Surveillance or Adjuvant Treatment With Chemotherapy or Radiotherapy in Stage I Seminoma: A Systematic Review and Meta-Analysis of 13 Studies

Biomarkers of disease recurrence in stage I testicular germ cell tumours

Stage I testicular cancer is a disease restricted to the testicle. After orchiectomy, patients are considered to be without disease; however, the tumour is prone to relapse in ~4-50% of patients. Current predictive markers of relapse, which are tumour size and invasion to rete testis (in seminoma) or lymphovascular invasion (in non-seminoma), have limited clinical utility and are unable to correctly predict relapse in a substantial proportion of patients. Adjuvant therapeutic strategies based on available biomarkers can lead to overtreatment of 50-85% of patients. Discovery and implementation of novel biomarkers into treatment decision making will help to reduce the burden of adjuvant treatments and improve patient selection for adjuvant therapy.

Surveillance versus Adjuvant Treatment with Chemotherapy or Radiotherapy for Stage I Seminoma: A Systematic Review and Meta-Analysis According to EAU COVID-19 Recommendations

Background and Objectives: During the coronavirus disease 2019 (COVID-19) outbreak, the European Association of Urology (EAU) Guidelines Office Rapid Reaction Group (GORRG) recommended that patients with clinical stage I (CSI) seminoma be offered active surveillance (AS). This meta-analysis aimed to evaluate the efficacy of AS versus adjuvant treatment with chemotherapy or radiotherapy for improving the overall survival (OS) of CSI seminoma patients. Materials and Methods: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed/Medline, EMBASE, and Cochrane Library databases were searched. The primary outcome was 5-year OS, and the secondary outcome was the 5-year relapse-free survival (RFS). The outcomes were analyzed as odds ratios (ORs) and 95% confidence intervals (CIs). Results: A total of 14 studies were included. Overall, the quality scores were relatively high, and little publication bias was noted. In terms of the 5-year OS, 7 studies were analyzed; there was no significant difference between AS and adjuvant treatment (OR, 0.99; 95% CI, 0.41−2.39; p = 0.97). In terms of 5-year RFS, 12 studies were analyzed. Adjuvant treatment reduced the risk of 5-year recurrence by 85% compared with AS (OR, 0.15; 95% CI, 0.08−0.26; p < 0.001). Conclusions: In terms of the OS in CSI seminoma patients, no intergroup difference was noted, so it is reasonable to offer AS, as recommended by the EAU GORRG until the end of the COVID-19 pandemic. However, since there is a large intergroup difference in the recurrence rate, further research on the long-term (>5 years) outcomes is warranted.

Patterns of Disease Progression and Outcome of Patients With Testicular Seminoma Who Relapse After Adjuvant or Curative Radiation Therapy

PURPOSE

Radiation therapy is a possible treatment strategy for patients with testicular seminoma after orchiectomy in clinical stage I or II disease. Little is known about the outcome of patients who experience a relapse after radiation therapy.

METHODS AND MATERIALS

Data from 61 patients who relapsed after adjuvant or curative radiation therapy from 17 centers in 11 countries were collected and retrospectively analyzed. Primary outcomes were disease-free and overall survival. Secondary outcomes were time to relapse, stage at relapse, treatment for relapse, and rate of febrile neutropenia during chemotherapy for relapse.

RESULTS

With a median follow-up of 9.9 years (95% confidence interval [CI], 7.5-10.9), we found a 5-year disease-free survival of 90% (95% CI, 79-95) and a 5-year overall survival of 98% (95% CI, 89-100). Sixty-six percent of patients had stage III disease at time of relapse and 93% of patients fell into the good prognosis group per the International Germ Cell Cancer Collaborative Group classification. The median time to relapse after radiation therapy was 15.6 months (95% CI, 12-23). Twenty-two (36%) patients relapsed more than 2 years after radiation therapy and 7 (11.5%) patients relapsed more than 5 years after radiation therapy. One-third of relapses was detected owing to patients' symptoms, whereas two-thirds of relapses were detected during routine follow-up. The majority (93%) of cases were treated with cisplatin-based chemotherapy. The rate of febrile neutropenia during chemotherapy was 35%. Five patients experienced a second relapse. At last follow-up, 55 patients (90%) were alive without disease. Only 1 patient died owing to disease progression.

CONCLUSIONS

Cisplatin-based chemotherapy for patients with seminoma who have relapsed after treatment with radiation therapy alone leads to excellent outcomes. Patients and physicians should be aware of possible late relapses after radiation therapy.

Management of stage I testicular cancer

PURPOSE OF REVIEW

Testicular cancer is the most common solid malignancy amongst young men, and a large proportion present with stage I disease. The options for management following radical orchiectomy are multifold. We review here approaches to treatment in this setting, providing an update on recent publications.

