The role of radiation in stage II testicular seminoma

Mortality and incidence of second cancers following treatment for testicular cancer

We studied 5555 seminoma patients and 3733 patients with nonseminomatous testicular cancers diagnosed in Southeast England between 1960 and 2004. For both groups survival improved over time: 10-year relative survival increased from 78% in 1960–1969 to 99% in 1990–2004 for seminomas, and from 55 to 95% for nonseminomas. In the early period mortality was still significantly increased more than 15 years after diagnosis in both groups, whereas in more recent periods the excess deaths mainly occurred in the first 5 years after diagnosis. For seminomas, there was a significant excess of cancers of the colon (standardised incidence ratio (SIR) 2.36; 95% confidence interval (CI) 1.13–4.35), soft tissue (SIR 13.64; CI 1.65–49.28) and bladder (SIR 4.28; CI 2.28–7.31) in the long term (20+ years after diagnosis), of pancreatic cancer in both the medium (10–19 years) (SIR 2.91; CI 1.26–5.73) and long term (SIR 5.48; CI 2.37–10.80), of leukaemia in both the short (0–9 years) (SIR 3.01; CI 1.44–5.54) and long term (SIR 4.48; CI 1.64–9.75), and of testis cancer in both the short (SIR 6.69; CI 4.28–9.95) and medium term (SIR 3.96; CI 1.08–10.14). For nonseminomas, significant excesses were found in the long term for cancers of the stomach (SIR 5.13; CI 1.40–13.13), rectum (SIR 4.49; CI 1.22–11.51) and pancreas (SIR 10.17: CI 3.73–22.13), and for testis cancer in the medium term (SIR 5.94; CI 2.18–12.93). Leukaemia was significantly increased in the short term (SIR 6.78; CI 2.93–13.36). The better survival observed is largely attributable to improved treatment, and the trend in reducing the toxicity of therapy should continue to reduce future health risks in testicular cancer survivors.

Mortality after cure of testicular seminoma

PURPOSE

To determine the incidence of potentially treatment-related mortality in long-term survivors of testicular seminoma treated by orchiectomy and radiation therapy (XRT).

PATIENTS AND METHODS

From all 477 men with stage I or II testicular seminoma treated at The University of Texas M.D. Anderson Cancer Center (Houston, TX) with post-orchiectomy megavoltage XRT between 1951 and 1999, 453 never sustained relapse of their disease. Long-term survival for these 453 men was evaluated with the person-years method to determine the standardized mortality ratio (SMR). SMRs were calculated for all causes of death, cardiac deaths, and cancer deaths using standard US data for males.

RESULTS

After a median follow-up of 13.3 years, the 10-, 20-, 30-, and 40-year actuarial survival rates were 93%, 79%, 59%, and 26%, respectively. The all-cause SMR over the entire observation interval was 1.59 (99% CI, 1.21 to 2.04). The SMR was not excessive for the first 15 years of follow-up: SMR, 1.30 (95% CI, 0.93 to 1.77); but beyond 15 years the SMR was 1.85 (99% CI, 1.30 to 2.55). The overall cardiac-specific SMR was 1.61 (95% CI, 1.21 to 2.24). The cardiac SMR was significantly elevated only beyond 15 years (P <.01). The overall cancer-specific SMR was 1.91 (99% CI, 1.14 to 2.98). The cancer SMR was also significant only after 15 years of follow-up (P <.01). An increased mortality was evident in patients treated with and without mediastinal XRT.

CONCLUSION

Long-term survivors of seminoma treated with post-orchiectomy XRT are at significant excess risk of death as a result of cardiac disease or second cancer. Management strategies that minimize these risks but maintain the excellent hitherto observed cure rates need to be actively pursued.

Radiotherapy for stages IIA/B testicular seminoma: final report of a prospective multicenter clinical trial

PURPOSE

A prospective multicenter trial was initiated to evaluate the role of modern radiotherapy with reduced treatment portals for stage IIA and IIB testicular seminoma.

PATIENTS AND METHODS

Patients with stages IIA/B disease (Royal Marsden classification) were assessable for the trial. Staging comprised computed tomography of the chest, abdomen, and pelvis as well as analysis of tumor markers alpha-fetoprotein and beta human chorionic gonadotropin. Linac-based radiotherapy was delivered to para-aortic and high ipsilateral iliac lymph nodes. The total doses were 30 Gy for stage IIA and 36 Gy for stage IIB disease.

