Complications from large field intermediate dose infradiaphragmatic radiation: an analysis of the patterns of care outcome studies for Hodgkin's disease and seminoma

Long-Term Results of IFRT vs. ISRT in Infradiaphragmal Fields in Aggressive Non-Hodgkins's Lymphoma Patients-A Single Centre Experience

(1) Background: This study aimed to examine the difference in efficacy and toxicity of involved-field (IFRT) and involved-site radiotherapy (ISRT) fields in infradiaphragmal aggressive non-Hodgkin lymphoma patients. (2) Methods: In total, 140 patients with infradiaphragmal lymphoma treated between 2003 and 2020 were retrospectively evaluated. There were 69 patients (49%) treated with IFRT, and 71 (51%) patients treated with ISRT. The median dose in the IFRT group was 36 Gy, (range 4-50.4 Gy), and in the ISRT group, it was 30 Gy (range 4-48 Gy). (3) Results: The median follow-up in the IFRT group was 133 months (95% CI 109-158), and in the ISRT group, it was 48 months (95% CI 39-57). In the IFRT group, locoregional control was 67%, and in the ISRT group, 73%. The 2- and 5-year overall survival (OS) in the IFRT and ISRT groups were 79% and 69% vs. 80% and 70%, respectively (p = 0.711). The 2- and 5-year event-free survival (EFS) in the IFRT and ISRT groups were 73% and 68% vs. 77% and 70%, respectively (p = 0.575). Acute side effects occurred in 43 (31%) patients, which is more frequent in the IFRT group, 34 (39%) patients, than in the ISRT group, 9 (13%) patients, p > 0.01. Late toxicities occurred more often in the IFRT group of patients, (10/53) 19%, than in the ISRT group of patients, (2/37) 5%, (p = 0.026). (4) Conclusions: By reducing the radiotherapy volume and the doses in the treatment of infradiaphragmatic fields, treatment with significantly fewer acute and long-term side effects is possible. At the same time, efficiency and local disease control are not compromised.

Efficacy and toxicity of infradiaphragmal radiotherapy fields in lymphoma patients: a single-centre experience

PURPOSE

Data on efficacy and toxicity of infradiaphragmal radiotherapy fields in lymphoma patients are scarce. We therefore performed this retrospective study to analyse our experience with radiotherapy exclusively to infradiaphragmal fields.

MATERIALS AND METHODS

we retrospectively evaluated 101 patients treated between 2003 and 2014. Median dose was 36 Gy, range 4 to 54 Gy. Medium dose per fraction was 2 Gy, range 1.5 to 7 Gy.

RESULTS

After a median follow-up of 66 months (range 1-211 months), we observed lymphoma recurrence in 38 patients (38%), five in the RT field and 33 out-of-field. Recurrences were significantly more frequent in the salvage group (17 out-of-field and 4 in-field in 31 patients) than in adjuvant group (16 out-of-field and 1 in-field in 70 patients; p < 0.001). The 2-, 5- and 10-year event-free survival (EFS) rates were 62%, 56% and 54%. The 2-, 5- and 10-year overall survival (OS) rates for the entire group of patients are 73%, 60% and 54%, respectively. Acute side effects occurred in 43 (43%) patients, most frequent gastrointestinal in 26 (26%) patients. Late side effects occurred in 12 (12%) of all patients, 6 of 23 (26%) followed up for more than 10 years. Six patients developed secondary cancers, four gastrointestinal disturbances, two diabetes mellitus and three renal failure.

CONCLUSION

Radiotherapy is an effective and safe treatment option for patients with infradiaphragmatic lymphoma providing excellent local disease control with minimal late toxicity. Infradiaphragmatic lymphoma localization should not be regarded as a contraindication for use of radiotherapy. However, patients should be monitored for a secondary malignancy.

Long-Term Results in Patients Affected by Testicular Seminoma Treated with Radiotherapy: Risk of Second Malignancies

Aims

To report clinical results in patients with testicular seminoma treated with postoperative radiotherapy with regard to survival, acute and late toxicity, and risk of second malignancy.

Materials and methods

176 stage I-II testicular seminoma patients treated with radiotherapy from 1964 to 1994 at the Radiotherapy Division of Pisa University, using 60Co or Linac, were analyzed retrospectively. The follow-up ranged from 0.13 to 32.37 years, with a median of 12.1 years. The observed numbers of second malignancies were compared with those expected, taking into account age, sex, and incidence rates from the Tuscany Tumor Registry.

Results

Overall and specific survival at 10-15 years were 89-82% and 93-92%, respectively. Multivariate analysis revealed a significantly better survival in patients younger than 50 years and in those treated with Linac. Severe late sequelae occurred in 8% of the patients. Sixteen second malignancies were observed (14 solid tumors and 2 leukemias); median latency was 13 years (range, 3-27) and the observed/expected ratio 1.4 ( P not significant). Solid cancers were localized in the bladder (2), kidney (2), skin (2), stomach (1), prostate (1), lung (1), larynx (1), uvea (1) and contralateral testicle (1); 1 patient presented an intestinal carcinoid and 1 a metastasis from an unknown primary. The risk of a second malignancy was higher in the patient group receiving less than 4000 cGy (observed/expected, 2.8; P = 0.015).

Conclusions

The study confirmed the high cure rate in stage III seminomas after postoperative radiotherapy. Incidence of a second malignancy was higher than expected, but the difference was not statistically significant.

Stage I Seminoma of the Testis: Long Term Results and Toxicity with Adjuvant Radiotherapy

Aims and background

Pure testicular seminoma has historically been treated with post-orchidectomy radiation therapy with excellent results. Recently, several aspects of the treatment of stage I seminoma have been questioned. We assessed long-term results and toxicity of patients with pure testicular seminoma treated at the Department of Radiation Oncology of S. Chiara Hospital, Trento.

Methods

From 1953 to 1987, 102 patients with stage I pure testicular seminoma were given megavoltage irradiation with curative intent. All patients had a minimum follow-up of 3 years (maximum 37 years, median 13 years). They received a mean para-aortic/pelvic dose of 33.07 Gy (range 23.70-45.20 Gy) with different doses and fields reflecting the change in techniques over a long period of time.