RECENT FINDINGS

At Princess Margaret Cancer Centre, we maintain a nonrisk adapted active surveillance approach. With a dedicated surveillance program using low-dose computed tomography imaging, patients are appropriately identified early for treatment on relapse. There are ongoing investigations into minimizing toxicities of treatments for relapse, and in particular, retroperitoneal lymph node dissection (RPLND) presents an attractive alternative. This, though, remains investigational in the setting of seminoma.

SUMMARY

Testicular cancer is a highly curable malignancy. In stage I disease, an active surveillance approach following radical orchiectomy is preferred, irrespective of risk-profile. This approach serves to limit the toxicity of adjuvant treatment in a significant proportion of patients, while maintaining excellent survival outcomes.

What radiologists should know about microRNA (miRNA) serum biomarkers for germ cell tumors

MicroRNAs expressed by germ cell tumors represent a novel approach to detection of metastatic disease during staging, surveillance, and recurrence post-therapy. It has particular promise in settings of equivocal imaging, such as clinical stage I GCT, tumor marker negative stage IIA, or after chemotherapy. These miRNAs have the potential to change typical serum marker evaluation and imaging surveillance schedules.

Two cycles of adjuvant carboplatin for clinical stage 1 testicular seminoma in New Zealand centres: A retrospective analysis of efficacy and long-term events

Background

Adjuvant carboplatin reduces relapse risk in clinical stage 1 (CS1) seminoma, though there is a paucity of long‐term safety data.

Aim

Our objective was to report long‐term outcomes of two cycles of adjuvant carboplatin dosed at area under the time–concentration curve (AUC) of 7.

Methods and results

We performed a retrospective analysis on treatment and outcomes of patients with CS1 seminoma who received adjuvant carboplatin from 2000 to 2016 at our centres in the Midland Region, New Zealand. Of 159 patients, median age 39 years, 153 received two cycles of carboplatin: 147 dosed at AUC7 and 6 at AUC6. Six patients had one cycle of carboplatin AUC7. One patient relapsed at 22 months and died of bleomycin pneumonitis 2 months after achieving a complete response with BEP chemotherapy. Neither RTI (present in 21.3%) nor tumor size >4 cm (in 43.3%) was predictive of relapse. Median follow‐up was 106 months. At 15 years, outcomes were: relapse‐free survival 99.4%, overall survival 91.4%, disease‐specific survival 100%, subsequent malignant neoplasm rate 7.6%, and second testicular germ cell tumor rate 3.85%. One patient had persistent grade 1 thrombocytopenia at 46 months.

Conclusions

These data add to the body of evidence that two cycles of carboplatin AUC7 is safe and effective adjuvant treatment for CS1 seminoma.

46, XX Ovotesticular disorder of sex development (true hermaphroditism) with seminoma: A case report

RATIONALE

Ovotesticular disorder of sex development (DSD), previously known as true hermaphroditism, is a disorder in which individuals have both testicular and ovarian tissues. Instances of tumors arising in the gonads of individuals with 46,XX ovotesticular DSD are uncommon.

PATIENT CONCERNS

We report a case of a 36-year-old phenotypical male with a chief complaint of an abdominal mass for 3 months. He reported normal erections and regular menses. Computerized tomography showed a large tumor measuring 15 × 10 cm in size, a uterus, and a cystic ovary.

DIAGNOSIS

46, XX ovotesticular DSD with seminoma.

INTERVENTIONS

The patient was treated with neochemotherapy (etoposide and cisplatin), surgery, chemotherapy, and testosterone replacement.

OUTCOMES

At the 13-month follow-up, the patient reported satisfactory erections, and no evidence of disease was found.

CONCLUSION

Cases of 46,XX ovotesticular DSD with seminoma are uncommon. Our case reveals the importance of surgery combined with neochemotherapy, chemotherapy, and testosterone replacement in these patients to improve the prognosis.

Imaging of scrotal masses

Testicular cancer is responsible for approximately 0.1% of all cancer deaths in the USA, and seminoma is the most common type of testicular tumor. Ultrasonography is the primary imaging modality for accessing testicular and extratesticular lesions, while magnetic resonance imaging can be used for problem solving in lesion characterization in certain cases. CT imaging is usually performed for retroperitoneal staging of testicular cancer metastasis and follow-up after treatment. Extratesticular masses are common, yet rarely malignant. Imaging plays an important role in primary diagnosis of testicular cancer and differentiating it from common non-neoplastic findings. The purpose of this article is to review various imaging findings in testicular and extratesticular masses.

