Seminoma at Roswell Park, 1970 to 1979. An analysis of treatment failures

Stage I testicular seminoma: management and controversies

Seminomas constitute more than half of testicular germ-cell tumours and 70-80% of patients with seminoma present with clinical stage I disease. Post-orchiectomy, management options include irradiation, surveillance or chemotherapy. Adjuvant irradiation to the infradiaphragmatic lymph nodes is the standard of care with relapse rates of 3-4%. Long-term follow-up data have shown association with late complications (cardiotoxicity, second malignancy, fertility impairment). Surveillance is an attractive alternative but relapse rates are higher ranging between 15 and 20%. Single agent carboplatin chemotherapy has demonstrated survival data equivalent to radiotherapy but long-term relapse and toxicity data are yet to be confirmed. Routine follow-up after irradiation and the role of risk stratification also remain unclear. Highly curative rates can be attained by all three modalities. Standard treatment with radiotherapy is challenged by surveillance and chemotherapy. Toxicity issues and patients' preferences are considered when management decisions are made.

Primary testicular seminoma in a patient with a history of extragonadal non-seminomatous germ cell carcinoma

Extragonadal germ cell carcinoma represents between 3% and 5% of all germ cell carcinomas. A metachronous primary germ cell carcinoma is exceedingly rare in these patients. We report the eighth case, which occurred in a 29-year-old man who presented with testicular seminoma 7 years after his initial presentation with extragonadal non-seminomatous germ cell carcinoma. The seven other patients also presented with extragonadal non-seminomatous germ cell carcinoma, followed subsequently by testicular seminoma in 6 patients and non-seminomatous germ cell carcinoma in the seventh. The mean time to presentation was 8 years. Although rare, this case emphasizes the need for long-term surveillance, including testicular evaluation of patients with a history of extragonadal germ cell carcinoma.

Testicular seminoma: a failure analysis and literature review

PURPOSE

A retrospective analysis of 74 patients with pure seminoma, treated at the University of Florida between 1964 and 1989, was undertaken.

METHODS AND MATERIALS

All patients received megavoltage irradiation, with chemotherapy reserved for salvage. At 10 years, the probability of relapse-free survival was 91% for Stage I, 93% for Stage IIA, 83% for Stage IIB, and 75% for Stage III patients.

RESULTS

There were seven recurrences, none of which occurred in irradiated areas. Only two of seven patients (29%) with recurrence were salvaged.

CONCLUSION

A literature review revealed an increasing rate of mediastinal or supraclavicular recurrence, correlating with the size of the subdiaphragmatic disease, in Stage II patients who did not receive elective mediastinal irradiation. Recommendations are made regarding the role of elective mediastinal irradiation for Stage II disease. We conclude that patients with Stage I or II seminoma can have high cure rates when treated with radiotherapy alone. Patients with Stage III seminoma should be treated initially with cisplatin-based chemotherapy.

Radiation therapy of early (stages I and II-A) seminoma of testis after initial orchiectomy

With initial orchiectomy and radiation therapy, the prognosis of the patients with early (Stages I and II-A) testicular seminoma is nearing almost 100 percent. Thirty-two patients with Stage I and 13 patients with Stage II-A seminoma of the testis were treated with initial orchiectomy. This was followed by estimation biochemical markers and radiologic investigations. All the patients with Stage I disease received radiotherapy to the ipsilateral pelvic and para-aortic nodes. The patients with Stage II-A disease also received radiation therapy to the supradiaphragmatic regions. The disease-free survival in both groups of patients was found to be 100 percent.

Radiation therapy of seminoma: 17-year experience at the Joint Center for Radiation Therapy

One hundred and sixteen patients with stage I and II primary testicular seminoma were treated at the Joint Center for Radiation Therapy (JCRT) between 1968 and 1984. Complete follow-up is available for 114 patients (98%) with a median follow-up time of 6 years. Actuarial relapse-free survival (RFS) and survival for the entire group at 10 years were 94 and 86%, respectively, with 27 patients still at risk beyond 10 years. Actuarial RFS and survival at 10 years by stage were 97 and 92% for stage I, 93 and 81% for stage IIa, 100 and 100% for stage IIb, but only 75 and 51% for stage IIc. The difference in actuarial survival between stage IIc patients and stage I, IIa and IIb patients was significant (p less than 0.01). These results indicate that radiation therapy is excellent treatment for stage I and II seminomas as long as the largest mass of disease is not greater than 5 cm (stage IIc). Patients with stage IIc seminoma are now treated with cisplatin-containing combination chemotherapy followed by radiation therapy to areas of bulk disease. Although the majority of patients with stage II disease in this series received mediastinal irradiation, this is no longer recommended at the JCRT.

Prognosis of testicular tumour since the introduction of complex therapy

Change of approach in dealing with testicular carcinoma has made it necessary to set up a central organization covering a larger geographic area in Hungary where 242 patients had been treated since 1980. Progress in the development of therapy-oriented methods cleared the way for reliable and accurate stage determination. Data analysis seems to indicate that correct therapeutic principles combined with plenty of surgical, radiological and chemotherapeutic experience may contribute a lot to improving the pathologic prospects. The mortality rates for the pure seminoma group and for the non-seminomatous plus mixed-cell group of patients were 7.5% and 26.5%, respectively. The results promise additional chances--even with increasing morbidity--to reduce the mortality rate and the incidence of complications.

