Evidence-based guidelines for following stage 1 seminoma

Optimal imaging techniques across the spectrum of testicular cancer

Over the years, several imaging techniques have been used in the diagnosis and management of testicular cancer. We compartmentalize disease stages into preorchiectomy, stage 1, initial stage 2 and 3 and postchemotherapy stage 2 and 3. We then elaborate on various imaging modalities that are relevant to each of these stages. We also describe evolving imaging tools that have shown promise. We attempt to provide a comprehensive review of these techniques over the spectrum of testicular cancer.

Testicular Mixed Germ Cell Tumor Presenting with Upper Gastrointestinal Bleeding: A Case Report

Testicular mixed germ cell tumors (TMGCTs) are aggressive neoplasms that often have metastases at the time of diagnosis, primarily in the lungs, bones, and brain. Gastrointestinal metastases are rare, occurring in less than 5% of cases, while duodenal involvement is extremely rare, with only few reported cases. Furthermore, gastrointestinal bleeding is an atypical initial presentation of metastatic TMGCTs. Herein, we present a very rare case of upper gastrointestinal bleeding caused by a duodenal metastasis of a TMGCT in a 24-year-old man. The patient was admitted to our hospital due to abdominal pain and melena with a hemoglobin level of 52 g/L. He had no history of testicular swelling, or any other symptoms or signs of a testicular tumor. Upper gastrointestinal endoscopy revealed a duodenal tumor mass with irregular bleeding, and abdominal ultrasound and computed tomography showed a duodenal mass that infiltrate retroperitoneum. Emergency surgery was performed, and the histopathological findings of the resected specimen were consistent with TMGCT metastasis. Subsequently, a testicular tumor was confirmed and surgically removed; however, multiple metastatic deposits were observed in the lungs. Due to the patient's poor general condition, chemotherapy was not performed. The patient died 3 months after the initial diagnosis. This case suggests that, although duodenal metastatic TMGCTs are rare, they should be considered in the differential diagnosis of gastrointestinal bleeding in young male patients.

The Role of CT in the Staging and Follow-Up of Testicular Tumors: Baseline, Recurrence and Pitfalls

Ultrasound imaging of the testis represents the standard-of-care initial imaging for the diagnosis of TGCT, whereas computed tomography (CT) plays an integral role in the initial accurate disease staging (organ-confined, regional lymph nodes, or sites of distant metastases), in monitoring the response to therapy in patients who initially present with non-confined disease, in planning surgical approaches for residual masses, in conducting follow-up surveillance and in determining the extent of recurrence in patients who relapse after treatment completion. CT imaging has also an important place in diagnosing complications of treatments. The aims of this article are to review these different roles of CT in primary TGCT and focus on different pitfalls that radiologists need to be aware of.

A Population-Based Analysis of Incidence, Mortality, and Survival in Testicular Cancer Patients in Lithuania

Background and objectives: The aim of this study was to analyze trends in testicular cancer incidence, mortality, and survival in Lithuania during the period 1998–2013. Materials and Methods: The study was based on all cases of testicular cancer reported to the Lithuanian Cancer Registry between 1998 and 2013. Age group-specific rates and standardized rates were calculated using the direct method (European standard population). The Joinpoint regression model was used to provide the annual percentage change (APC). Five-year relative survival estimates were calculated using period analysis. Relative survival was calculated as the ratio of the observed survival of cancer patients and the expected survival of the underlying general population. Results: During the study period, the age-standardized incidence rate of testicular cancer increased from 1.97 to 3.45 per 100,000, with APC of 2.97% (95% CI 0.9 to 5.1). Incidence rate of seminomas changed from 0.71 to 1.54 per 100,000, with APC of 2.61% (95% CI −0.4 to 5.7), and the incidence rate of non-seminomas increased from 0.84 to 1.83 per 100,000, with APC of 4.16% (95% CI 1.6 to 6.8). The mortality rate of testicular cancer in Lithuania during this period declined from 0.78 to 0.51 per 100,000, with APC of −2.91% (95% CI −5.5 to −0.3). Relative five-year survival ratio for the period 2009–2013 was 89.39% (95% CI 82.2 to 94.4). In our study, the overall five-year relative survival increased slightly (10.1%) from 2004–2008 to 2009–2013 (from 79.3% to 89.4%). Conclusions: A moderate increase of testicular cancer incidence has been observed in Lithuania between the years 1998 and 2013, while the mortality rate decreased. The five-year relative survival increased according to different period estimates; however, the results could have been higher if a multidisciplinary approach to diagnostics and management in the concerned centers had been implemented in Lithuania as in other countries.