RESULTS

Between April 1991 and March 1994, 94 patients were enrolled for the trial by 30 participating centers throughout Germany. Seven patients were lost to follow-up. Median time to follow-up of 87 assessable patients was 70 months. There were 66 stage IIA and 21 stage IIB patients. One mediastinal and one field-edge relapse were observed in the stage IIA group. In the stage IIB group, there was one mediastinal and one mediastinal/pulmonary relapse. All patients were treated with a salvage regimen of platinum-based chemotherapy. Actuarial relapse-free survival at 6 years was 95.3% (95% confidence interval [CI], 88.9% to 100%) and 88.9% (95% CI, 74.4% to 100%) for stage IIA and IIB groups, respectively. Maximum acute side effects were 8% grade 3 nausea for stage IIA and 10% grade 3 nausea and diarrhea for stage IIB groups. No late toxicity was observed.

CONCLUSION

Radiotherapy for stages IIA/B seminoma with reduced portals yields excellent tumor control at a low rate of acute toxicity and no late toxicity, which supports the role of radiotherapy as the first treatment choice for these patients.

Radiotherapy for stage II testicular seminoma

PURPOSE

To compare the outcome of patients with Stage II seminoma treated with prophylactic mediastinal irradiation, without any supradiaphragmatic irradiation, and with prophylactic left supraclavicular irradiation (PLSCI).

METHODS AND MATERIALS

Between 1960 and 1999, 73 men with Stage II seminoma received postorchiectomy radiotherapy. Before 1984, 36 received prophylactic mediastinal irradiation (Series I); between 1984 and 1992, 17 received no supradiaphragmatic irradiation (Series II); and after 1992, 20 received PLSCI (Series III). The outcomes in these series were compared.

RESULTS

The abdominal tumor sizes were as follows: Series I, <or=2 cm, n = 4; >2 and <or=5 cm, n = 12; >5 and <or=10 cm, n = 16; Series II, <or=2 cm, n = 1; >2 and <or=5 cm, n = 12; >5 and <or=10 cm, n = 4; and Series III, <or=2 cm, n = 1; >2 and <or=5 cm, n = 14; >5 and <or=10 cm, n = 5 (p = 0.75). The median duration of follow-up was 14.4, 9.3, and 4.5 years for Series I, II, and III, respectively. The 6-year freedom from relapse was 94%, 71%, and 95% for Series I, II, and III, respectively. The differences between Series I and II (p = 0.014) and between II and III (p = 0.042) were significant. Three patients in Series II had a relapse in their left supraclavicular fossa-a failure pattern abrogated by PLSCI.

CONCLUSIONS

PLSCI significantly diminishes the likelihood of relapse for Stage IIA, IIB, and IIC seminoma (mass <or=10 cm).

E400P in advanced seminoma of good prognosis according to the international germ cell cancer collaborative group (IGCCCG) classification: the Spanish Germ Cell Cancer Group experience

PURPOSE

To evaluate the efficacy and toxicity of primary chemotherapy with the schedule E400P in the treatment of patients with early stage II (IIa and IIb) and advanced seminoma of good prognosis according to the international classification (IGCCCG).

PATIENTS AND METHODS

Sixty-four patients were included. E400P consisted of cisplatin 25 mg/m2/day and etoposide 100 mg/m2/day for four days, every three weeks. Royal Marsden stages were IIab: 53% and IIc-IV: 47%. Twenty-three percent had high BHCG levels, twenty-seven percent had LDH > 2 x N. Sixty-two patients were of good prognosis according to the Medical Research Council classification.

RESULTS

Response rate was 98% (69% complete remission, 29% residual disease). After a median follow-up of 34 months, treatment failure was seen in 7 patients (11%). Neutropenia (32%) was the most relevant grade 3-4 toxicity. Other important grade 3-4 side effects were found in less than 5%. Three-year time to treatment failure (TTF) was 89% (95% confidence intervals (CI): 80%-97%) for all patients, 91% (95% CI: 80%-99%) for stages IIa-b, and 87% (95% CI: 74%-99%) for stages IIc-IV. Three-year overall survival (OS) was 97% (95% CI: 93%-99%) for all patients and 95% (95% CI: 85%-99%) for stages IIa-b.