Results

The cause-specific actuarial survival at 30 years was 99% and crude survival 67%. One patient had an out-field relapse (inguinal) after a few months and was cured with radiotherapy and chemotherapy. Another patient relapsed with widespared metastases and died after 1 year of progressive disease. Early toxycity was mild and the treatment was well tolerated. Late side effects were reported in 8/102 patients.

Conclusion

In our series adjuvant radiation therapy resulted in cure rates corresponding to those reported in the literature. The 30-year actuarial survival of 99% was extremely good and the toxicity of the treatment was mild. Post-orchidectomy radiation to the para-aortic and ipsilateral pelvic nodes is a safe and effective method of preventing recurrences and is currently to be considered the treatment of choice in stage I testicular seminoma.

Bone marrow-sparing intensity-modulated radiation therapy for Stage I seminoma

BACKGROUND

A direct association between radiotherapy dose, side-effects and secondary cancers has been described in patients with seminoma. A treatment planning study was performed in order to compare computed tomography-based traditional radiotherapy (CT-tRT) versus bone marrow-sparing intensity-modulated radiation therapy (BMS-IMRT) in patients with Stage I seminoma.

MATERIAL AND METHODS

We optimized in 10 patients a CT-tRT and a BMS-IMRT treatment plan to deliver 20 Gy to the para-aortic nodes. CT-tRT and IMRT consisted of anteroposterior-posterioranterior parallel-opposed and seven non-opposed coplanar fields using 16 and 6-MV photon energies, respectively. Dose-Volume Histograms for clinical target volume (CTV), planning target volume (PTV) and organs at risk (OARs) were compared for both techniques using Wilcoxon matched-pair signed rank-test.

RESULTS

D(mean) to CTV and PTV were similar for both techniques, even if CT-tRT showed a slightly improved target coverage in terms of PTV-D(95%) (19.7 vs. 19.5 Gy, p = 0.005) and PTV-V(95%) (100 vs. 99.7%, p = 0.011) compared to BMS-IMRT. BMS-IMRT resulted in a significant reduction (5.2 Gy, p = 0.005) in the D(mean) to the active bone marrow (ABM). The V(100%) and V(75%) of the OARs were reduced with BMS-IMRT by: ABM-V(100%) = 51.7% and ABM-V(75%) = 42.3%; bowel-V(100%) = 15.7% and bowel-V(75%) = 16.8%; stomach-V(100%) = 22% and stomach-V(75%) = 27.7%; pancreas-V(100%) = 37.1% and pancreas-V(75%) = 35.9% (p = 0.005 for all variables).

CONCLUSIONS

BMS-IMRT reduces markedly the dose to the OARs compared to CT-tRT. This should translate into a reduction in acute and long-term toxicity, as well as into the risk of secondary solid and hematological cancers.

Evolving role of radiation therapy for hematologic malignancies

Radiation therapy continues to play a paramount role in the therapy of hematologic malignancies, whether as definitive therapy, as consolidation after chemotherapy, as part of bone marrow transplantation protocols, or in palliation. During the past 2 decades, significant advances in radiation therapy have occurred, including the evolution of involved-field irradiation and the adoption of conformal radiation administration. It is hoped that modern techniques will reduce the long-term sequelae associated with radiation-based treatments.

Adverse effects after radiotherapy for early stage (I,IIa,IIb) seminoma

BACKGROUND AND PURPOSE

The evaluation of adverse effects after radiotherapy for early stage (I,IIa,IIb) seminoma.

PATIENTS AND METHODS

A retrospective analysis of 164 patients with stage I, IIa, IIb seminoma treated with post-orchidectomy irradiation, between 1974 and 1990 was performed. Patients had been treated with infradiaphragmatic radiotherapy only (IDRT) in 48%, and prophylactic mediastinal and left supraclavicular irradiation (supradiaphragmatic radiotherapy, SDRT) was performed additionally in the remaining 52% of patients. Median follow-up was 12 years. The incidence of late morbidity was evaluated with respect to treatment-related factors like: PTV, number of fields irradiated each day, beam energy, total dose and dose per fraction. Afterwards, the dose distribution in normal tissues-based on dose per fraction at 3 cm depth and total dose at 3 cm depth, was evaluated in relation to late morbidity.

RESULTS

Overall 5-year and 10-year survival was 92 and 86%. For IDRT, dose per fraction at midline and dose per fraction from AP field at 3 cm depth were not significantly associated with Gastro-Intestinal morbidity. For SDRT, dose per fraction at 3 cm depth from AP field was significantly associated with cardiac morbidity (mean-1.98 Gy in patients without and 2.27 Gy in patients with cardiac morbidity P=0.006), however total dose at 3 cm was not significantly associated with cardiac morbidity. Dose per fraction at 3 cm depth from AP field significantly (P=0.047) influenced cardiac morbidity probability in multivariate logistic regression, which included patients' age, smoking habits and total dose at 3 cm.

CONCLUSIONS

Excessive dose maximum in normal tissues from each fraction to anterior mediastinum is associated with increased cardiac morbidity.

Quality of life after radiotherapy for early-stage testicular seminoma

BACKGROUND AND PURPOSE

Standard therapy in early-stage testicular seminoma (TS) includes inguinal orchiectomy followed by irradiation (XRT) of the pelvic and para-aortic nodes. Since this treatment is highly effective in controlling the disease and leads to many long survivors, the quality of life (QL) may be impaired by treatment-induced side-effects. The aim of this study was to provide a QL evaluation of patients treated with XRT after orchiectomy for TS.

MATERIALS AND METHODS

We used a validated self-completed questionnaire based on a series of 44 items covering all QL fields. The items were grouped into six subscales with standardized scores. The questionnaire was mailed to a consecutive series of 143 patients treated between 1961 and 1995 for TS with no evidence of disease after primary treatment.