Lymph node imaging in testicular cancer

Testicular cancer is a rare malignancy mainly affecting young men. Survival for testicular cancer remains high due to the effectiveness of multimodal treatment options. Accurate imaging is imperative to both treatment and follow-up. Both computed tomography (CT) and magnetic resonance imaging (MRI) suffer from size cut-offs as the only distinguishing characteristic of benign vs. malignant lymph nodes and may miss up to 30% of micro-metastatic disease. While functional [positron emission tomography (PET)] imaging may rule out disease in patients with seminoma who have undergone chemotherapy, there is insufficient evidence to recommend its use in other settings. This review highlights the uses and pitfalls of conventional imaging during staging, active surveillance, and post-treatment phases of both seminomatous and non-seminomatous germ cell tumors (NSGCT).

Recommendations for followup of stage I and II seminoma: The Princess Margaret Cancer Centre approach

Testicular seminoma most commonly affects young men and is associated with favourable prognosis. Various followup schedules and imaging protocols for testicular seminoma have been described without overall consensus. We reviewed the literature together with our experience at the Princess Margaret Cancer Centre and present an evidence-based followup approach for patients with stage I and II seminoma.

Clinical Characteristics and Outcomes of Late Relapse in Stage I Testicular Seminoma

AIMS

To identify the characteristics and outcomes associated with late relapse in stage I seminoma.

MATERIALS AND METHODS

A retrospective review was carried out of all patients with stage I seminoma managed at our institution between 1981 and 2011. Data were obtained from a prospectively maintained database. Late relapse was defined as tumour recurrence > 2 years after orchiectomy.

RESULTS

Overall, 1060 stage I seminoma patients were managed with active surveillance (n=766) or adjuvant radiotherapy (n=294). At a median follow-up of 10.6 years (range 1.2-30), 142 patients relapsed at a median (range) of 14 (3-129) months; 128 on active surveillance and 14 after adjuvant radiotherapy. The late relapse rate for the active surveillance and adjuvant radiotherapy groups was 4% and 1%, respectively. There was no specific clinicopathological factor associated with late relapse. Isolated para-aortic node(s) was the most common relapse site in active surveillance patients either in late (88%) or early relapse (82%). Among the active surveillance group, no patients with late relapse subsequently developed a second relapse after either salvage radiotherapy (n=25) or chemotherapy (n=6), whereas in early relapse patients a second relapse was reported in seven (10%) of 72 patients treated with salvage radiotherapy and one (4%) of 23 patients who received chemotherapy; all second relapses were subsequently salvaged with chemotherapy. No patient in the adjuvant radiotherapy group developed a second relapse after salvage chemotherapy (n=10) or inguinal radiotherapy/surgery (n=4). Of seven deaths, only one was related to seminoma. Among active surveillance patients, the 10 year overall survival for late and early relapse groups were 100% and 96% (P = 0.2), whereas the 10 year cancer-specific survival rates were 100% and 99% (P = 0.3), respectively.

CONCLUSIONS

In stage I seminoma, the extent and pattern of late relapse is similar to that for early relapse. For active surveillance patients, selective use of salvage radiotherapy/chemotherapy for relapse results in excellent outcomes regardless of the timing of relapse, whereas salvage radiotherapy for late relapse seems to be associated with a minimal risk of second relapse.