CONCLUSIONS

E400P was a very active and safe regimen in good-prognosis advanced seminoma, with low toxicity rates. Definitive comparisons of this regimen with radiotherapy in stages IIa-b or with the more standard E500P or BEP, could be of interest.

Testicular cancer

The following article provides a comprehensive review of male germ cell tumors; the pathology and the clinical manifestations of the tumors are discussed, as are the modern concepts of clinical staging. Patients with bulky stage II and stage III non-seminomatous germ cell tumors are treated with chemotherapy. The new international classification system has provided a very useful way to categorize these patients by prognosis. Patients with good- or intermediate-risk tumors may be treated with 3 courses of cisplatin, etoposide, and bleomycin (BEP) or 4 courses of etoposide and cisplatin (EP), and more than 90% of these patients will survive. Randomized trials have shown that, if only 3 courses of chemotherapy are to be given, the substitution of carboplatin for cisplatin and the omission of bleomycin are deleterious to outcome. Patients who still have a significant residual mass and normal markers after treatment should undergo a surgical resection of the residual tumor. Patients who are classified by the international classification system as having poor-risk tumors have about a 50% likelihood of survival, and many of these patients will require surgical resection of a residual tumor after chemotherapy. No randomized trial has proved a regimen to be superior to that of 4 courses of BEP. Currently, an ongoing trial is evaluating the effect of the early use of high-dose therapy in combination with hematopoietic rescue in patients with these types of tumors. Patients with small-volume stage II tumors are generally treated with retroperitoneal lymph node dissection (RPLND). About 25% of the patients selected for this procedure will actually have pathologically negative nodes. Those with positive nodes may elect to receive adjuvant chemotherapy (2 courses of BEP), which will almost always prevent relapse. An alternate approach for patients willing to comply with monthly follow-up is surveillance, with chemotherapy deferred until relapse is noted. About 50% of these patients will be cured with surgery (as many as 75% have microscopic disease only). With careful follow-up, those destined to relapse can be treated promptly and at a time when they have small-volume tumors and an excellent prognosis if they go on to receive chemotherapy. Patients with clinical stage I nonseminomatous germ cell tumors may also undergo RPLND, although an acceptable alternative for these patients is surveillance. The advantages and the disadvantages of each approach are discussed. The overall risk of recurrence is about 30%, but there have been patient groups defined that may vary in risk from 10% to 15% up to 50% or more. Patients with advanced seminoma are treated with chemotherapy. When this procedure is used, outcomes are favorable and all patients are either in good- or intermediate-risk groups, according to the international classification system. Patients with small-volume stage II tumors are treated with radiotherapy. Radiation is also generally used for the treatment of clinical stage I patients, although surveillance is growing in prominence as a means to treat these patients. Late effects of treatment are also discussed in this article. Ejaculatory function can be preserved in most patients who have early stage tumors and who undergo RPLND and in some patients who undergo surgery after chemotherapy. The most troubling effect of chemotherapy is the development of etoposide-induced leukemia, a unique--and fortunately rare--clinical entity.

Relapses in early-stage testicular seminoma: radiation therapy versus retroperitoneal lymphadenectomy

Being among the most radiosensitive tumours, radiation therapy has replaced retroperitoneal lymphadenectomy in the treatment of early-stage testicular seminoma. One hundred and sixty-one patients who were treated from 1975 through to 1991 with histologically confirmed testicular seminoma of stages I and II were analyses retrospectively. After high semicastration, 98 patients were treated by radiation therapy of regional lymph nodes and 63 patients received retroperitoneal lymphadenectomy. Until 1985 retroperitoneal lymphadenectomy was preferred, but after 1985 radiotherapy outweighed retroperitoneal lymphadenectomy. The follow-up ranged from 11 months to 13.5 years, with a median of 79 months. Retroperitoneally, in-field relapses occurred in 9.5% (6/63 patients) after retroperitoneal lymphadenectomy and in 2.0% (2/98 patients) after radiation therapy (Fisher exact test, p = 0.057). A trend to a higher frequency of retroperitoneal relapses after retroperitoneal lymphadenectomy seemed to be apparent. Relapses outside the operation site or radiation fields were registered with non-significantly different frequencies (p = 0.741) of 4.8% (3/63 patients) and 7.1% (7/98 patients), respectively. Relapses increased from 4.1% for stage I (5/121 patients) up to 58.3% for stage IIC (7/12 patients).