RESULTS

Ninety-eight questionnaires (68.5%) were returned and are assessable. The median age of the patients was 48 years (range, 26-85 years) at the time of completing the questionnaire, with a median follow-up after completion of treatment of 123 months (range, 15-432 months). The physical and autonomy subscale standardized scores were > or =1 in 83 and 95% of the cases, respectively. Psychological problems were reported by a small percentage of patients, ranging from 13, who reported a depressive condition, to 16%, who declared feeling tense. Of the patients, 86 and 89% have regularly met relatives and friends. The urinary score was above the central point in 99% of the patients. Only 6% of the patients perceived their body image as worsened by treatment. The patients who were more informed about the disease and therapy had a better physical and psychological adjustment.

CONCLUSIONS

The QL in our patients resulted as satisfactory, with a maintained body image and few side-effects. The information given to the patients about their disease and its treatment influenced the post-treatment QL adjustment.

The optimal dose of radiation in Hodgkin's disease: an analysis of clinical and treatment factors affecting in-field disease control

PURPOSE

The purpose of this study is to analyze the effect of radiation dose, as well as other clinical and therapeutic factors, on in-field disease control.

PATIENTS AND MATERIALS

The study population comprised 232 patients with Stage I and II Hodgkin's disease (HD) treated with curative intent at the University of Florida with radiotherapy (RT) alone (169 patients) or chemotherapy and radiotherapy (CMT) (63 patients). Sites of involvement and radiation doses were prospectively recorded and correlated with sites of disease recurrence.

RESULTS

Freedom from relapse and absolute survival rates at 10 years were as follows: 76% and 77%, entire group; 76% and 80%, RT group; 79% and 70%, CMT group; 85% and 78%, Stage I; and 71% and 77%, Stage II. Treatment failure occurred in 50 patients (22%) including in-field failure in 22 patients (9%). In-field failure was rare in electively treated sites. Multivariate analysis of clinical factors (tumor size, number of sites involved, B-symptoms, gender, histology, age, and site of involvement) and treatment factors (use of chemotherapy, number of cycles of chemotherapy, radiation dose, radiation treatment volume, and radiation treatment time) showed only tumor size (p = 0.0001) to be significantly correlated with in-field disease control. In RT patients, the in-field failure rate according to tumor size was as follows: 0% for < or = 3 cm; 4% for > 3 cm and < or = 6 cm; 23% for > 6 cm and < or = 9 cm; and 36% for > 9 cm. In CMT patients, the in-field failure rate was as follows: 0% for < or = 3 cm; 0% for > 3 and < or = 6 cm; 5% for > 6 cm and < or = 9 cm; and 26% for > 9 cm. In-field recurrence was not a predominant pattern of failure in RT patients with small tumors (< or = 6 cm); thus, the difference in in-field control in tumors < or = 6 cm between doses < or = 35 Gy (6%) and doses > or = 36 Gy (0%) was not statistically significant. In larger tumors (> 6 cm), in-field recurrence was a predominant pattern of failure; the in-field failure rate in RT patients with tumors > 6 cm of 30% for doses < or = 35 Gy was not significantly different from 25% for doses > 35 Gy. In moderately bulky tumors (> 6 cm and < or = 9 cm), the addition of chemotherapy did appear to increase in-field disease control; the in-field failure rate was 23% with RT and 5% with CMT (p = 0.07).

CONCLUSION

Our data do not demonstrate statistically significant evidence of increasing tumor control in HD with doses > 30 Gy. The data do show that increasing tumor size is associated with increased rates of in-field failure, and the addition of chemotherapy may improve in-field disease control in tumors > 6 cm. In-field recurrence in large tumors remains a predominant pattern of failure, however, and the role of radiation doses higher than 30-35 Gy in this high-risk subset warrants further study.

Results of the 1988-1989 Patterns of Care Study process survey for Hodgkin's disease

PURPOSE

To document national standards of care for patients receiving radiotherapy as part of curative treatment for Hodgkin's disease.

MATERIALS AND METHODS

A national survey was conducted of 61 institutions treating 275 patients with Stages I-III Hodgkin's disease and representing six facility type strata. Pretreatment evaluation, radiotherapy treatment parameters, and use of combined modality therapy were assessed.

RESULTS

Ann Arbor stage for the 275 patients was as follows: IA, 69 (25%); IB, 7 (3%); IIA, 123 (45%); IIB, 36 (13%); IIIA 23 (8%), IIIB, 14 (5%); unknown, 3 (1%). Pretreatment evaluation included complete blood count for 93%, sedimentation rate in 29%, chest CT in 88%, abdominal CT scan in 87%, and bone marrow biopsy in 81%. Lymphangiograms were obtained in 50% of cases; laparotomy was performed in 46%. The yield of positive findings in the spleen at laparotomy was 6.5 % overall. Facility differences with respect to staging were seen only for the use of gallium scans, which were more commonly used in academic centers (44% vs. 15-23% elsewhere, p<0.001). Radiotherapy was delivered with a linear accelerator in 94% of cases. Treatment simulation was performed for 94% and individualized blocks constructed for 95% overall; however, freestanding facilities had a lower rate of performance of these procedures (78% vs. 98-99% for simulation and 88% vs. 96-99% for customized blocking, p<0.001). The mean supradiaphragmatic dose was 36.74 Gy and the mean subdiaphragmatic dose was 33.81 Gy. Planned combined modality therapy was given in 36% of patients. The use of combined modality therapy by stage was as follows: IA, 11%; IB, 43%; IIA, 30%; IIB, 68%; IIIA, 57%; IIIB, 100%. Chemotherapy was completed prior to radiation in 80% of cases and generally consisted of ABVD (32%), an alternating regimen (25%), or MOPP (22%). Among Stage I/II patients, use of chemotherapy was associated with reduced radiation doses (mean supradiaphragmatic dose 34.53 Gy vs. 38.43 Gy and mean subdiaphragmatic dose 31.27 Gy vs. 34.51 Gy), and reduced volumes of treatment (87% vs. 28% treated to one side of the diaphragm only). Laparotomy was not associated with decreased supra- or subdiaphragmatic radiation doses or decreased volumes of treatment.

CONCLUSIONS

With the exception of gallium scans, pretreatment evaluation is relatively uniform across facility strata. Increased understanding of prognostic factors in Hodgkin's disease and greater use of planned combined modality therapy for higher risk patients appears to have contributed to a decreased use of and low yield of positive findings for laparotomy. Laparotomy was not associated with reduced radiation volumes or doses. Freestanding radiation facilities had a lower rate than other facility types for the performance of treatment simulation and customized patient blocking.