Mitosis counting in seminoma: an exercise of questionable significance

Two pathologists reviewed and classified 45 cases of testicular seminoma, evaluating each case for multiple histologic variables, including mitotic rate. In addition to recording the mitotic count for each of thirty 0.1963-mm2 high-power fields, the investigators recorded the distribution of mitotic counts in many non-spermatocytic seminomas. Statistically significant differences for mitotic rate in the nonspermatocytic tumors were noted between the observers; one observer found a mean mitotic rate of 1.815/high-power field for 43 such tumors, whereas the other noted a mean mitotic rate of 1.388/high-power field (p = 0.001). These differences led to disagreement on the classification of 3 tumors. Of the 4 cases considered to be high-mitotic-rate seminomas by one or both observers, all patients had presented with stage I disease. Three of the patients were followed up for 23, 55, and 56 months, and all were free of disease; the fourth was lost to follow-up. The patient with the highest mitotic rate was free of disease at 55 months of follow-up. On the basis of our findings we question the value of the designation high-mitotic-rate seminoma. Analysis of the distribution of mitotic counts within the tumors revealed them to be Poisson distributed. With these data and other empirically derived data, it was possible to estimate the probability of misclassification of seminoma based on mitotic rate, the diagnostic mitotic rate threshold, and the number of fields counted for mitoses. Similar analysis might be valuable for other tumors, particularly those of smooth muscle origin, in which mitotic rate is of diagnostic or prognostic value.

Cardiac disease after mediastinal irradiation for seminoma

One hundred twenty-four patients with seminoma (119 primary testis, five primary extragonadal) were treated between 1968 and 1984 at the Joint Center for Radiation Therapy. Fifty-seven of the 124 patients were treated with irradiation to the mediastinum as well as to an infradiaphragmatic field. One patient received supradiaphragmatic radiotherapy only. The remaining patients had radiation treatment limited to the infradiaphragmatic field only. Median dose to the mediastinum among the 58 patients was 2400 cGy. Four patients developed heart disease (one fatal myocardial infarction, one uncomplicated myocardial infarction, one constrictive pericarditis resulting in permanent total body anasarca, and one patient requiring aortic valve replacement and coronary artery bypass grafting for atherosclerotic disease) and two died suddenly. The two sudden deaths were thought to be cardiac in origin by the patient's primary physicians. All six complications occurred in the group that received mediastinal irradiation. No cardiac disease was manifested in the group not treated with mediastinal irradiation. This difference in the incidence of cardiac disease between the two groups is statistically significant (two sided, P = 0.019). Neither group had a statistically significant difference in cardiac disease rate from a normal population (Framingham study), although the ratio of observed to expected cardiac disease was 1.97 in the group receiving mediastinal radiation. Further experience from this and other institutions is necessary to confirm this finding.

The role of radiation in stage II testicular seminoma

This is a retrospective review of 62 patients with Stage II testicular seminoma treated either by initial radiation therapy (48 patients) or by platinum-containing chemotherapy (14 patients). For all 62 cases, disease-free survival from 2 to 20 years was 86%, uncorrected survival was 86% at 5 years and 83% at 15 years, and survival corrected for deaths from intercurrent disease was 90% from 2 to 20 years. There were no significant differences in outcome between the two treatment groups. An analysis of potential prognostic factors for the initial radiation therapy group and for the whole group revealed that age, site of primary, cryptorchidism, ipsilateral hernia repair, contralateral testicular atrophy, scrotal incision, elevated postorchiectomy beta-human chorionic gonadotropin level, epididymal invasion, spermatic cord involvement, and vascular invasion in the primary were not significant. However, bulk of abdominal disease was a prognostic factor. Patients with small-volume abdominal disease defined as nonpalpable disease or as a mass less than 10 cm in largest diameter accounted for two-thirds of the series and had a disease-free survival of 95% when treated with initial radiation therapy. Patients with bulky disease, either palpable or greater than or equal to 10 cm in diameter, had a disease-free survival of 64%. The relative roles of the two treatments in bulky abdominal disease are discussed, but in the absence of a prospective study it is not possible to definitively answer the question of which modality is best in this setting. In our series, the patients treated with platinum-containing chemotherapy fared as well as the primarily irradiated patients, but 71% of the former had palpable masses, compared with 22% of the latter. The chemotherapy-treated patients who relapsed were treated with radiation therapy for salvage, leading to a 100% survival corrected for intercurrent death. We have therefore elected to continue the policy of initial radiation therapy for small-volume (less than 10 cm) disease and platinum-containing chemotherapy for bulky disease (greater than or equal to 10 cm), with irradiation used for residual masses.

Primary or secondary extragonadal germ cell tumors?

