Treatment results and acute and late toxicity of radiation therapy for testicular seminoma

Postsurgical Policy in Stage I Testicular Seminoma: Cost and Benefit of Prophylactic Irradiation in a Long-term Experience

The definitive cure rate for clinical stage I testicular seminoma is very close to 100%, and prophylactic irradiation of the regional lymph nodes is associated with a low morbidity. Nevertheless, in recent years a “wait-and-see” policy has been proposed by some researchers. We analysed the cost/benefit ratio of radiotherapy (RT) by review of the case histories of 299 patients treated at the Department of Radiotherapy of the Istituto Nazionale per lo Studio e la Cura dei Tumori in Milan from January 1968 to December 1989. The 5-year overall survival was 99% (97.5% at 10 years), while the 10-year disease-free survival was 96%. The recurrence rate was 2.3%, but no patient relapsed in the irradiated areas. Acute toxicity was very moderate with only 4 (1.3%) serious radiation sequelae occurring 6 to 27 years after treatment. However, 9 second malignancies (3%) were observed. Lastly, we have calculated the costs for our National Health Service comparing surveillance policy and prophylactic irradiation.

Stage I Seminoma of the Testis: Long Term Results and Toxicity with Adjuvant Radiotherapy

Aims and background

Pure testicular seminoma has historically been treated with post-orchidectomy radiation therapy with excellent results. Recently, several aspects of the treatment of stage I seminoma have been questioned. We assessed long-term results and toxicity of patients with pure testicular seminoma treated at the Department of Radiation Oncology of S. Chiara Hospital, Trento.

Methods

From 1953 to 1987, 102 patients with stage I pure testicular seminoma were given megavoltage irradiation with curative intent. All patients had a minimum follow-up of 3 years (maximum 37 years, median 13 years). They received a mean para-aortic/pelvic dose of 33.07 Gy (range 23.70-45.20 Gy) with different doses and fields reflecting the change in techniques over a long period of time.

Results

The cause-specific actuarial survival at 30 years was 99% and crude survival 67%. One patient had an out-field relapse (inguinal) after a few months and was cured with radiotherapy and chemotherapy. Another patient relapsed with widespared metastases and died after 1 year of progressive disease. Early toxycity was mild and the treatment was well tolerated. Late side effects were reported in 8/102 patients.

Conclusion

In our series adjuvant radiation therapy resulted in cure rates corresponding to those reported in the literature. The 30-year actuarial survival of 99% was extremely good and the toxicity of the treatment was mild. Post-orchidectomy radiation to the para-aortic and ipsilateral pelvic nodes is a safe and effective method of preventing recurrences and is currently to be considered the treatment of choice in stage I testicular seminoma.

Management options for stage I seminoma

Stage I seminoma is the most common clinical scenario among patients with testicular cancer. Following orchiectomy, various treatment alternatives (adjuvant radiotherapy, surveillance, chemotherapy) can be offered that yield similar efficacy results and definitive cure is the rule. However, there is no consensus on the optimal management choice and considerable debate has been raised in recent years. The pros and the cons associated with each therapy, as well as their long-term outcomes are discussed in this review. Overall burden of treatment needed, therapy-related morbidity, economic costs, quality of life issues and patient preferences should all be considered. Refinement in the knowledge of predictive factors for relapse and mounting experience with both surveillance and adjuvant chemotherapy have led to consideration of risk-adapted treatment strategies as an alternative to standard radiotherapy. Although this model needs to be improved and validated, active close surveillance for low-risk patients and adjuvant therapy for those uncompliant or at higher risk of relapse seem to be acceptable options for patients with stage I seminoma.