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.

Management of seminoma of the testis: recommendations based on treatment results

BACKGROUND

The results of management of seminoma of the testis at the Department of Radiation Oncology St Vincent's Hospital, Sydney were evaluated retrospectively to: (i) establish that outcomes were in keeping with published results from centres in Australia and overseas; (ii) assess the impact of chemotherapy on management; and (iii) to determine 'best practice' management protocols based on our results and a review of the relevant literature.

METHODS

(i) Assessment of treatment results for stage I and II seminoma of the testis treated by post-orchidectomy radiotherapy and/or chemotherapy at St Vincent's Hospital between 1979 and 1993; (ii) literature review of published data from Australian and overseas centres on the management of seminoma of the testis, and in particular the use of surveillance or chemotherapy either alone, at time of relapse or combined with radiotherapy; and (iii) development of recommendations for use as management protocols in our department.

RESULTS

Our data and a review of the literature suggest that post-orchidectomy radiotherapy with chemotherapy for relapse in stage I and IIA disease results in long-term cure rates approaching 100%. Treatment with chemotherapy either routinely or selectively or using a surveillance policy is unlikely to show any improvement in outcome and may be less cost-effective and/or produce increased morbidity and the risk of secondary leukaemia. For stage IIB disease (5-10 cm) the use of initial combination chemotherapy with or without subsequent radiotherapy did not appear to give better outcomes than initial radical radiotherapy alone, reserving chemotherapy or further radiotherapy for relapse. For bulkier stage IIB disease (> 10 cm), the use of initial chemotherapy plus consolidation radiotherapy appeared to be an appropriate treatment.

CONCLUSIONS

Management protocols for seminoma of the testis at St Vincent's Hospital, Sydney Department of Radiation Oncology currently are (i) stage I, IIA and IIB (5-10 cm): post-orchidectomy radiotherapy alone with chemotherapy or further radiotherapy for relapse; and (ii) stage IIB (> 10 cm) disease: initial chemotherapy post-orchidectomy followed by radiotherapy to sites of initial disease involvement.

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.

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.

Radiation therapy for stage I and IIA testicular seminoma

PURPOSE

To review the survival, cure rate, treatment morbidity, and late sequelae of histologically confirmed seminoma patients who underwent orchiectomy and radiation therapy at the Radiation Oncology Center, Mallinckrodt Institute of Radiology, from 1964 to 1988.

METHODS AND MATERIALS

There were 128 patients, with a median patient age of 37 years (range, 17-79 years). Follow-up ranged from 1-24 years, with a median of 6.7 years. There were 95 patients with Stage I and 33 with Stage IIA disease. All patients were treated with orchiectomy followed by iliac and paraaortic irradiation (median tumor dose: 2500 cGy for Stage I and 3400 cGy for Stage IIA patients). Twenty-five of 33 patients with Stage IIA disease received prophylactic mediastinal and left supraclavicular irradiation (median dose, 2700 cGy).

RESULTS

For patients with Stage I disease, 5-year disease-free survival, overall survival, and survival corrected for intercurrent disease were 97%, 100%, and 100%, respectively. For patients with Stage IIA disease, the 5-year disease-free survival, overall survival, and survival corrected for intercurrent disease were 93%, 89%, and 97%, respectively. Four patients (3%) had recurrences; all were outside the radiation treatment field. Three of four were successfully salvaged with chemotherapy and rendered disease-free; the other patient refused treatment. There were no mediastinal recurrences whether prophylactic mediastinal irradiation was administered or not. Bowel obstruction and necrosis developed in one patient who received 3363 cGy midplane dose to the pelvic and paraaortic areas as well as additional intraperitoneal colloidal 198Au (150 mCi) for a ruptured seminoma from an undescended testis.

CONCLUSION

In summary, radical orchiectomy and irradiation of the iliac and paraaortic lymphatics is the treatment of choice for patients with Stage I and IIA testicular seminoma.