Management and long-term complications of pediatric cancer

The impact of recently intensified and novel therapies for the treatment of childhood cancer has been an increased number of survivors and an increase in the number of treatment complications among survivors. Thus, it is important for the primary care practitioner to be aware of not only acute but chronic complications of therapy, including the possibility of second malignancies. Long-term follow-up is essential, and continuous education of patients and health care personnel is an important aspect for the complete success of treatment. Primary care practitioners also need to incorporate other subspecialties in the management of these patients to ensure that they receive complete evaluation and treatment.

[D-xylose test of resorption as a method to determine radiation side effects in the small intestine]

BACKGROUND

The D-xylose test is the most important method to determine a disorder of carbohydrates resorption in proximal small intestine. The application is based on an impaired resorption due to pathological change of small intestine surface, leading to a decreased blood level or decreased excretion in urine.

PATIENTS AND METHOD

D-xylose test was applied in 91 patients before, shortly after, 1/2 and 1 year after radiotherapy. All patients received an abdominal radiotherapy. We determined the blood level of D-xylose by a capillary blood sample 1 hour after oral D-xylose administration.

RESULTS

A significant decrease of the mean blood level of D-xylose to 1.88 mmol/l was determined after radiotherapy in comparison with 2.17 mmol/l before radiotherapy. Half a year after radiotherapy the mean blood level of D-xylose returned to normal. Regarding a threshold value of D-xylose blood level of 1.70 mmol/l 29 patients (32%) showed a pathologically decreased D-xylose resorption after radiotherapy. Twenty out of the 29 patients already showed a normal resorption half a year after the determination of the resorption disorder, 5 patients after 1 year and 4 patients after 1 1/2 years. There was no correlation between the detection of a disorder of D-xylose resorption and of a loss of body weight. The acute clinical side effects seemed to be more marked in connection with a disorder of D-xylose resorption, but this correlation is not significant. Eleven or 14 of the 29 patients, respectively, with pathologically decreased D-xylose resorption only had complaints of lower or upper gastrointestinal tract, respectively, and 10 patients did not have abdominal complaints at all.

CONCLUSIONS

The D-xylose test is an important and simple method for determination of radiogen induced carbohydrate malabsorption in proximal small intestine. By means of it radiation side effects on small intestine can also be determined in patients who are otherwise free of complaints.

Radiation techniques for the treatment of Hodgkin's disease with combined modality therapy or radiation alone

This article reviews radiation techniques including field arrangements, anatomic borders, and doses for the treatment of Hodgkin's disease when radiotherapy is being used as the sole treatment and when it is part of a planned combined modality program with chemotherapy. We describe the techniques currently in use at Duke University Medical Center. Particular emphasis is placed on the evidence regarding the appropriate extent of the treatment field and the doses of radiation necessary to achieve local control. These issues assume increasing importance as we attempt to maintain high cure rates for Hodgkin's disease but lower the frequency of serious long-term complications.

Radiotherapy in stage IIA and IIB testicular seminoma with reduced portals: a prospective multicenter study

PURPOSE

A prospective multicenter study was carried out to estimate the treatment outcome of radiotherapy in Stage II seminoma after the application of modern staging and radiotherapy techniques. The lower margin of the iliac field was positioned on the upper rim of the acetabulum to reduce the amount of scattered irradiation to the remaining testicle.

METHODS AND MATERIALS

The study was carried out in 25 centers in Germany. Patients with pure seminoma, negative AFP-values, and retroperitoneal lymph node metastases of less than 5 cm in diameter were entered into the study. All patients received a ventrodorsal opposed field irradiation of the para-aortic and the ipsilateral iliac lymph nodes. The fields extended from the top of the 11th thoracic vertebra to the top of the acetabulum. Patients in Stage IIA (lymph nodes <2 cm ) received 30 Gy, and patients with Stage IIB (lymph nodes between 2 and 5 cm) 36 Gy total dose.

RESULTS

39 patients in Stage IIA and 19 patients in Stage IIB were evaluated. After a median observation time of 37 months all patients are alive and disease free. Recurrence free survival in stage IIA was 100%. Two patients in Stage IIB experienced a recurrence 10 and 17 months after the end of radiotherapy. The actuarial recurrence free survival estimate in Stage IIB was 94.1% for 1 year and 87.4% for 2 years. One recurrence in Stage IIB occurred in the mediastinum, one in the mediastinum, and one the lung. Both patients could be salvaged by chemotherapy. There were no pelvic recurrences. The treatment was well tolerated, with nausea being the most common side effect (56.9% Grade 1, 15.5% Grade 2, and 8.6% Grade 3). Diarrhea occurred in 15.5% (Grade 1), 15.5% (Grade 2), and 5.2% (Grade 3) of the patients.

CONCLUSIONS

The outcome of para-aortic and ipsilateral iliac irradiation in Stage IIA/B testicular seminoma is excellent with the currently available staging methods and treatment facilities. The treatment is well tolerated. The lower margin of the iliacal field can be placed at the acetabulum.

Combined modality therapy for early Hodgkin's disease: heterogeneity in Australasian clinical practice

Two case studies of locally extensive clinical stage IIA Hodgkin's disease (HD) were presented to radiation oncologists at a meeting of the Australasian Radiation Oncology Lymphoma Group, and subsequently to non-attending members who were asked to indicate their recommended treatment. This paper discusses the 25 responses which were notable by considerable heterogeneity in philosophy and detail. There is clearly no consensus among Australasian radiation oncologists at present, although combined modality therapy (CMT) with Adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by low-medium-dose involved field radiotherapy (25-36 Gy) was the most popular response. The literature on radiation dose and chemotherapy in CMT for HD is then reviewed. It seems very likely that low doses in the range of 25-30 Gy (at 1.5-2.0 Gy per fraction) are sufficient. The ABVD should be considered as the 'standard' regimen at present, although the optimal sequencing with radiation and number of cycles remain unknown. The heterogeneity of responses to management of the case studies raises questions about ongoing education processes in radiation and medical oncology. Hypothetical case management review may complement currently proposed methods of assessing continuing medical education.