Management of stage I seminomatous testicular cancer: a systematic review

The treatment options available for the management of stage I seminoma consist of either a surveillance strategy or adjuvant therapy after orchidectomy. A systematic review was undertaken to identify the optimal management strategy. The MEDLINE and EMBASE databases, in addition to the American Society of Clinical Oncology Meeting Proceedings, were searched for the period 1981 to May 2007. Studies were eligible for inclusion if they discussed at least one of survival, recurrence, second malignancy, cardiac toxicity, or quality of life for patients with stage I seminoma. A search update was carried out in June 2009. Fifty-four reports satisfied the eligibility criteria, including seven clinical practice guidelines, one systematic review, three randomised controlled trials focused on treatment options, 26 non-randomised studies of treatment options, and 15 non-randomised long-term toxicity studies. The existing data suggest that virtually all patients with stage I testicular seminoma are cured regardless of the post-orchidectomy management. The 5-year survival reported in all the studies identified in this systematic review was over 95%, regardless of the management strategy, including surveillance alone with no adjuvant therapy. In conclusion, to date, the optimal management of stage I seminoma remains to be defined. Surveillance seems to be the preferable option, as this strategy minimises the toxicity that might be associated with adjuvant treatment, while preserving high long-term cure rates. The currently available evidence should be presented to patients in order to select the most appropriate option for the individual.

Transjugular intrahepatic portosystemic shunt for the treatment of portal hypertension secondary to non-cirrhotic perisinusoidal hepatic fibrosis

Non-cirrhotic perisinusoidal hepatic fibrosis is a process of imprecise pathogenesis involving collagenization of the space of Disse. Exposure to chemicals, auto-immunity, thrombophilia and/or infections are suspected primary agents. Here, we present the case of a patient who developed severe portal hypertension with histological features suggesting a non-cirrhotic perisinusoidal hepatic fibrosis. A 52-year-old man was hospitalized for oesophageal variceal haemorrhage. Liver cirrhosis or portal vein thrombosis were absent as attested by laboratory tests, duplex sonography, computed tomography scan and histological examination of a liver biopsy specimen. Presinusoidal portal hypertension was suggested by a normal wedge-free hepatic vein gradient. Only electron microscopy examination of a liver biopsy specimen could disclose perisinusoidal fibrosis. This was most probably secondary to a combined chemotherapy received 4 years earlier for non-Hodgkin large-cell lymphoma. As variceal ligation failed to control oesophageal varices while liver function tests were normal, a transjugular intrahepatic portosystemic shunt (TIPS) was performed. This dramatically improved the signs of portal hypertension. This case illustrates the use of TIPS in the treatment of portal hypertension secondary to non-cirrhotic perisinusoidal fibrosis.

Surveillance for stage I testicular seminoma. a review

There is good evidence that patients with stage I seminoma can be managed equally well after orchidectomy with surveillance and adjuvant retroperitoneal radiation therapy. There is considerable reluctance amongst many physicians to accept surveillance as a management option in stage I seminoma and this is largely based on the excellent results achieved with adjuvant retroperiteonal radiation for many years. However, patients with stage I seminoma have a long life span and it is possible that the long-term sequelae of radiation treatment could have a negative impact on quality of life and longevity. It is of utmost importance to continue the study of the long-term effects of all current treatment approaches, in particular the risk of induction of second malignancies. However, the psychosocial impact on patients of surveillance and other management strategies must also be assessed. Stage I testicular seminoma is highly curable with currently available management approaches and the current challenge for clinicians is to maintain these excellent results while minimizing toxicity and individualising treatment to the specific social, economic and emotional circumstances of each patient. Surveillance should be one of the management options offered to patients with stage I seminoma.

Is surveillance for stage 1 germ cell tumours of the testis appropriate outside a specialist centre?

OBJECTIVE

To assess the results of treatment for stage 1 germ cell tumours of the testis, outside a specialist centre.

PATIENTS AND METHODS

From May 1984 until March 1996, 123 patients with stage 1 disease were treated at our institution. Sixty patients with seminoma and 31 with teratoma were treated with orchidectomy only and surveillance; 32 patients with stage 1 seminoma elected for orchidectomy and adjuvant radiotherapy. The mean ages were 40, 31 and 35 years, and the median follow-up 52, 47 and 49 months, respectively.

