Controversies in management of stages I and II testicular seminomas

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.

Management of testicular seminoma at Westmead Hospital from 1980 to 87

Testicular seminoma comprises fewer than 1% of male cancers but is a relatively common malignancy in young men. The management and outcome of 73 consecutive patients with testicular seminoma were reviewed. Median follow-up was 51 months (range: 15-109 months). Their median age was 37 years (range: 21-67 years). There was a history of testicular maldescent in 5.5% of patients. Beta-human chorionic gonadotropin was elevated in 22% of patients prior to orchidectomy and in 5% post-surgery. The majority of patients had stage I (78%) or stage II (19%) seminoma after clinical staging. One patient (2%) with stage I seminoma relapsed, while two patients (14%) with stage II seminoma relapsed. The latter two were salvaged with further therapy. One of two patients treated for stage III seminoma died. A residual mass after radiotherapy was commonly observed in patients with stage II seminoma, but did not represent viable tumour. These results reflect the high cure rates that are achievable in seminoma with radiotherapy for early stage and non-bulky abdominal disease and, more recently, with cisplatin-based chemotherapy for bulky abdominal or disseminated disease.

Radiologic staging of chest in testicular seminoma

We investigated the usefulness of chest x-ray (CXR), conventional planar tomography (TOM), and computerized axial tomography (CAT) in evaluating patients with Stages I and II testicular seminoma. All patients had a CXR, and 22 patients had either TOM or CAT as part of initial staging. No occult pulmonary or mediastinal nodal disease was found during initial staging, and none of the patients manifested recurrence of tumor in these sites as a first event. Review of the literature corroborates our finding of a very small thoracic failure rate in early stage seminoma. Routine use of CAT or TOM is not indicated in staging these patients.

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

From 1977 to 1988, 215 patients with a diagnosis of testicular seminoma were referred to the University Hospital, Hamburg, West Germany, for radiation therapy (RT). In 15 patients a careful review of the histologic condition showed signs of embryonal cell carcinoma. Three patients refused completion of therapy. No patient was lost to follow-up. On this basis, a retrospective review of 197 patients was carried out. One hundred thirty-three patients were classified as Stage I (67%), 39 as Stage II (20%), 8 as Stage III (4%), and 17 as Stage IV (9%). One hundred eighty patients had classic seminoma and 17 had anaplastic seminoma. All patients underwent high inguinal orchiectomy before treatment. Seven patients with Stages III and IV received chemotherapy before RT. Patients with Stages I and II were treated with 40-Gy photons to paraaortic and parailiac fields. Ten patients with Stage III and IV seminoma received 30-Gy photons to mediastinal and supraclavicular fields as well. Sixty patients received additional inguinal RT. The overall 5-year survival rate (corrected for intercurrent death, except for treatment toxicity) was 100% for Stage I, 100% for Stage II, 87% for Stage III, and 87% for Stage IV. The mean follow-up time was 6.3 years (range, 0.6 to 11.9 years). An evaluation of all patients showed no difference according to histologic condition or prior chemotherapy. Mediastinal and supraclavicular irradiation showed no improvement in treatment results. Acute toxicity consisted of mild to moderate emesis, increased bowel frequency, erythema, and, in four cases leucopenia and thrombopenia (all World Health Organization [WHO] Grades I to II). However, one patient died of a pulmonary fibrosis 1 month after mediastinal irradiation and 2 months after polychemotherapy, and a gastroduodenal ulcer developed in another patient 1.5 months after paraaortic RT and prior polychemotherapy. Overall, the data suggest that to avoid overtreatment and consecutive treatment morbidity reduced doses of 30 Gy and a restrictive treatment planning adapted to the individual risk are sufficient for RT for testicular seminoma. An alternative to postoperative RT in Stage I (and possibly Stage II) seminoma could be no RT, but close follow-up instead.