External beam abdominal radiotherapy in patients with seminoma stage I: field type, testicular dose, and spermatogenesis

PURPOSE

To establish a predictive model for the estimation of the gonadal dose during adjuvant para-aortic (PA) or dog leg (DL: PA plus ipsilateral iliac) field radiotherapy in patients with testicular seminoma.

METHODS AND MATERIALS

The surface gonadal dose was measured in patients with seminoma Stage I receiving PA or DL radiotherapy. Sperm cell analysis was performed before and 1 year after irradiation. PA and DL radiotherapy were simulated in the Alderson phantom while we measured the dose to the surface and middle of an artificial testicle, varying its position within realistic anatomical constraints. The symphysis-to-testicle distance (STD), field length, and thickness of the patient were experimental variables. The developed mathematical model was validated in subsequent patients.

RESULTS

The mean gonadal dose in patients was 0.09 and 0.32 Gy after PA and DL irradiation, respectively (p < 0.001). DL radiotherapy, but not PA irradiation led to significant reduction of the sperm count 1 year after irradiation. The gonadal dose-reducing effect of PA irradiation was confirmed in the Alderson phantom. A significant correlation was found between the STD and the gonadal dose during DL irradiation. A mathematical model was established for calculation of the gonadal dose and confirmed by measurements in patients.

CONCLUSIONS

During radiotherapy of seminoma, the gonadal dose decreases with increasing STD. It is possible to predict the individual gonadal dose based on delivered midplane dose and STD.

Hodgkin's disease. Treatment sequelae and quality of life

Hodgkin's disease is considered a curable disease. The use of appropriate staging techniques and treatment methods has resulted to long-term cause-specific survival rates as high as 90% in early stages, 75% or greater in advanced stages. Long-surviving Hodgkin's disease patients, however, face new problems which have become apparent as greater numbers of successfully treated patients are followed for longer periods of time. These problems mostly concern chronic medical as well as psychosocial complications which can interfere with survivors' quality of life. Specific therapy may result in severe infections, thyroid, cardiovascular, pulmonary, digestive or gonadal dysfunction. It may also result in secondary malignancy which is considered the most serious complication. Because the vast majority of patients who achieve remission will remain symptom-free and do enjoy a normal life, long-term follow-up should concentrate on prevention and early detection of treatment-related complications and of secondary malignancy.

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.

Late complications after Hodgkin's disease

Hodgkin's disease is considered a curable disease. The use of appropriate staging techniques and treatment methods has resulted in long-term survival rates as high as 90% in early stages, 75% or greater in advanced stages. Long-surviving Hodgkin's disease patients, however, face new problems which have become apparent as greater numbers of successfully treated patients are followed for longer periods of time. They concern mostly chronic medical as well as psychosocial complications which can interfere with survivors quality of life. Hodgkin's disease therapy may result in severe infections, thyroid, cardiovascular, pulmonary, digestive or gonadal dysfunction. It may also result in secondary malignancy which is considered the most serious complication. This review focuses on the variety of medical problems considering subsequent nonmalignant complications, secondary malignancies, long-term patient quality of life and causes of death. Because the vast majority of patients who achieve remission remain symptom-free and enjoy a normal life, an attempt is made to provide estimated risk for individuals based on available data.

Adjuvant carboplatin treatment for seminoma clinical stage I

The traditional adjuvant therapy for seminoma stage I is abdominal radiotherapy. Although the relapse rate ranges below 5% this treatment is challenged because concerns about adverse late effects are accumulating. Carboplatin is effective in metastatic seminoma and two pilot studies have indicated effectivity in the adjuvant setting also. As this drug is almost non-toxic in moderate doses it could be an ideal adjuvant treatment for seminoma stage I. A group of 82 patients, mean age 37.5 years (range 22-73 years), with histologically pure seminoma stage I, were given carboplatin 400 mg/m2 after orchiectomy; 60 patients received only one course of carboplatin, and 22 patients received two courses. The median time of observation is 24 months, ranging from 2 to 48 months, and 66 patients have a minimum follow-up of 1 year. There is one relapse so far. Toxicity is rather mild with no severe nausea/emesis. Mean platelet counts were 164/nl after 3 weeks and 208/nl after 4 weeks; thus, myelotoxicity was negligible. Gonadal toxicity was measured by serial follicle-stimulating hormone levels. The mean level was 11.4 U/l before treatment, and 16.2 U/l after 5 weeks, 17.3 U/l after 4 months, 14.5 U/l after 8 months and 13.5 U/l after 12 months. Thus, gonadal toxicity also appeared to be mild. In summary, the efficacies of adjuvant carboplatin and of abdominal radiotherapy seem to be identical. As carboplatin, in the dosage used, involves no severe acute side-effects and probably few late adverse effects, this regimen constitutes a promising new treatment option in seminoma patients stage I that deserves to be studied in randomized trials.

Radiotherapy for stages I and II testicular seminoma: results and morbidity in 238 patients

We have undertaken a retrospective analysis of 238 patients with Stages I and II seminoma of the testis treated with radiotherapy in Edinburgh between 1974 and 1989. There were five deaths from seminoma. Cause-specific survival for the whole group at 2 and 5 years was 99.2% and 98.1%, respectively. Cause-specific survival at 2 and 5 years by stage (Royal Marsden staging classification) was: Stage I, 99.5% and 98.7% and Stage II, 98.1% and 96.1%. Fourteen (5.9%) patients relapsed (one after treatment for his second testicular seminoma). Eight were given successful salvage treatment, five died of seminoma and one died of intercurrent disease. 13 (5.5%) patients developed World Health Organisation (WHO) grade 3 gastrointestinal or haematological toxicity and two developed grade 4 gastrointestinal toxicity as a result of abdominal radiotherapy. 22 patients (9.2%) developed problems ascribed to late morbidity of abdominal radiotherapy including 18 with peptic ulcer disease. Contralateral testicular tumours occurred in seven (2.9%) patients and five (2.1%) patients developed malignancies at other sites.