RESULTS

There were no disease- or treatment-related deaths. However, 18 (30%) patients with seminoma treated by orchidectomy only relapsed (median time 8 months, range 3-19); 14 of these responded to radiotherapy, three to radiotherapy and chemotherapy for second relapses outside the irradiated fields, and one to chemotherapy initially, for large-volume relapse. Fifteen (48%) patients with teratoma relapsed (median time 3 months, range 1-12); all responded to 4-6 courses of bleomycin/etoposide/cisplatin chemotherapy. One patient had a second relapse and is currently disease-free 3 years after surgical excision of a lung metastasis.

CONCLUSION

These results show that stage 1 testis tumours can be managed successfully in a district general hospital. However, we are concerned about the high relapse rates and are now attempting to identify patients at greater risk of recurrence, to consider adjuvant therapy in this group.

The management of stage I testis cancer

For clinical stage I seminoma, conventional management consists of adjuvant RT after orchiectomy. Only 5% of patients relapse. The majority can be salvaged by chemotherapy. The overall survival of 98% is excellent. Seminoma is radiosensitive. A lower dose of RT is required than for NSGCT. Standard therapy presently is 30 Gy in 3 weeks, as suggested by the MRC study. RT is generally well tolerated. There have been recent concerns about second malignancies after 10 to 15 years. Surveillance studies have shown that 18% of patients relapse, the majority in para-aortic lymph nodes. About 15% require salvage RT and 5% salvage chemotherapy. Second relapses are seen in patients treated with RT at first relapse, and occur outside of the radiation field. The main advantage of surveillance is that 80% of patients can be spared slightly toxic overtreatment. The main disadvantage is the need for long-term follow-up, which is expensive and stressful to the patient. Good patient compliance, mandatory to an observation policy, is often difficult on a long-term basis. Seminoma is clearly responsive to chemotherapy. Adjuvant carboplatin in clinical stage I has only been evaluated in two studies. Because reliable prognostic factors have not been established, a high-risk group cannot be identified, and chemotherapy must be given to all patients. Whether or not one cycle of chemotherapy is sufficient requires further confirmation, particularly in view of the results with carboplatin as compared with cisplatin in patients with advanced NSGCT. Results of the randomized MRC trial comparing RT with carboplatin are of interest.

Surveillance for stage I testicular seminoma. Is it a good option?

Postorchidectomy treatment options in patients with stage I seminoma include surveillance (reserving treatment for patients who relapse), adjuvant radiation therapy (RT), and adjuvant chemotherapy. Adjuvant retroperitoneal RT remains the treatment of choice in most centers; however, the success of surveillance in stage I nonseminomatous germ cell testis tumors, the establishment of curative chemotherapy for advanced disease, and the improvements in CT have led to re-examination of the standard treatment approach. The available data from the surveillance and adjuvant RT series suggest that almost 100% of patients with stage I testicular seminoma are cured, whichever approach is chosen. This article presents an overview of the available information on all treatment options, the pros and cons of each approach, and indications for where surveillance fits into the armamentarium of clinicians dealing with this disease.

Contribution of cell proliferative activity to malignancy potential in testicular seminoma

Testicular anaplastic seminoma, which has a high mitotic activity, is regarded as more malignant than typical seminoma, although its prognosis is still unclear. To determine whether seminoma with relatively greater malignancy potential can be identified based on the cell proliferative activity, the mitotic rate (MR; mitotic count per high-power field), mitotic index (MI; mitotic count per 1000 cells), Ki-67 labeling index (Ki-67 LI; the percentage of positive cells) and proliferating cell nuclear antigen LI (PCNA LI; the percentage of positive cells) were histologically examined in 44 patients. The MI, Ki-67 LI and PCNA LI in patients with metastatic disease were significantly higher than those in patients without metastatic disease, and the MI in patients with fatal disease was significantly higher than those in patients cured of the disease. However, these distributions of the MI, Ki-67 LI and PCNA LI values overlapped for both pairs of groups. There were no significant differences in the MR. These results suggest that the cell proliferative activity makes a small contribution to the malignancy potential in testicular seminoma, with the activity being not necessarily indicative of metastasis and prognosis.