ACR Appropriateness Criteria Follow-Up of Malignant or Aggressive Musculoskeletal Tumors

Appropriate imaging modalities for the follow-up of malignant or aggressive musculoskeletal tumors include radiography, MRI, CT, (18)F-2-fluoro-2-deoxy-D-glucose PET/CT, (99m)Tc bone scan, and ultrasound. Clinical scenarios reviewed include evaluation for metastatic disease to the lung in low- and high-risk patients, for osseous metastatic disease in asymptomatic and symptomatic patients, for local recurrence of osseous tumors with and without significant hardware present, and for local recurrence of soft tissue tumors. The timing for follow-up of pulmonary metastasis surveillance is also reviewed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Advances in the treatment of testicular cancer

Germ cell tumors (GCT) are relatively uncommon, accounting for only 1% of male malignancies in the United States. It has become an important oncological disease for several reasons. It is the most common malignancy in young men 15-35 years old. GCTs are among a unique numbers of neoplasms where biochemical markers play a critical role. Finally, it is a model of curable cancer. In this review we discuss cancer epidemiology, genetics, and therapeutic principles. Recent advances in the management of stage I GCT and controversies in the management of post chemotherapy residual mass are presented.

[Incidental undifferentiated carcinoma of the prostate: A case with unusual diagnosis]

A 69-year-old man presented with an incidental undifferentiated carcinoma of the prostate. Ten years ago the patient had clinical stage I seminoma of the right testis with adjuvant radiotherapy. Follow-up care was without pathological findings. Staging examinations did not show metastatic disease. After radical prostatectomy with pelvic lymphadenectomy, the histological examination revealed a metastatic seminoma in the prostate. Therefore, the diagnosis was a late relapse in an extremely rare location. So far only four other reports describe testicular seminoma with metastases to the prostate.

Current management of testicular cancer

Germ cell tumors (GCTs) of the testis are rare, but are the most common cancer in young men. GCTs may consist of one predominant histologic pattern or may represent a mixture of multiple histologic types. For treatment purposes, two broad categories are recognized: 1) pure seminoma and 2) others, which together are termed nonseminomatous GCTs (NSGCTs). In general, seminoma tends to be less aggressive, to be diagnosed at an earlier stage, and to spread predictably along lymphatic channels to the retroperitoneum before spreading hematogenously to the lung or other organs. Compared with NSGCTs, seminoma is exquisitely sensitive to radiation therapy and platinum-based chemotherapy. NSGCTs are usually mixed tumors and teratoma often exists at the sites of metastasis with other GCT elements; cure often requires chemotherapy to kill the chemosensitive-components and surgery to remove the teratomatous components. The main factors contributing to excellent cure rates of GCTs are careful staging at diagnosis; adequate early treatment using chemotherapeutic combinations, with or without radiotherapy and surgery; and very strict follow-up and salvage therapy. We review several clinical studies and summarize the current trends in the management of GCTs.

Minimizing toxicity in early-stage testicular cancer treatment

Testicular cancer is the paradigm of a curable malignancy, with 10-year survival rates exceeding 95%. Cisplatin-based regimes offer a survival gain of several decades of life; however, measures of outcomes in testicular cancer are evolving. Survivorship issues are becoming increasingly important in this young adult population. Long-term risks of second malignancy and cardiovascular disease secondary to chemotherapy and radiotherapy have been extensively documented, leading to an increased uptake of surveillance. However, the optimal surveillance schedule is not universally agreed upon. Research into modalities to detect relapse and frequency is ongoing. Reducing the treatment burden with fewer cycles of chemotherapy (one cycle of bleomycin, cisplatin and etoposide instead of two for stage I high-risk nonseminomatous tumors) or less toxic alternatives (carboplatin instead of radiotherapy for stage I seminomas) is currently being explored. This article details the toxicities associated with the diagnosis and treatments of early-stage testicular cancer and current strategies used to minimize toxicity while retaining the excellent cure rates.