Late effects of radiation therapy on the gastrointestinal tract

Late gastrointestinal complications of radiation therapy have been recognized but not extensively studied. In this paper, the late effects of radiation on three gastrointestinal sites, the esophagus, the stomach, and the bowel, are described. Esophageal dysmotility and benign stricture following esophageal irradiation are predominantly a result of damage to the esophageal wall, although mucosal ulcerations also may persist following high-dose radiation. The major late morbidity following gastric irradiation is gastric ulceration caused by mucosal destruction. Late radiation injury to the bowel, which may result in bleeding, frequency, fistula formation, and, particularly in small bowel, obstruction, is caused by damage to the entire thickness of the bowel wall, and predisposing factors have been identified. For each site a description of the pathogenesis, clinical findings, and present management is offered. Simple and reproducible endpoint scales for late toxicity measurement were developed and are presented for each of the three gastrointestinal organs. Factors important in analyzing late complications and future considerations in evaluation and management of radiation-related gastrointestinal injury are discussed.

Testicular seminoma: 20-year experience at the Northern Israel Oncology Center (1968-1988)

Eighty-four patients with testicular seminoma were treated at the Northern Israel Oncology Center during the years 1968-1988. Using the staging classification of Hussey, 69 patients (82%) had Stage I, eight (10%) had Stage IIA, four (5%) had Stage IIB, one (1%) had Stage IIIA, and two (2%) had Stage IIIB disease. Sixty-nine patients (82%) had classic pure seminoma, nine (11%) had anaplastic seminoma and six (7%) had spermatocytic seminoma. Seventy-four patients (88%) underwent high inguinal orchiectomy and ten (12%) had a scrotal approach. Seventy-five patients (85%) were treated with postoperative irradiation. Stage I patients received 26-30 Gy to the paraaortic and ipsilateral pelvic lymph nodes. Stage IIA patients were treated in the same manner with a boost to the involved lymph nodes. With a mean follow-up of 97 months, 65 patients (77%) are alive and well with no evidence of disease, 7 patients (8%) are dead due to disease progression. The 5-, 10-, 15-, and 20-year actuarial survival for all patients was 90%, and for early stage patients 94%. Eight patients (14%) relapsed; 3 of them were salvaged by chemotherapy. Serious side effects of irradiation included lethal respiratory failure due to bleomycin-induced pulmonary fibrosis in one patient, peptic ulcer in three patients, hydronephrosis due to paraureteral fibrosis in one patient and recurrent paralytic ileus in one patient. Eight patients (10%) developed nine second cancers, three of them within the previous radiation field.(ABSTRACT TRUNCATED AT 250 WORDS)

The importance of staging laparotomy in pediatric Hodgkin's disease

The findings of 247 pediatric patients who presented with supradiaphragmatic Hodgkin's disease and underwent staging laparotomies between April 1969 and December 1991 were reviewed to assess the importance of the staging laparotomy in pediatric Hodgkin's disease. A change in stage occurred in 25% of the cases reviewed. Fifty of the 202 (25%) clinical stage (CS) I or II patients were upstaged to pathological stage (PS) III or IV, and 12 of the 45 (27%) clinical stage III or IV patients were downstaged to pathological stage I or II. Possible risk factors for positive surgical staging, including gender, age, presence or absence of B symptoms, extent of involvement above the diaphragm, and histological type, were used to define subgroups of patients. Three statistically significant subgroups of patients with less than a 10% chance of restaging were identified. These groups included CS I and II patients with lymphocyte-predominant histology, CS I females, and CS III and IV females with nonlymphocyte predominant histology. These subgroups represent 24% of the cohort. Because CS is an accurate predictor of PS in these groups, treatment could be based solely on CS. The impact of radiographic imaging techniques on correctly predicting pathological stage was assessed. The rates of restaging for individuals with lymphangiography or computed axial tomography were not statistically different from those of patients without these radiographic studies. Therefore, abdominal imaging is not a substitute for surgical staging. No mortality and 2.8% morbidity occurred from staging laparotomy. Postsplenectomy sepsis and small bowel obstruction were the most common complications. Ninety-six percent of upstaged patients had splenic involvement, and 54% had positive nodal involvement.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Radiation therapy for early stage seminoma of the testis. Analysis of survival and gastrointestinal toxicity in patients treated with modern megavoltage techniques over 10 years

Seventy-seven patients treated with megavoltage irradiation to the para-aortic and/or pelvic nodal areas, for stage I and non-bulky (< 5 cm) stage II seminoma of the testis, were studied at the Royal Adelaide Hospital from 1981 to 1990. The aim was not only to assess overall and relapse-free survival, but also early and late gastrointestinal toxicity in a group of patients treated in a uniform manner using modern techniques. The 10 year actuarial survival was 96.1% for all patients, being 95.6% for stage I and 100% for stage II. The 10 year actuarial complication rate for all late gastrointestinal effects was 9.1%. This consisted of a 6.5% risk of peptic ulceration and a 2.6% risk of chronic diarrhoea at 10 years. At least one acute gastrointestinal effect occurred during radiotherapy in the vast majority of patients (90.9%). Analysis of the effect of age (< or = 34 years vs > 34 years), stage (I vs II) and dose of radiation (< or = 30 Gy vs > 30 Gy), showed none of these variables to have a significant influence on overall survival or on the incidence of late complications. The results of these findings are discussed in the light of recent studies of a surveillance policy following orchidectomy for stage I seminoma of the testis. Given that gastrointestinal toxicity is the major toxicity associated with the treatment of stage I patients, the data from this study should assist clinicians and their patients to arrive at an informed decision regarding adjuvant radiotherapy.

Results of a policy of surveillance in stage I testicular seminoma

PURPOSE

To determine what proportion of patients with Stage I testicular seminoma will be cured with orchidectomy alone.

METHODS AND MATERIALS

From August 1984 to December 1991 148 patients with Stage I testicular seminoma were entered on a prospective study of surveillance following orchidectomy. The eligibility criteria included a normal chest X ray, lymphogram, computed tomography (CT) of the abdomen and pelvis, and normal post-orchidectomy tumor markers (AFP and BHCG). Patients were followed with a clinical assessment (markers, chest X ray and CT abdomen and pelvis) at 4 to 6 monthly intervals.