Post-orchiectomy radiotherapy for stages I and II testicular seminoma

PURPOSE

In 1984 the following changes were made in the management of testicular seminoma at The University of Texas M.D. Anderson Cancer Center: (1) abdominopelvic computerized tomography replaced the bipedal lymph-angiogram for evaluating retroperitoneal nodes; (2) elective mediastinal radiation was totally abandoned; (3) patients with abdominal adenopathy < 10 cm were classified as having Stage IIA disease. This report evaluates the impact of these management policy changes on disease outcome.

METHODS AND MATERIALS

Between 1960 and 1991, 350 patients with Stages I or II testicular seminoma received post-orchiectomy radiation. The 241 patients treated prior to 1984 constitute our old series, and the 109 patients treated since then are our new series. The outcomes in the new series were compared to those in the old series.

RESULTS

The distribution of patients by stage was Stage I, 282 (old series, 190; new series, 92); Stage IIA, 55 (old series, 39; new series, 16); Stage IIB, 13 (old series, 12; new series, 1). The freedom-from-relapse at 5 years correlated with stage: Stage I, 97%; Stage IIA, 87%; Stage IIB, 69%. Elevated post-orchiectomy chorionic gonadotropin levels or involvement of the spermatic cord were adverse for disease relapse in Stage I but not Stage II disease. Patients with Stage I disease fared extremely well in both series (freedom-from-relapse 97%); the outcome for patients with Stage IIA was significantly worse in the new series (5-year freedom-from-relapse 73% vs. 92%) because of a 20% actuarial incidence of apparently solitary left supraclavicular nodal relapse. Although elective mediastinal radiation in the old series prevented this failure pattern, such treatment appeared to significantly decrease the survival of patients older than 40 years.

CONCLUSIONS

(1) Abdominopelvic computerized tomography scanning is adequate for the evaluation of abdominal lymph nodes in patients with seminoma; (2) Post-orchiectomy radiation to the para-aortic and ipsilateral hemipelvic regions remains the treatment of choice for patients with Stage I disease; (3) Patients with Stage IIA disease experience a 20% relapse rate especially in the left supraclavicular fossa and we recommend elective radiation to this site delivered concomitantly with para-aortic irradiation.

Para-aortic nodal irradiation for early stage testicular seminoma

Early stage seminoma of the testis has an excellent prognosis when post-orchidectomy para-aortic and ipsilateral pelvic radiotherapy is given. However, studies on testicular lymphangiograms and the rarity of isolated pelvic nodal disease suggest that pelvic radiotherapy is not necessary, except in cases where there is the possibility of altered lymphatic drainage. We report on 27 patients with stage I and IIA seminoma treated between 1983 and 1989. Seventeen patients received radiotherapy to the para-aortic region only. There have been no pelvic recurrences. No long term complications have been encountered. We discuss the reported data which suggest that a reduced complication rate should result from the proposed field reduction. We conclude that irradiating only the para-aortic region in early stage seminoma is logical, should not increase the relapse rate and should reduce the complication rate.

Treatment of seminoma arising in cryptorchid testes

We reviewed the clinical characteristics, treatment methods, and outcome of 26 patients presenting with seminoma arising in an undescended testis. The tumor-bearing testis was located in the iliac fossa in 17 patients and in the inguinal canal in nine. The most common presenting symptoms were pain or an enlarging mass. At diagnosis, the tumors tended to be relatively advanced, and 16 of 26 patients (62%) had nodal metastases. In addition to the paraaortic nodes, metastases were frequent to the ipsilateral iliac and inguinal nodes even in the absence of prior inguinal-scrotal surgery. Four patients had documented pelvic peritoneal tumor seeding. All patients received treatment in addition to resection of the primary tumor. Fifteen patients received radiotherapy only, 10 received chemotherapy only, and one received both modalities. At a median follow-up of 9.6 years, only one patient had relapsed. He was initially treated with radiation and after relapse was successfully salvaged with chemotherapy. The 5 and 10-year disease-free rate was 96%, and the 5 and 10-year survival rates were 92% and 79%, respectively. Appropriate treatment of seminoma arising in an undescended testis results in an excellent outcome equivalent to that observed for the more usual scrotal seminomas.

