[An interdisciplinary consensus conference on the diagnosis and therapy of testicular tumors]

Mortality of Testicular Cancer in East and West Germany 20 Years after Reunification: A Gap Not Closed Yet

BACKGROUND

The decline of testicular cancer mortality in East Germany began in the 1980s, about 10 years later than that recorded in West Germany. We aimed at providing up-to-date time trends of testicular cancer mortality rates in Germany.

MATERIAL AND METHODS

Mortality data from East Germany (1971-2010) and West Germany (1954-2010) were provided by the Federal Bureau of Statistics. We estimated age-specific and age-standardized mortality rates using the World Standard Population.

RESULTS

Despite the declining trend in the 2000s, the mortality rates of testicular cancer remained higher in East than in West Germany. These rates were 5.5 and 2.6 per million person-years in 2010, respectively. Age-specific mortality trends by period and birth cohort showed that the mortality decline was larger among younger (15-44 years) than elderly men.

CONCLUSION

The mortality of testicular cancer is still higher in East than West Germany. Despite very similar densities of hospital beds, urologists and oncologist per million male population in both parts of Germany, we hypothesized that a paucity of centers of expertise for treating testicular cancers in the East could account for this particular pattern.

Radiotherapy with 16 Gy may fail to eradicate testicular intraepithelial neoplasia: preliminary communication of a dose-reduction trial of the German Testicular Cancer Study Group

Low-dose radiotherapy to the testis is effective in eradicating testicular intraepithelial neoplasia (TIN, carcinoma in situ of the testis) at the risk of androgenic deficiency. The present trial was designed to define the lowest dose effective to control TIN assuming a dose-response relation of radiation-induced endocrinological damage. Patients with TIN in a solitary testicle or with bilateral TIN were treated with 18 Gy (14 patients) and 16 Gy (26 patients) (5 x 2 Gy per week). Biopsies to ascertain clearance of TIN were performed after 6 and 24 months. The median time of follow-up is 20.5 months. There were three adverse events. In one patient, relapse of TIN along with microinvasive seminoma was observed 2 years after 16 Gy irradiation. In two other patients, persistent spermatogonia were observed with the 16 and 18 Gy regimen after 6 and 24 months, respectively. All other post-treatment biopsies showed the Sertoli cell-only pattern. These results confirm that TIN is a radiosensitive lesion efficiently controlled in most cases with doses below 20 Gy. However, sporadic failures may occur. A dose of 16 Gy is probably unsafe and should no longer be used. Future investigations should not only focus on total dosage of irradiation but also on fractionation schedules.

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

BACKGROUND AND PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

[Testicular intraepithelial neoplasms (TIN). An indication for radiotherapy?]

BACKGROUND

Testicular intraepithelial neoplasia (TIN), synonymous for carcinoma in situ of the testis, is a rarely observed preinvasive neoplasia located within the germinative epithelium. According to the current knowledge of the biology of TIN, it is the common precursor of all testicular germ cell neoplasms except spermatocytic seminoma.

MATERIAL AND METHODS

This report provides a review of histopathology, epidemiology and diagnostic procedures for TIN and discusses the therapeutic options with particular respect to radiooncological aspects.

RESULTS

TIN has a 70% rate of progression to invasive cancer within 7 years. Depending on the individual therapeutic setting surgery, chemotherapy and radiotherapy are alternative treatment modalities. In case of TIN in a single testis or bilateral TIN, local radiotherapy is the standard procedure. With 20 Gy recommended as standard dose in Germany, radiotherapy yields safe eradication of TIN. However, some of the patients show significantly reduced synthesis of testicular androgens. With respect to sporadic reports in the literature, total doses well below 20 Gy might be equally efficient to treat TIN safely. Yet, up to date neither the minimum dose for efficient treatment nor the toxicity profile after consecutive chemo-radiotherapy has been established.

CONCLUSIONS

The currently recommended standard dose of 20 Gy in Germany is probably in excess of the minimum dose needed for safe eradication of TIN. Thus, new radiooncological strategies should aim at reducing the total dose of treatment in order to minimize late side effects while maintaining the high efficacy of radiotherapy. This topic is under investigation in a multicenter clinical trial.