RESULTS

With a median follow-up of 47 months (range 7-87 months), the actuarial relapse-free rate was 81% at 5 years. Twenty-three patients have relapsed with a median time to relapse of 15 months (range 2-61 months). Four patients (17%) relapsed at 4 or more years from diagnosis. Twenty-one of the 23 relapses occurred in the paraaortic lymph nodes, one patient relapsed in the mediastinum and ipsilateral inguinal nodes and one patient had an isolated ipsilateral inguinal node relapse. Nineteen patients were treated for relapse with external beam radiation therapy of which three developed a second relapse and were salvaged with chemotherapy. Four patients were treated for first relapse with chemotherapy and one developed a second relapse and died of disease. Age at diagnosis was the only prognostic factor for relapse, with patients age < or = 34 having an actuarial relapse-free rate at 5 years of 70% in contrast to a 91% relapse-free rate in those > 34 years of age.

CONCLUSIONS

We recommend that surveillance in Stage I testicular seminoma should only be performed in a study setting until further data regarding the risk of late relapse and the efficacy of salvage chemotherapy is available.

Sexual morbidity following radiotherapy for germ cell tumours of the testis

An anonymous questionnaire study was designed to assess sexual function after orchidectomy and radiotherapy for testicular cancer. Questionnaires were sent to: (1) 237 patients treated with orchidectomy and abdominal radiotherapy in Edinburgh from 1974 to 1988; (2) 32 patients under "surveillance" following orchidectomy alone; (3) 402 "normal" age-matched controls. All were asked questions concerning sexual function over the preceding 6 months. All the patients were also asked the same questions with reference to the first 6 months after completion of treatment. Completed questionnaires were returned from 137 (62%) radiotherapy patients, 18 (56%) surveillance patients and 121 (35%) controls. There was a significant difference between the radiotherapy patients and the controls in almost all the parameters looked at including erection, ejaculation and libido with the treated group performing less well. In addition, almost 24% of the radiotherapy patients felt disabled or disfigured by the treatment, most commonly because of the presence of only one testicle. A deterioration in sexual function was observed with increasing age. In the radiotherapy group of patients there was no difference in response between the two time periods or in any of the treatment variables. The clinical significance of these observations are unclear but together with the increasing information on other toxicities emerging following this therapy the role of radiation for early stage seminoma is being brought into question. This study also confirms the morbidity of orchidectomy. We suggest that testicular implants should be offered more widely.

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.

An updated dose-response analysis in Hodgkin's disease

Although radiotherapy cures a very high percentage of early stage patients with Hodgkin's disease (HD), there is a controversial dichotomy in the dose recommendations believed necessary to achieve greater than 95% local control: Whereas one school of thought is to administer 40-44 Gy, other reports claim equal results with about 36 Gy. It is also not clear what doses are required for various tumor cell burdens. The original recommendation of 40-44 Gy was derived from a retrospective analysis of in-field control of disease from mostly kilovoltage data three decades ago. However, there have been many advances in the evaluation of the extent of the disease and in the practice of radiotherapy since the 1960s. Many more dose-control studies have been published in recent years, necessitating a revisit to the dose-response question in HD. Here we have compiled the dose-control data from the 60s to the 90s and analyzed the original and the updated data with the same statistical method to see any differences. We also have performed similar analysis of dose-control information for subclinical disease, less than 6 cm and greater than 6 cm disease. Whereas original analysis (1040 sites at risk) suggested 98% in-field control with 44 Gy, our re-analysis including modern megavoltage data (4117 sites at risk) shows that similar in-field control rates could be achieved with 37.5 Gy. With megavoltage radiotherapy, the doses required for 98% in-field control for subclinical disease and disease of less than 6 cm and greater than 6 cm are, 32.4 Gy (1426 sites at risk), 36.9 Gy (1005 sites at risk) and 37.4 Gy (98 sites at risk), respectively. The results of current updated analysis will provide in-field disease control probabilities for different disease burdens and can serve as a guide in deciding dose prescriptions for practicing radiation oncologists.

Retroperitoneal fibrosis following radiotherapy for stage I testicular seminoma

Retroperitoneal fibrosis, proved by surgical exploration and pathology, was discovered in a patient 13 years after 3,000 rad external beam cobalt retroperitoneal radiation therapy for stage I testicular seminoma. Ureteral obstruction resulted in the loss of 1 kidney, necessitating ipsilateral nephrectomy and contralateral ureterolysis. To my knowledge this is the first reported case of retroperitoneal fibrosis occurring after radiotherapy for testicular cancer.

Acute and subacute side effects due to infra-diaphragmatic radiotherapy for testicular cancer: a prospective study

Acute/subacute side effects were evaluated in 39 testicular cancer patients before infra-diaphragmatic radiotherapy, twice during therapy and 3, 6, and 12 months after treatment discontinuation. The evaluation was primarily based on questionnaires filled in by the patients. At the end of radiotherapy nausea was reported by all responding patients, and 29 patients complained of diarrhea. Two-thirds of the patients reported abdominal pain and/or meteorism, and one-half complained of retching and/or vomiting. During therapy the median weight was significantly reduced by three kilos and the median value of the performance status decreased by 20%. The hematological and biochemical toxicity was low. At the 3-month evaluation more patients complained of nausea, abdominal pain, and meteorism than before irradiation. Compared to the pretreatment situation the patients evaluated their physical condition to be reduced during treatment and at the first follow-up visit. One year posttreatment the patients had regained their physical fitness. All patients in income-producing activity were on sick leave during the period of radiotherapy and for 5 weeks (median) thereafter. In conclusion, infra-diaphragmatic radiotherapy leads to significant but reversible acute/subacute side effects lasting for a median of 9 weeks. It is hoped that better symptomatic therapy and modifications of the radiotherapy technique will reduce the side effects.