Utility of serum tumor markers during surveillance for stage I seminoma

BACKGROUND

The serum tumor markers α-fetoprotein (AFP), β-human chorionic gonadotropin (HCG), and lactate dehydrogenase (LDH) are often measured as part of surveillance protocols in patients with stage I seminoma. In this study, the authors evaluated the utility of routine measurement of these markers in the detection of disease relapse.

METHODS

Data were gathered from a prospectively maintained database of patients who underwent surveillance for stage I testicular seminoma diagnosed between 1982 and 2005 at Princess Margaret Hospital. Patients were followed on a predefined schedule with physical examination (PE), serum tumor markers, abdominopelvic computed tomography, and chest x-rays. The records of patients who relapsed were examined for details of imaging and serum tumor markers throughout the period of follow-up until the time of relapse.

RESULTS

Of the 527 patients who were managed by surveillance, 75 patients (14%) relapsed at a median follow-up of 72 months. Of these, 65 patients relapsed within the first 3 years and had routine serum tumor markers measured. In total, 11 patients had abnormal tumor markers at the time of relapse (AFP, 0 patients; HCG, 6 patients; LDH, 4 patients; and HCG and LDH, 1 patient). Only 1 patient had an elevated tumor marker (LDH) before relapse, as defined by an abnormal imaging study (n = 64) or physical examination (n = 1), for which the treatment and outcome were not affected.

CONCLUSIONS

Serum tumor marker levels did not aid in the early diagnosis of disease relapse in patients with stage I seminoma who were managed with surveillance. The current results indicated that routine measurement of serum tumor markers can be discontinued safely in seminoma surveillance schedules.

Late relapse of germ cell tumors

This article highlights relevant aspects of the rare late relapses of malignant germ cell tumors (MGCTs), which by definition occur at least 2 years after successful treatment. In most reports, 1% to 6% of patients with MGCT experience a late relapse. Surgery is the most important part in the treatment of late relapses. Viable MGCT or teratoma with malignant transformation may require multimodal treatment with chemotherapy, radiotherapy, and/or surgery. Salvage chemotherapy should be based on a representative biopsy. Referring patients with late relapse to high-volume institutions ensures the best chances of cure and enables multimodal treatment.

Side Effects of Adjuvant Radiotherapy in Men with Testicular Seminoma Stage I

In this study we followed up the side effects of adjuvant radiotherapy in patients with testicular seminoma stage I over a period from 13 to 84 months (median 28 months). The most frequent side effects during radiotherapy were gastrointestinal (nausea/vomiting), psychological, cognitive, and minor sexual problems.

The reported side effects were treated by antiemetics and anxiolytics. After radiotherapy, the side effects persisted in 6 % of patients, but only a few of them required additional treatment. Healthy children were born to 76 % of patients in the 18 to 39 years age group. This study shows that adjuvant radiotherapy of the para-aortic lymph nodes with the total dosage of 24 Gy in 16 daily fractions administered to testicular seminoma patients causes acceptable side effects, does not adversely affect quality of life and fertility, if the approach to treatment is individual and family consulting is provided. This makes adjuvant radiotherapy of the para-aortic lymph nodes an acceptable treatment for testicular seminoma stage I patients.

[Abdominal ultrasonography versus abdominal CT in the follow-up of testicular germ cell tumors]

INTRODUCTION

Testicular germ cell tumors are common in young men. There is a wide consensus regarding the key points in their diagnosis and treatment, although some elements, including the best approach to follow-up, are being reviewed and revised. We present a statistical study that uses tools for the evaluation of diagnostic tests to compare the usefulness of abdominal ultrasonography (US) in comparison with that of abdominal CT, taken as the gold standard, in the detection of liver metastases and retroperitoneal adenopathies in patients with testicular germ cell tumors.

MATERIAL AND METHODS

We analyzed a total of 308 diagnostic tests (154 CT studies and 154 US studies) from 59 patients with at least one year's follow-up at our institution. Patients underwent abdominal US before abdominal CT following a standard protocol.