Long-term evaluation of postorchiectomy radiotherapy for stage II seminoma

PURPOSE

To determine survival, long-term tumor control, and the effects of irradiation for stage II seminoma.

MATERIALS AND METHODS

Forty-five patients with stage II testicular seminoma were treated between 1966 and 1989. There were 31 patients with stage IIA disease and 14 with stage IIB disease. All patients underwent orchiectomy followed by iliac and paraaortic irradiation (median dose: 30 Gy), with 37 patients receiving prophylactic mediastinal and supraclavicular irradiation (median dose: 30 Gy). Follow-up ranged from 6 months to 20.6 years, with a median of 9.4 years.

RESULTS

Uncorrected survival was 98% at 5 years, 84% at 10 years, and 79% at 15 years. Survival corrected for intercurrent disease was 98% at 5, 10, and 15 years. Five patients developed recurrences with four successfully salvaged by chemotherapy and/or irradiation. There were no serious acute toxicities, and no late complications have developed from infradiaphragmatic irradiation. Supradiaphragmatic irradiation was associated with an increased risk of coronary artery disease compared to the age-matched general population.

CONCLUSION

Radiotherapy remains an effective treatment for stage II testicular seminoma, with a 98% adjusted survival rate at 15 years, without serious acute toxicity. Supradiaphragmatic irradiation should not be used in stage IIB patients for whom salvage chemotherapy is an option.

Toxicity in patients with testicular seminoma treated with radiotherapy. Different dose levels and treatment fields

The aim of this study was to evaluate the acute and late effects of irradiation in 56 patients with stage I and II testicular seminomas. A retrospective study of patients' records was performed paying attention to the acute and late toxicity of radiation in relation to treatment fields and radiation doses. Treatment groups were compared using the chi squared-test. Mild to moderate nausea and/or vomiting was seen in 66% of patients and occurred equally independent of the treatment volume or radiation dose. Increased bowel frequency was seen in 59% and was more common when a larger treatment volume was used. Skin reactions increased with increase in treatment volume and dose (p = 0.046). Severe late complications were recorded in two patients (myocardial damage-1/4 at risk, duodenal ulcer-1/56 at risk). These could not be attributed solely to the irradiation as other contributing factors might play a role. Overall the data suggest that the risk of major posttreatment morbidity is minimal for patients with testicular seminoma treated with postoperative radiotherapy.

Low-dose radiotherapy for stage I seminoma: early results

One hundred and one patients with stage I seminoma were irradiated with total doses of 30, 25.5 and 20 Gy to gradually reduced target volumes (paraaortic, pelvic, and inguinal regions to paraaortic only). Low doses and small target volumes resulted in excellent survival and freedom of recurrence but in more frequent nausea.

Testicular seminoma: 20-year experience at the Northern Israel Oncology Center (1968-1988)

Eighty-four patients with testicular seminoma were treated at the Northern Israel Oncology Center during the years 1968-1988. Using the staging classification of Hussey, 69 patients (82%) had Stage I, eight (10%) had Stage IIA, four (5%) had Stage IIB, one (1%) had Stage IIIA, and two (2%) had Stage IIIB disease. Sixty-nine patients (82%) had classic pure seminoma, nine (11%) had anaplastic seminoma and six (7%) had spermatocytic seminoma. Seventy-four patients (88%) underwent high inguinal orchiectomy and ten (12%) had a scrotal approach. Seventy-five patients (85%) were treated with postoperative irradiation. Stage I patients received 26-30 Gy to the paraaortic and ipsilateral pelvic lymph nodes. Stage IIA patients were treated in the same manner with a boost to the involved lymph nodes. With a mean follow-up of 97 months, 65 patients (77%) are alive and well with no evidence of disease, 7 patients (8%) are dead due to disease progression. The 5-, 10-, 15-, and 20-year actuarial survival for all patients was 90%, and for early stage patients 94%. Eight patients (14%) relapsed; 3 of them were salvaged by chemotherapy. Serious side effects of irradiation included lethal respiratory failure due to bleomycin-induced pulmonary fibrosis in one patient, peptic ulcer in three patients, hydronephrosis due to paraureteral fibrosis in one patient and recurrent paralytic ileus in one patient. Eight patients (10%) developed nine second cancers, three of them within the previous radiation field.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of stage I testis seminoma by radiotherapy: long-term results--a 30-year experience

