 (95% CI 3. 0-7.3). The risk of having a subsequent testicular tumor is RR = 44. 8 (95% Cl 23.9-76.7). 1.1% of the patients developed a nontesticular second tumor. The risk of having a nontesticular second cancer is RR = 2.1 (95% CI 1.0-4.0). A significantly increased risk was observed for renal cell cancer as well (RR = 12.5; 95% Cl: 1.5-45.1). Increased RR without reaching statistical significance were found for rectal cancer (RR = 5.0; 95% Cl: 0.1-27.9) and non-Hodgkin lymphoma (RR = 6.7; 95% CI 0.2-37.1). None of the second cancers were directly located within the radiation field; 5 neoplasms arose at the border of the radiation field.

CONCLUSIONS

This study confirmed the increased risk of having a second testicular germ cell cancer. There is also a small but definitely increased overall risk of having a nontesticular second cancer. Treatment-unrelated factors - possibly genetic predisposition - must be considered for a substantial number of these second tumors, since in the present study the follow-up was rather short and most of the second cancers were located outside of the radiation fields. In particular, the association of renal cancer with testicular cancer appears to be a more than chance occurrence. Second cancer is a real hazard following treatment of testicular cancers and should always be considered during follow-up.

[Value of radiotherapy in interdisciplinary management of testicular germ cell tumors]

Radiotherapy unequivocally has to be regarded as standard therapy in stage I and IIA/B testicular seminoma. Using low dose abdominal irradiation tumour control rates of 95-98% in stage I disease and 80-95% in stage IIA/B can be achieved. Disease specific survival reaches 100%. Likewise, radiotherapy is treatment of first choice in case of testicular intraepithelial neoplasia (TIN) in a solitary testis or in case of a double-sided TIN yielding safe eradication of the in-situ carcinoma of the testis. Objectives of further clinical research in radiotherapy of testicular malignancies aim at reduction of treatment intensity in order to minimize acute and late side effects of irradiation without compromising tumour control rates.

Categorizing a prognostic variable: review of methods, code for easy implementation and applications to decision-making about cancer treatments

Categorizing prognostic variables is essential for their use in clinical decision-making. Often a single cutpoint that stratifies patients into high-risk and low-risk categories is sought. These categories may be used for making treatment recommendations, determining study eligibility, or to control for varying patient prognoses in the design of a clinical trial. Methods used to categorize variables include: biological determination (most desirable but often unavailable); arbitrary selection of a cutpoint at the median value; graphical examination of the data for a threshold effect; and exploration of all observed values for the one which best separates the risk groups according to a chi-squared test. The last method, called the minimum p-value approach, involves multiple testing which inflates the type I error rates. Several methods for adjusting the inflated p-values have been proposed but remain infrequently used. Exploratory methods for categorization and the minimum p-value approach with its various p-value corrections are reviewed, and code for their easy implementation is provided. The combined use of these methods is recommended, and demonstrated in the context of two cancer-related examples which highlight a variety of the issues involved in the categorization of prognostic variables.

Radiotherapy for stages I and IIA/B testicular seminoma

Radiotherapy is generally accepted as a standard treatment for early-stage testicular seminoma. Relapse rates of 2% to 5% in clinical stage I and 10% to 20% in stage IIA/B (according to the Royal Marsden classification) can be achieved. Disease-specific survival reaches 100%. With such excellent cure rates, treatment-related side effects gain particular importance. Therefore, a prospective multicenter trial was initiated for radiotherapy of testicular seminoma with limited treatment portals and low total doses of irradiation. In clinical stage I, 483 patients were treated with 26 Gy to the para-aortic region only. In stage IIA, 42 patients and, in stage IIB, 18 patients received irradiation to the para-aortic and high iliac lymph nodes with 30 and 36 Gy, respectively. With a median time to follow-up of 55 months for stage I and 55.5 months for stage IIA/B, there were 18 (3.7%) and 4 (6.7%) cases of relapse in both treatment groups. Disease-specific survival was 99.6% in stage I and 100% in stage IIA/B. Acute toxicity was dominated by moderate gastro-intestinal side effects. No major late toxicity has been observed to date. Limited volume pure para-aortic treatment for stage I and para-aortic/high iliac irradiation for stage IIA/B with 26, 30 and 36 Gy, respectively, yields excellent cure rates with only moderate acute toxicity and is therefore recommended as standard treatment.