Estimation of doses to heart, coronary arteries, and spinal cord in mediastinal irradiation for Hodgkin's disease

Early-stage Hodgkin's disease is highly curable with radiotherapy. However, radiotherapy for Hodgkin's disease is not without complications, particularly those related to irradiation of the mediastinum. In attempts to decrease complications, it is important not to compromise the results. To plan such a strategy, one needs to know the doses delivered to various volumes of normal tissues with present techniques. However, such dose-volume data do not exist. Here we demonstrate, with computerized tomography-based dosimetric techniques, such a dose-volume relationship for the heart, coronary arteries, and spinal cord. The doses were determined retrospectively in eight patients. With a prescribed dose of 44 Gy, the volumes of the heart receiving at least 22, 26, 31, 35, 40, or 44 Gy were: 77%, 75%, 70%, 57%, 33%, and 2%, respectively. The average modal doses to the coronary arteries were: anterior interventricular artery, 18.48 Gy; circumflex arterial branch, 37.84 Gy; left coronary artery, 34.76 Gy; and right coronary artery, 36.96 Gy. The average maximum spinal cord dose was 37.25 Gy. A similar prospective documentation of dose-volume relationships and correlation with (functional) long-term complications may be helpful in the development of new strategies for decreasing complications.

Long-term morbidity of adjuvant infradiaphragmatic irradiation in patients with testicular cancer and implications for the treatment of stage I seminoma

Long-term abdominal or urological morbidity and second malignancies in 289 surviving patients with infradiaphragmatic adjuvant radiotherapy (RT) for testicular cancer between 1950 and 1988 are analysed by retrospective chart review. After RT with single doses between 1.5 and 2.0 Gy and a total dose between 30 and 35 Gy, we did not observe any peptic ulcer nor other abdominal or urological long-term morbidity, except second tumours. The cumulative incidence of 16 second extratesticular malignancy was (in years after RT): 0.4% (4 years), 1.3% (9 years), 4.5% (14 years), 6.3% (19 years), 7.5% (24 years), 15.6% (29 years) and 23.6% (35 years). The ratio of observed to expected incidence of extratesticular malignancies did not differ significantly from unity; only the frequency of penile cancer (n = 2) was somewhat higher than expected. The cumulative risk of bilateral testicular cancer was 4.8% with no difference between patients with seminoma or non-seminomatous germ cell tumours. In a recent group of 128 patients with a stage I seminoma staged and treated between 1978 and 1988 by modern standard, there was no recurrence.

Stage I seminoma of the testis. Adjuvant radiotherapy or surveillance?

Lately the role of radiotherapy in stage I seminoma of the testis has been questioned by some authors who reported on a "surveillance" strategy for these patients. Since 1980, 124 patients with seminoma of the testis have been referred to this institution; 97 of 116 patients analysed presented with stage I disease and 10 of these had elevated levels of beta HCG. A total of 64 patients were given radiotherapy after orchiectomy and 33 entered a surveillance protocol. After a median follow-up of 48 months, 3 patients in the surveillance group relapsed after 5, 13 and 49 months and 2 of the irradiated patients did so after 25 and 33 months. Elevation of beta HCG was not significant because none of these patients showed progression. A low rate of progression and excellent survival are associated with standard treatment (orchiectomy and radiotherapy) and good results have been achieved with chemotherapy in cases of relapse. A surveillance policy is not recommended in stage I seminoma because of its slower growth compared with non-seminomatous germ cell tumours (NSGCT), the absence of a specific tumour marker, the 10% risk of occult metastases and the 3-fold higher progression rate compared with irradiated patients. We suggest the use of a reduced dosage and radiation field.

The risk of second cancer (SC) in patients treated for testicular seminoma

The exact risk of second cancer (S.C.) following treatment of testicular seminoma is not well determined in most series. At our institution, 122 patients with pure seminoma were treated by orchidectomy followed by radiation therapy from 1951 to 1986. Six were lost to follow-up. For the 116 remaining patients, the overall 5-, 10-, 15- and 20-year survival probability was 95%, 90%, 87%, and 84%, respectively. Eleven patients developed 12 second cancers, with a cumulative risk of 7%, 16%, and 16% at 10, 15, and 20 years, respectively. Overall, the risk of second cancer was increased (O/E = 1.97, p = 0.023). There were 3 controlateral seminoma (O/E = 50, p = 0.001), 2 transitional carcinoma of the bladder (O/E = 6.9, p = 0.035), 2 non-Hodgkin's lymphoma (N.S.), 1 acute myeloblastic leukemia, 1 chronic lymphocytic leukemia, 1 intracranial dysgerminoma, 1 rectal and 1 lung adenocarcinoma. Four tumors developed within the previously irradiated field (O/E = 2.2, N.S.). Excluding second seminoma, the overall risk of second cancer was not significant (O/E = 1.33). Five of the 11 patients with second cancer are currently alive without recurrent cancer. We conclude that patients treated for seminoma have an increased risk of second cancer but the overall prognosis remains excellent. The potential factors responsible for second cancer, including irradiation, are discussed.

Testicular seminoma: clinical and pathological features that may predict para-aortic lymph node metastases

Patients with clinical stage I testicular seminoma usually receive elective para-aortic lymph node radiation after orchiectomy, which is effective in controlling subclinical microscopic disease. However, the majority of patients with clinical stage I seminoma do not harbor occult metastases and, therefore, do not require elective nodal treatment. Vascular space invasion by the primary testis tumor recently has been shown to be an important predictor of metastases in nonseminomatous tumors but no such information exists to date in pure seminoma. Therefore, patients with clinical stage I testicular seminoma were compared to clinical stage II to IV cancer patients with respect to the presence of several features of the primary tumor. Vascular space invasion was identified significantly less frequently in stage I cancer patients (17%, 5 of 29) than in those with stage II or greater disease (39%, 11 of 28, p equals 0.03, 1-tailed t test). Microscopic invasion of the tunica and rete testis, and necrosis also were identified slightly more frequently in the higher stage cancer patients. Of the 12 patients with a maximum tumor dimension of more than 6 cm. 9 (75%) were in the stage II or higher group. Patient age, symptom duration and presenting complaint were similar in the 2 groups. Many higher stage cancer patients did not exhibit aggressive histological characteristics and, therefore, the absence of these features cannot be used to select patients for surveillance. On the other hand, patients with clinical stage I tumors that exhibit vascular space invasion may have an increased rate of occult para-aortic lymph node metastases. Therefore, the presence of vascular space invasion may be a useful criterion for exclusion of patients from surveillance protocols. Confirmatory data are needed before a final recommendation can be made.