PURPOSE

From 1956 to 1986, we have retrospectively studied 184 patients with a Stage I testis seminoma treated by orchidectomy and radiotherapy at the Institut Gustave Roussy.

METHODS AND MATERIALS

The 184 patients received adjuvant radiotherapy to the para-aortic and ipsilateral iliac nodes. Of the 184 patients, 133 received additional mediastinal and supraclavicular irradiation, 47 received supraclavicular without mediastinum irradiation, 98 patients received additional radiotherapy given to inguino-scrotal area. The mean dose of irradiation is 21 Gy which is the lowest dose published. The actuarial survival rate is, respectively, 96%, 93%, 83% and 77% at 5, 10, 15, and 20 years.

RESULTS

Four patients relapsed, and four died of progressive disease. Four patients presented cardiovascular disease, all of them had mediastinal irradiation, two were heavy smokers. Seventeen second malignancies were observed, six tumors in the contralateral testis. The actuarial risk of developing a second malignancy is 10% at 10 years, 21% at 20 years. The cure rate and relapse rate in our patients is the same as that obtained by higher dosage of irradiation.

CONCLUSION

We conclude that low dose of prophylactic irradiation in lumbo aortic and ipsilateral iliac lymph nodes is active and safe in the treatment of Stage I testis seminoma.

Testicular seminoma stage I: treatment results and long-term follow-up (1968-1988)

Sixty-nine patients with stage I testicular seminoma were referred to the Northern Israel Oncology Center between 1968 and 1987. Sixty-four patients were irradiated postoperatively and five patients had surveillance alone. Complete follow-up was available for all patients, with a median follow-up of 86 months (range 9-239 months). The last follow-up was in December 1988. Actuarial survival was 94% to 5, 10, 15, and 20 years. Six patients relapsed following completion of irradiation. All the recurrences occurred outside the radiation field. Three of the relapsed patients could be salvaged with cisplatinum-based chemotherapy and are alive at 4, 7, and 10 years following second-line treatment. Acute or chronic side effects were mild and manageable. Seven patients developed second primary cancers, two within and six outside the radiation field. While surveillance policy alone in stage I testicular seminoma may be successful in terms of patient outcome, it requires prolonged observation, good compliance of patients, and intensive use of resources. Thus, until proved otherwise, infradiaphragmatic radiotherapy should further remain the optimal routine treatment in seminoma patients with stage I disease.

Post-orchiectomy management in stage I testicular seminoma: elective irradiation or surveillance?

Fifty-six patients with stage I testicular seminoma were treated at this institute between January 1982 and December 1988. Post-orchiectomy elective radiotherapy to ipsilateral iliac-inguinal and para-aortic lymph nodes was delivered in 54 cases. An overall 3 year survival rate of 96% was observed in this series. Four patients (7%) relapsed (one junctional recurrence in iliac node region, two mediastinal/hilar nodes and one skeletal metastasis). Salvage chemotherapy proved successful in two out of three cases with nodal relapse. No dose limiting acute or late radiation related complications were noticed. No definite correlation was found between the patients who relapsed and various known adverse prognostic factors. We recommend elective irradiation of the draining lymph nodes in stage I seminoma, particularly at centres where surveillance is not feasible.