Role of lymphangiography in staging testicular seminoma

Bipedal lymphangiography (LAG) and abdominal/pelvic computerized tomography (CT) are both useful in evaluating retroperitoneal lymph nodes in early-stage testicular seminoma. Fifty-four patients who had both radiologic studies performed between 1982 and 1986 were identified, and their films were reviewed. Four patients had evidence of retroperitoneal lymph node metastases on both CT and LAG. Of the 50 patients who had normal findings on CT scan, 39 (78%) had a normal LAG and 11 (22%) had a positive LAG. All 11 patients had architectural abnormalities within normal-sized nodes. No patient had positive findings on CT with negative LAG. In addition to aiding in staging, LAG is very useful in designing radiation treatment portals. Therefore, we believe that LAG can continue to play an important role in the accurate staging and treatment of patients with testicular seminoma.

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.

Radiation therapy of early (stages I and II-A) seminoma of testis after initial orchiectomy

With initial orchiectomy and radiation therapy, the prognosis of the patients with early (Stages I and II-A) testicular seminoma is nearing almost 100 percent. Thirty-two patients with Stage I and 13 patients with Stage II-A seminoma of the testis were treated with initial orchiectomy. This was followed by estimation biochemical markers and radiologic investigations. All the patients with Stage I disease received radiotherapy to the ipsilateral pelvic and para-aortic nodes. The patients with Stage II-A disease also received radiation therapy to the supradiaphragmatic regions. The disease-free survival in both groups of patients was found to be 100 percent.

Modern radiotherapy results with bulky stages II and III seminoma

We treated 20 patients with stage II seminoma by primary radiotherapy from 1971 to 1982. Median patient age was 38 years (range 26 to 52 years) and median disease width in the transverse plane was 11 cm. (range 5 to 25 cm.). Four tumors were 5 to 9 cm., 9 were 10 to 14 cm. and 7 were 15 cm. or more wide. Tumor was palpable in 13 patients. Generous radiation ports (such as wide hockey stick or whole abdomen) often followed by a boost to the area of bulky disease were used as primary therapy in all patients. Median tumor dose was 37.5 Gy. (range 13.3 to 56.7 Gy.). Supradiaphragmatic prophylactic radiation was given to 16 patients (median dose 26 Gy., range 12 to 37.3 Gy.). Median followup was 56 months, and all patients currently are free of disease except for 1 who died without disease more than 10 years after completion of all therapy. Mediastinal failure occurred in 2 of 4 patients without and 1 of 16 with mediastinal prophylaxis. All 4 patients with relapse are currently free of disease after salvage therapy. Five patients 16 to 42 years old (median age 30 years) received primary radiation therapy for stage III disease. The median size of abdominal disease was 10 cm. (range 5 to 17 cm.). Of the 5 stage III cancer patients 3 had supradiaphragmatic disease demonstrated only in supraclavicular lymph nodes and all 3 were continuously free of disease 115 to 136 months after therapy. The remaining 2 stage III cancer patients had supradiaphragmatic disease by virtue of bulky mediastinal disease with or without supraclavicular involvement. Both patients had relapse in-field and distantly, and they died of disease despite salvage chemotherapy. A total of 30 fields with bulky disease (greater than 5 cm.) was treated either primarily or at relapse among the 25 stages II and III cancer patients. In-field relapse occurred in 3 of 21 patients receiving less than or equal to 36 Gy. and 0 of 9 who received greater than 36 Gy. These results justify radiation therapy as an acceptable initial primary treatment modality for typical bulky stage II seminoma. Disease greater than 5 cm. should receive greater than 36 Gy. Prophylactic radiation to the mediastinum is effective. However, patients who have mediastinal failure often can be salvaged with chemotherapy and/or radiation, and prophylactic mediastinal radiotherapy may be associated with poor tolerance to salvage chemotherapy and other significant late effects.(ABSTRACT TRUNCATED AT 400 WORDS)