RESULTS

Compared to the gold standard, abdominal US had 95% sensitivity, 92% specificity, 82% PPV, and 98% NPV.

CONCLUSION

US is very sensitive and can be used in protocols for the follow-up of primary testicular tumors to rule out disease.

[Stage I seminoma: therapeutic strategy: surveillance, radiotherapy, chemotherapy. A case-report]

The management guide-lines about stage I seminoma (pT1 à pT4, No, Mo) recommend to perform a surveillance, an adjuvant chemotherapy based on carboplatine, or a radiotherapy. However, these options are not equivalent for side effects and relapse risk. Debates are in progress in order to simplify the surveillance protocols which remain essential because of the tumoral relapses for 15% of the patients. The occurrence of a tumoral relapse during the follow-up does not decrease the specific survival. The para-aortic 20 Gy radiotherapy is efficient on the seminoma and decreases the relapse risk. Its main side-effect is a long-term risk of secondary cancer. Carboplatine chemotherapy is also an efficient option which provides good results on the specific survival and the survival without progression. Very few studies assess the long-term side effects of chemotherapy. In the end, the therapeutic decision must be taken with the patient after informing him about all the therapeutic options.

Interdisciplinary evidence-based recommendations for the follow-up of early stage seminomatous testicular germ cell cancer patients

PURPOSE

To provide guidance regarding follow-up procedures after initial treatment of early stage testicular seminoma (clinical stages (CS) I-II A/B) based on current published evidence complemented by expert opinion.

METHODS AND MATERIAL

An interdisciplinary, multinational working group consisting of urologists, medical oncologists, and radiation oncologists analyzed the published evidence regarding follow-up procedures in various stages of seminomatous and nonseminomatous testicular cancers. Focusing on radiooncological aspects, the recommendations contained herein are restricted to early stage seminoma (with radiotherapy being a standard treatment option). In particular, extent, frequency, and duration of imaging at follow-up were analyzed concerning relapse patterns, risk factors, and mode of relapse detection.

RESULTS

Active surveillance, adjuvant carboplatin or radiotherapy are equally accepted options for CS I seminoma but they result in different relapse rates and patterns. Usually relapses occur within the first 2(-6) years. Routinely performed follow-up using computerized tomography (CT) after adjuvant treatment yield only low detection rates of recurrences. Therefore, there is no evidence to maintain routine examinations every 3-4 months. After treatment of stage IIA/B, detection rates of relapses or progression identified solely by routinely performed CT during follow-up are low.

CONCLUSION

Considering lifelong cure rates of up to 99% for patients treated for seminoma CS I-IIA/B, the negative impact of unnecessary ionizing radiation exposure has to be considered. The presented recommendations for various follow-up scenarios for early stage seminoma strongly promote the restrictive use of imaging procedures that utilize ionizing radiation (especially CT), due to its potential to induce secondary malignancies.

Randomized trial of carboplatin versus radiotherapy for stage I seminoma: mature results on relapse and contralateral testis cancer rates in MRC TE19/EORTC 30982 study (ISRCTN27163214)

PURPOSE

Initial results of a randomized trial comparing carboplatin with radiotherapy (RT) as adjuvant treatment for stage I seminoma found carboplatin had a noninferior relapse-free rate (RFR) and had reduced contralateral germ cell tumors (GCTs) in the short-term. Updated results with a median follow-up of 6.5 years are now reported.

PATIENTS AND METHODS

Random assignment was between RT and one infusion of carboplatin dosed at 7 × (glomerular filtration rate + 25) on the basis of EDTA (n = 357) and 90% of this dose if determined on the basis of creatinine clearance (n = 202). The trial was powered to exclude a doubling in RFRs assuming a 96-97% 2-year RFR after radiotherapy (hazard ratio [HR], approximately 2.0).

