Clinical stage I seminoma: the case for surveillance

Patterns of care in the management of seminoma stage I: results from a European survey

Study Type - Therapy (practise pattern survey). Level of Evidence 3b. What's known on the subject? and What does the study add? The uncertainties about differences in relapse and rates of other late events such as second malignancy and cardiovascular events for the three post-orchidectomy strategies in seminoma stage I patients has led to debates about whether the three strategies are equally effective and safe. The differences in interpretation of the data as well as the debates are likely to result in differences in treatment after orchidectomy in seminoma stage I patient management. Current care patterns after orchidectomy are, however, unknown. We assessed patterns of care for seminoma stage I patients after orchidectomy by distributing a survey among doctors treating such patients across Europe. The 969 respondents showed large differences in care strategies between specialties and countries that indicate the need for research into long-term relapse rates and long-term adverse effects to standardize and optimize care for seminoma stage I patients.

OBJECTIVE

• To assess precise patterns of care after orchidectomy in Europe for stage I seminoma patients, we aimed to perform a survey among doctors in the various European countries.

PATIENTS AND METHODS

• We distributed a survey in 2009 and 2010 among American Society of Clinical Oncology and European Association of Urology members.

RESULTS

• In total, 969 questionnaires were included in the analysis. More than half of the 969 physicians (58%) currently offer only one post-surgical treatment: 18% only surveillance, 19% only radiotherapy and 21% only chemotherapy. Thirteen percent of the 969 physicians currently offer all three strategies, 25% offer surveillance and adjuvant radiotherapy or chemotherapy, and 5% offer either adjuvant radiotherapy or chemotherapy without surveillance. • We found large differences in care patterns between specialties and countries. Even within countries, care after orchidectomy was not standardized. • Before 2005, 73% of the physicians offered only one treatment and of those 51% gave adjuvant radiotherapy.

CONCLUSIONS

• Large differences in pattern of care after orchidectomy for stage I seminoma patients exist between specialties and countries within Europe. • More information on long-term relapse rates and long-term adverse effects of the three strategies is needed to standardize and optimize care after orchidectomy.

[What's new in the treatment of seminomas?]

Pure testicular seminoma is a rare disease with an excellent prognosis. Its management is controversial. In stage I disease, several treatment options are considered. Those are radiation therapy alone, chemotherapy alone or active surveillance, which is becoming increasingly popular. For more advanced stages, treatment is based on chemotherapy with or without radiation therapy. In this article, we review thoroughly the existing literature and recent recommendations the various treatment options, their advantages and disadvantages in different stages of the disease.

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.