The case for relevant staging of germ cell tumors

Successful treatment of germ cell tumors arising in the testes or extragonadal sites has become routine. The therapeutic approaches available for patients with germ cell tumor are determined by stage, histology, and site of tumor origin. Staging systems have played an important role in the development of therapy for patients with germ cell tumors. Staging systems must address not only the prognostic variables that determine survival but also the correct therapeutic approach available for such patients (surgery, chemotherapy, surgery plus chemotherapy). Trials are under way in many centers with the intention of reducing the intensity of therapy for patients with a good prognosis and increasing the intensity for those with a poor prognosis. The ability to compare data and, more importantly, to select safely and appropriately those patients to be placed at risk by reduced or increased intensity of therapy will require clinically relevant staging systems. Histologic type and the site of tumor origin markedly determine the clinical dilemmas existing for each group of patients. The subgroup with pure seminoma has tumors with a unique spectrum of sensitivity and toxicity to chemotherapy. A staging system for such patients must be necessity be designed specifically to meet their needs. Patients with nonseminomatous germ cell tumors have benefitted most from the introduction of chemotherapy. Tumor volume, histologic types, and site of origin greatly influence the results of treatment. Staging systems must be developed that meticulously evaluate tumor volume, secretion of serum biomarkers, and site of origin of tumor. The results of the M.D. Anderson Cancer Center experience treating germ cell tumors support the use of such clinically relevant staging systems. The therapeutic dilemmas outlined for each of the histologic subtypes will serve as the basis of future studies.

Stage II testicular seminoma: evolution of radiotherapeutic practice in the United States

We studied the evolution of treatment philosophy for testicular seminoma, by means of a questionnaire mailed to radiation oncologists practising in the United States. Of the 600 respondents 65% indicated a change in treatment policy since 1982. In patients with stage IIA disease the mediastinum is no longer treated by 62% of physicians, whereas 38% omit such treatment in Stage IIB patients. A trend towards the use of lower doses of radiation in areas treated was also noted. Omission of mediastinal irradiation in some stage II patients may be associated with an increased risk of failure in this site. Patients who do not receive treatment to the mediastinum must be carefully followed for recurrent tumour.

Testicular seminoma. Results of the Yale University experience, 1964-1984

Eighty-three testicular seminoma patients were treated with radiation therapy from 1964 through 1984. Seventy-nine (95%) of the 83 patients had early disease that included 61 Stage I, 15 Stage IIA (pelvic or paraaortic lymph node involvement less than or equal to 5 cm), and 3 Stage IIB (pelvic or paraaortic lymph node involvement greater than 5 cm) patients. The 15-year actuarial survival for this group of Stage I and II patients was 95% (+/- 5%). Stage I patients were treated with a mean paraaortic/pelvic dose of 2924 cGy and only one patient developed recurrent disease. This recurrence was at the margin of the radiation field and probably represents a marginal miss. The Stage IIA patients were treated with slightly higher doses (mean, 3335 cGY) to the paraaortic/pelvic region and there were no recurrences. The three Stage IIB patients received tumor doses of 3245 cGy, 4090 cGy, and 4500 cGy, respectively, and there were no recurrences. Low dose prophylactic mediastinal and supraclavicular irradiation (mean, 2320 cGy) was used in 17 (94%) of the 18 Stage II patients and there were no mediastinal or supraclavicular recurrences. Four patients presented with advanced disease (one Stage III, three Stage IV) and the only disease-free survivor was treated with cisplatinum-based combination chemotherapy and radiation therapy. Three patients developed minor complications from the radiation therapy: one patient had persistent scrotal and leg edema and two patients treated with prophylactic mediastinal irradiation had chronic low leukocyte counts. Two of the 79 Stage I and II patients developed a second malignancy: one had bronchogenic carcinoma at the margin of a mediastinal field, and one had diffuse histiocytic lymphoma both in and out of the radiation therapy fields. The 15-year actuarial probability of developing a second malignancy was 3.3%. Radiation therapy after operation is a successful treatment option for most patients with Stage I and II seminoma.

Controversies in management of stages I and II testicular seminomas

The general success in treating seminoma (Stages I and II) of the testicle has prompted questions regarding the extent of treatment that these patients require. We reviewed 79 patients treated at NYU/Bellevue Medical Center from 1965 to 1984 to establish a data base from which the controversies surrounding this disease can be viewed. Standard treatment involved a radical inguinal orchiectomy as primary therapy. Stage I patients received adjuvant radiation to para-aortic and ipsilateral iliac nodes, with additional radiation given routinely to the mediastinum of patients with Stage II disease. No major complications were observed. All Stage I patients remain free of recurrent tumor with a median follow-up of eight years. There were 4 deaths from seminoma among the Stage II patients. The use of prophylactic mediastinal radiation for Stage II patients, and observation only for Stage I patients are reviewed in light of our results and other published series. While early evidence suggests that both approaches may be reasonable, their adoption awaits confirmation by prospective trial.