RESULTS

Overall, 1,447 patients were randomly assigned in a 3-to-5 ratio (carboplatin, n = 573; RT, n = 904). RFRs at 5 years were 94.7% for carboplatin and 96.0% for RT (RT-C 90% CI, 0.7% to 3.5%; HR, 1.25; 90% CI, 0.83 to 1.89). One death as a result of seminoma (in RT arm) occurred. Patients receiving at least 99% of the 7 × AUC dose had a 5-year RFR of 96.1% (95% CI, 93.4% to 97.7%) compared with 92.6% (95% CI, 88.0% to 95.5%) in those who received lower doses (HR, 0.51; 95% CI, 0.24 to 1.07; P = .08). There was a clear reduction in the rate of contralateral GCTs (carboplatin, n = 2; RT, n = 15; HR, 0.22; 95% CI, 0.05 to 0.95; P = .03), and elevated pretreatment follicle-stimulating hormone (FSH) levels (> 12 IU/L) was a strong predictor (HR, 8.57; 95% CI, 1.82 to 40.38).

CONCLUSION

These updated results confirm the noninferiority of single dose carboplatin (at 7 × AUC dose) versus RT in terms of RFR and establish a statistically significant reduction in the medium term of risk of second GCT produced by this treatment.

Randomized trials in 2466 patients with stage I seminoma: patterns of relapse and follow-up

BACKGROUND

From July 1, 1989, through March 31, 2001, 2466 patients with stage I seminoma were evaluated in three randomized noninferiority trials: the TE10, TE18, and TE19 trials. We analyzed mature results of these studies.

METHODS

The TE10 trial randomly assigned 478 patients to para-aortic and ipsilateral iliac lymph node (dogleg field) or para-aortic only radiation therapy (total dose = 30 Gy). The TE18 trial randomly assigned 1094 patients to a total dose of 30 or 20 Gy of radiation therapy, predominantly to a para-aortic field. The TE19 trial randomly assigned 1477 patients to radiation therapy or a single injection of carboplatin at a dose of seven times the area under the curve. Time to relapse was determined from Kaplan-Meier curves, and such data were compared by use of Cox regression models. Noninferiority in TE18 and TE19 required the upper limit of the 90% confidence intervals (CIs) (reflecting the one-sided test for noninferiority at a 5% statistical significance level) to exclude a hazard ratio (HR) of greater than 2.0 and a doubling of the 5-year relapse rates observed in the control arm. The TE10 trial was not powered to exclude clinically relevant differences in overall relapse rates but was assessed against the same criteria.

RESULTS

Median follow-up times were 6.4-12 years in the three trials. We identified the noninferiority of the following treatments: 20 Gy of radiation therapy in the TE18 trial (HR of relapse = 0.63, 90% CI = 0.38 to 1.04) and carboplatin in the TE19 trial (HR of relapse = 1.25, 90% CI = 0.83 to 1.89). Para-aortic radiation therapy in the TE10 trial was associated with a hazard ratio of relapse of 1.15 (90% CI = 0.54 to 2.44). Relapse occurred after 3 years in only four (0.2%) of all 2466 patients. Computed tomography scans had little impact on the detection of relapse after radiation therapy; seven of the 904 patients allocated radiation therapy in TE19 had a relapse detected by this method.

CONCLUSION

This large and mature dataset from three randomized trials has provided support for the use of either radiation therapy or carboplatin therapy as adjuvant treatment for stage I seminoma.

Outcome of different post-orchiectomy management for stage I seminoma: Japanese multi-institutional study including 425 patients

OBJECTIVES

To clarify the contemporary clinical outcome of stage I seminoma and to provide information on treatment options to patients.

METHODS

A retrospective analysis of 425 patients who underwent orchiectomy for stage I seminoma between 1985 and 2006 at 25 hospitals in Japan. Relapse-free survival rates were calculated using the Kaplan-Meier method and clinicopathological factors associated with relapse were examined by univariate and multivariate analyses using the Cox proportional hazards model.