We reviewed 16 patients treated for primary extragonadal germ cell tumors whose testes were initially negative for cancer at palpation. Residues compatible with an occult testicular primary, overlooked at the pretreatment examination, were found in 10 of 12 patients with retroperitoneal germ cell tumors, whereas the testes in all 4 patients with mediastinal germ cell tumors showed no pathological signs. Therefore, we conclude that mere palpation to exclude a testicular primary is not sufficient and the testes of patients with so-called extragonadal germ cell tumors should be examined by all available means, at least by high frequency ultrasound. Orchiectomy is advisable if a focal lesion is found.

Testicular seminoma: analysis of treatment results and failures

Pure testicular seminoma has historically been treated primarily with radiation therapy, and excellent results have been achieved. Recently, several aspects of the treatment of seminoma have been questioned; namely, the value of mediastinal irradiation in Stage II disease, and whether a dose response curve existed for seminoma. Because these questions have remained unanswered, we undertook a retrospective review of all patients with pure testicular seminoma treated in the Department of Radiation Oncology at Indiana University Medical Center. From 1961-1981, 54 patients with pure testicular seminoma were given megavoltage irradiation with curative intent. Thirty three patients were Stage I, with tumor confined to the testicle with no evidence of nodal spread. Fifteen patients were Stage IIA, with metastases less than 5 cm in size in the retroperitoneal nodes. Four patients were Stage IIB, with metastases greater than 5 cm in size in the retroperitoneal nodes. One patient was Stage III, with supradiaphragmatic metastases confined to the mediastinum and supraclavicular area. One patient was Stage IV, with evidence of extralymphatic metastases. The crude survival rate (corrected for intercurrent death, except for treatment toxicity) for the entire group was 87%. For Stage I, it was 91%, Stage IIA-80%, Stage IIB-75%, Stage III-100%, and Stage IV-0%. All patients had a minimum follow-up of 2 years with a range of 2 to 21 years. Evaluation of the Stage I patients reveals that 2500 rad in 3 weeks appears to be adequate in controlling microscopic disease, as there were no in-field recurrences when this dose was given. Those patients with Stage IIA and IIB disease who received greater than or equal to 3500 rad to macroscopic disease had 100% (7/7) survival and local control, while those receiving less than or equal to 3000 rad had a 66.6% (8/12) survival with three of four demonstrating persistent or recurrent abdominal disease. Thus, we feel that macroscopic disease requires 3500 rad to 4000 rad for control. All Stage II and III patients had planned mediastinal irradiation. No patients who received mediastinal irradiation recurred in the mediastinum. Whether this is because of our treatments or the natural disease process remains unanswered. Overall, we were able to salvage 12.5% (1/8) of our recurrences, while 37.5% (3/8) died from toxicity of their salvage therapy.(ABSTRACT TRUNCATED AT 400 WORDS)

Seminoma of the testis with bone involvement: a report of three cases

Three cases of seminoma metastasising to bone and treated with radiotherapy are reported. All three patients are alive and disease-free between 6 and 16 years after diagnosis. The value of radiotherapy in this situation should be borne in mind.

Controversies in the management of testicular seminoma

The 5-year cause specific actuarial survival rate for 178 patients treated for testicular seminoma at The Princess Margaret Hospital 1977 to 1981 is 97%. Controversies exist over how to optimally use and integrate chemotherapy (CT) and radiation therapy (RT) to minimize morbidity and achieve these high cure rates. These are as follows: "surveillance only" for Stage I, the necessity of prophylactic mediastinal RT (PMI) for Stage IIA, initial RT versus CT for Stage IIB, optimal therapy for Stages III and IV, and the significance of elevated serum tumour markers. In Stage I, relapse after abdominopelvic RT (2500 cGy in 20 fractions) occurred in 2 of 150 patients (1.3%). Without routine RT relapse rates are unknown. Only 1/370 Stage IIA patients in the literature treated with infradiaphragmatic RT without PMI developed uncontrolled mediastinal disease. Prophylactic mediastinal RT confers a possible survival benefit of only 0.2% and cannot be recommended. Stage IIB is rare (only 4% of 178 patients). Initial CT produces complete responses in approximately 80% of patients, but its curative potential is unknown therefore consolidation RT or surgery is often given. Initial subdiaphragmatic RT followed by CT for relapse cures at least 85% of patients (5/5 marker negative) and spares 50% of unnecessary CT. Sequential therapy minimizes potential treatment morbidity without compromising cure. Initial CT is recommended for Stages III and IV. The literature survival after RT is only 36% (136/375). The role of consolidation RT is unknown. Optimal management of seminoma implies integration of RT and CT to decrease morbidity and still maintain high cure rates.

Testicular carcinoma. A curable malignancy

The progress in the management of testicular germ cell tumours is reviewed. A marked improvement of the treatment results has been obtained in non-seminomas, especially by the use of cis-platinum based chemotherapy. At present long term survival can be expected in 85 per cent of all non-seminomas and in 95 per cent of all seminomas after adequate treatment. The natural history of the disease, symptomatology, diagnostic procedures, staging and different treatment modalities, as surgery, radiation therapy, chemotherapy and their combination, are discussed.