Seminoma of the testis: long-term beneficial and deleterious results of radiation

PURPOSE

The followup of 387 patients in a USA national survey of seminoma treated with radiation in 1973 and 1974 has been extended beyond 15 years to assess the long-term benefits and problems resulting from treatment.

RESULTS

Survival at 15 years is 83% for Stage I, 68% for Stage II; freedom from recurrence at 15 years is 93% for Stage I, 96% for Stage II; NED survival at 15 years is 80% for Stage I, 68% for Stage II; cause specific freedom from cancer death is 98% for Stage I and 97% for Stage II at 15 years. Second malignancy rates were 8% at 15 years, and observed in 14 patients versus 4.2 expected (p < .001). Deaths due to these second cancers were also increased with seven observed versus two expected (p < .01). Non-cancer intercurrent disease death occurred in 23 patients versus 7.5 expected (p < .01). The most frequent cause was cardiac death which appeared in 10 patients versus 4.4 expected (p < .05) and 8 of the 10 patients received mediastinal radiation. Two additional patients died of pulmonary fibrosis after mediastinal radiation. Mediastinal radiation correlated with all intercurrent disease and cardio-pulmonary deaths (p < .05), but not with second malignancies. With the exception of one, all patients experiencing cardiac death after mediastinal irradiation were 40 years or older at the time of treatment, with a range of 32-58 years and a mean interval to death of 9.8 years.

CONCLUSIONS

Recommendations for the future management of seminoma include: reducing the irradiated volume in the treatment of Stage I patients, completely eliminating mediastinal radiation in the treatment of patients with Stage IIA seminoma and treating patients with Stage IIB seminoma with chemotherapy. Radiation dose should not exceed 30 Gy for Stage I or 35 Gy for Stage IIA.

Second cancer in patients treated for testicular seminoma

The exact risk of developing a second primary cancer following radiotherapy for testicular seminoma is not known. At the Northern Israel Oncology Center, between the years 1968-1988, 75 patients with early stage (I,IIA) testicular seminoma were treated by orchiectomy followed by radiation therapy. The overall 10- and 20-year survival probability was 95% and 90%, respectively. Eight patients (11%) developed nine second cancers, with a cumulative rate of one case per 1,000 years of follow-up. The second primary cancers were: two bronchogenic carcinomas, one contralateral seminoma, one thymoma, one papillary carcinoma of the thyroid, one carcinoma of the stomach, one transitional cell carcinoma of the urinary bladder, one carcinoma of the colon, and one malignant melanoma. Three of these tumors developed within the irradiated field. Five of these eight patients are alive with no evidence of recurrent cancer. We conclude that patients treated for seminoma have an increased risk of developing a second cancer. There is a need for greater awareness of this possibility. The overall prognosis remains favorable.

Acute and subacute side effects due to infra-diaphragmatic radiotherapy for testicular cancer: a prospective study

Acute/subacute side effects were evaluated in 39 testicular cancer patients before infra-diaphragmatic radiotherapy, twice during therapy and 3, 6, and 12 months after treatment discontinuation. The evaluation was primarily based on questionnaires filled in by the patients. At the end of radiotherapy nausea was reported by all responding patients, and 29 patients complained of diarrhea. Two-thirds of the patients reported abdominal pain and/or meteorism, and one-half complained of retching and/or vomiting. During therapy the median weight was significantly reduced by three kilos and the median value of the performance status decreased by 20%. The hematological and biochemical toxicity was low. At the 3-month evaluation more patients complained of nausea, abdominal pain, and meteorism than before irradiation. Compared to the pretreatment situation the patients evaluated their physical condition to be reduced during treatment and at the first follow-up visit. One year posttreatment the patients had regained their physical fitness. All patients in income-producing activity were on sick leave during the period of radiotherapy and for 5 weeks (median) thereafter. In conclusion, infra-diaphragmatic radiotherapy leads to significant but reversible acute/subacute side effects lasting for a median of 9 weeks. It is hoped that better symptomatic therapy and modifications of the radiotherapy technique will reduce the side effects.