RESULTS

A total of 30 out of 425 patients had relapsed. Relapse-free survival rates at 10 years were 79, 94 and 94% in the surveillance, chemotherapy and radiotherapy groups, respectively. Post-orchiectomy management and rete testis invasion were identified as independent predictive factors associated with relapse. Rete testis invasion remained to be an independent predictive factor, even if the cases with relapses in the contralateral testis were censored. Only one patient, who relapsed after adjuvant radiotherapy, died of the disease. Overall survival at 10 years was 100, 100 and 99% in the surveillance, chemotherapy and radiotherapy groups, respectively. More than half of the patients were lost to follow up within 5 years.

CONCLUSIONS

The outcome of Japanese patients with stage I seminoma is similar to previously published Western reports. Surveillance policy is becoming a popular option in Japan, although the relapse rate in patients opting for surveillance policy is higher than those opting for adjuvant chemotherapy or radiotherapy. Rete testis invasion is an independent predictive factor associated with relapse regardless of the post-orchiectomy management. Long-term follow up is mandatory for detection of late relapse.

Lymph node growth rate in testicular germ cell tumours: implications for computed tomography surveillance frequency

AIM

To estimate the growth rate of lymph nodes in patients on surveillance for testicular cancer who developed recurrent disease.

MATERIALS AND METHODS

During a 7-year period, 318 patients at our institution were managed by surveillance and 39 relapsed (12.3%). The computed tomography scans of 28 patients (median age 32 years; range 19-51 years) who met our inclusion criteria and who developed recurrent disease in the abdomen/pelvis were retrospectively reviewed. Thirteen patients had non-seminoma and 15 had seminoma. To estimate the lymph node growth rate, the slope of lymph node size over time was calculated.

RESULTS

The median length of time from orchiectomy to the recurrence computed tomography was 131 days (range 49-520) or about 4.4 months for non-seminoma patients and 373 days (range 129-675) or about 12.3 months for seminoma patients. The median size of the involved lymph node at final computed tomography for seminoma patients was 12 mm (range 9-31 mm) and for non-seminoma patients was 15 mm (range 10-56 mm). The median lymph node growth rate for patients with seminoma was 1.35 mm/month (range 0.62-4.56) and for patients with non-seminoma 2.99 mm/month (range 0.77-7.06); the difference in growth rates was statistically significant (P=0.029).

CONCLUSIONS

There is a statistically significant faster growth rate of lymph nodes in patients with recurrent non-seminoma compared with patients with seminoma. This finding supports a more frequent computed tomography schedule during the first 2 years of surveillance in non-seminoma patients compared with seminoma patients.

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.

Quality of care for testis cancer

This article explores the delivery of high quality care in patients with testicular cancer. Critical issues relate to an individualized, risk-stratified, and multidisciplinary approach to patient care at centers of excellence and subsequent close patient follow-up. The necessary integration of multiple therapeutic modalities makes testis cancer outcomes highly susceptible to variations in quality of care, which deserves further investigation in well designed population-based studies.

Late relapse of germ cell tumors

OBJECTIVE

To assess the main characteristics of late relapsing malignant germ cell tumors (MGCTs). These tumors are rare and occur by definition 2 years or later after successful treatment.

METHODS

We present relevant literature on relapsing MGCT in order to highlight the following issues: incidence, impact of initial treatment on the subsequent risk of late relapse, treatment, and survival.

RESULTS

A pooled analysis of 5,880 patients with MGCT revealed late relapses in 119 of 3,704 (3.2%) and in 31 of 2,176 (1.4%) patients with non-seminoma and seminoma, respectively. The retroperitoneal space is the predominant site of relapse in both histological types. The initial treatment is important for the risk and localization of late relapses. Patients with single site teratoma are usually cured by surgery alone, whereas viable MGCT or teratoma with malignant transformation may require multimodal treatment with chemo- and/or radiotherapy as well as surgery. Surgery is the most important part in the treatment of late relapses. Salvage chemotherapy should, if feasible, be based on a representative biopsy. Five-year cancer-specific survival is above 50% in the recent large series and reaches 100% in case of single site teratoma.

CONCLUSIONS

Treatment of late relapsing MGCT patients is challenging and should be performed in experienced centers only. Referral of late relapsing patients to high-volume institutions ensures the best chances of cure and enables multimodal treatment, and contributes to increased knowledge of tumor biology as well experience with the clinical course of these patients.

Controversies in the management of early-stage germ cell tumors

The optimal management of clinical stage I testicular germ cell tumors remains controversial despite a cure rate of 99%. Alternatives for stage I nonseminomas include close surveillance, retroperitoneal lymph node dissection, and chemotherapy. For pure seminomas, the options are surveillance, chemotherapy, and radiation. Understanding the pros and cons of each approach may help in choosing a management plan.

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.

Contemporary management of stage I testicular seminoma: a survey of Canadian radiation oncologists

Recently published studies clearly indicate that there are now several acceptable options for managing stage i testicular seminoma patients after orchiectomy. We therefore decided to survey Canadian radiation oncologists to determine how they currently manage such patients and to compare the results with previous surveys.

Our results demonstrate that adjuvant single-agent chemotherapy is being considered as an option by an increasing proportion of radiation oncologists (although it is not considered the preferred option), the routine use of radiotherapy is declining, and surveillance is becoming increasingly popular and is recommended most often.

Influence of year of diagnosis, patient age, and sociodemographic status on recommending adjuvant radiation treatment for stage I testicular seminoma

PURPOSE

Adjuvant radiation therapy (ART) for stage I seminoma can cause adverse late effects and alternative postorchiectomy management strategies have been developed. This study evaluated ART trends in the United States and the impact of clinical and sociodemographic factors on ART recommendations.

METHODS

Of men diagnosed with stage I seminoma from 1990 through 2004, 3,125 were identified using the Surveillance, Epidemiology, and End Results cancer registry. A multivariable logistic regression analysis was performed to assess whether there was a significant association between diagnosis year, diagnosis age, race, county education level, region, tumor size, tumor category, and the recommendation for ART.

RESULTS

There was a significant association (P < .001) between later year of diagnosis and a decrease in ART recommendation. Compared with men diagnosed in 1990 to 1994, men diagnosed in 1995 to 1999, and 2000 to 2004 were less likely to have ART (adjusted odds ratio [OR], 0.63; 95% CI, 0.48 to 0.84; and OR, 0.49; 95% CI, 0.37 to 0.63, respectively). There also was a significant association (P < .001) between county education level and ART recommendation. Men residing in counties with the highest education level were more likely to receive ART than men residing in counties with the lowest education level (OR, 2.12; 95% CI, 1.59 to 2.82). Also, men older than 30 years were more likely to receive ART than men age 30 or younger (OR, 1.26; 95% CI, 1.03 to 1.55).

CONCLUSION

ART recommendations for stage I seminoma are declining. Men in less educated regions and the youngest men were less likely to receive a recommendation for ART.

Evidence-based pragmatic guidelines for the follow-up of testicular cancer: optimising the detection of relapse

Testicular germ cell tumours (TGCTs) are the most common cause of cancer in men between the ages of 15 and 40 years, and, overall, the majority of patients should expect to be cured. The European Germ Cell Cancer Consensus Group has provided clear guidelines for the primary treatment of both seminoma and nonseminomatous germ cell tumours. There is, however, no international consensus on how best to follow patients after their initial management. This must promptly and reliably identify relapses without causing further harm. The standardising of follow-up would result in optimising risk-benefit ratios for individual patients, while ensuring economic use of resources. We have identified the seven common scenarios in managing seminomas and nonseminomas of the various stages and discuss the pertinent issues around relapse and follow-up. We review the available literature and present our comprehensive TGCT follow-up guidelines. Our protocols provide a pragmatic, easily accessible user-friendly basis for other centres to use or to adapt to suit their needs. Furthermore, this should enable future trials to address specific issues around follow-up giving meaningful and useful results.