Prognostic value of primary tumor surgery in seminoma patients with distant metastasis at diagnosis: a population-based study

The aims of this study were to determine the prognostic value of primary tumor surgery and identify optimal candidates for such surgery among patients with seminoma and distant metastasis at diagnosis. We identified 521 patients with seminoma and distant metastasis at diagnosis between 2004 and 2014 from the Surveillance, Epidemiology, and End Results database. Among these patients, 434 had undergone surgery, whereas 87 had not. The prognostic value of primary tumor surgery was assessed by Kaplan–Meier methods, log-rank analyses, and multivariate Cox's proportional hazards model. Survival curves and forest plots were also plotted. Survival analysis indicated that patients who underwent surgery had a better 5-year overall survival and cancer-specific survival than those who did not. Multivariate analyses demonstrated that primary tumor surgery is an independent prognostic factor for overall survival and cancer-specific survival, along with age at diagnosis, M stage, and marital status. In addition, primary tumor surgery still had considerable prognostic value in the subgroup of patients with lymph node metastasis. Further, forest plots demonstrated that patients with M1a stage, N1 or N2–3 stage, and a younger age at diagnosis (<60 years) may benefit from primary tumor surgery. In conclusion, our findings indicate that primary tumor surgery is correlated with improved survival in patients with seminoma and distant metastasis. Furthermore, primary tumor surgery is an independent prognostic indicator for patients with seminoma and distant metastasis.

Management of Clinical Stage I Germ Cell Tumors

Experience demonstrates multiple paths to cure for patients with clinical stage I testicular cancer. Because all options should provide a long-term disease-free rate near 100%, overall survival is no longer relevant in decision making, allowing practitioners to factor in quality of life, toxicity, cost, and impact on compliance. Surveillance for clinical stage I seminoma and clinical stage I nonseminoma has become the preferred option. The contrarian view is that a risk-adapted approach should persist, with surveillance for low-risk individuals and active therapy high-risk individuals. However, results obtained in unselected patients provide a strong argument against the need for such an approach.

Serum tumor markers and testicular germ cell tumors: a primer for radiologists

Serum tumor markers (STMs) play a critical role in the diagnosis, staging and follow-up of both seminomatous and nonseminomatous testicular germ cell neoplasms. Levels of alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and lactate dehydrogenase (LDH), especially those measured after orchiectomy, also have implications for patient prognosis. Given that testicular germ cell tumors represent the most common solid tumor in men aged 20-34, radiologists must have familiarity with the clinical utilization and implications of these STMs. This article will review the classical patterns of STM elevation most commonly seen in pure seminomatous and nonseminomatous germ cell tumors while also providing case-based examples highlighting the importance of STM correlation with imaging. The role of STMs in clinical staging and disease surveillance will also be discussed.

Testicular Cancer Biomarkers: A Role for Precision Medicine in Testicular Cancer

Testicular germ cell tumors (TGCTs) represent the most common solid tumors among men aged 15 to 34 years. Fortunately, recent advances have made testicular cancer a highly curable disease. Despite the high cure rates, there are still several areas in testis cancer care where treatment decisions are controversial and guided only with clinical factors and historic serum tumor markers. Unfortunately, unlike other genitourinary malignancies, modern research techniques have not been widely tested or applied to germ cell tumors, perhaps as a result of excellent prognosis in this cohort of young men. Despite this, there remain numerous challenges and pitfalls in testis cancer care that need to be addressed. A reliable set of biomarkers could be extremely useful in helping risk-stratify patients, detect relapse early, guide surgical decision-making, and tailor follow-up. Current tumor markers (Alpha-fetoprotein, human chorionic gonadotrophin, and lactate dehydrogenase) have low accuracy and low sensitivity when used not only as diagnostic but also as prognostic and predictive markers. In twenty-first century medicine, there is a role for further prognostic stratification and the development of novel biomarkers that offer greater sensitivity and specificity for TGCTs. Despite the initial promising results, the majority of preclinical biomarkers do not, as yet have a proven validated role in clinical practice, and future prospective trials are needed to support and confirm the results of cohort studies. In this narrative review, we aimed to highlight the recent innovations in the development and implementation of novel testicular tumor markers and discuss their clinical applications and limitations in the management of this disease.

Adjuvant radiation therapy in stage I seminoma: 20 years of oncologic results

Aim

To report long term oncologic outcomes after adjuvant radiotherapy (RT) for stage I seminoma.

Method

We reviewed the complete data set for all patients treated at our institute between 1988 and 2005 for stage I seminoma with adjuvant RT after radical orchiectomy.

Results

A total of 85 patients were included. The median follow-up was 15 years. The 20-year overall survival (OS) and relapse free survival (RFS) were 92% and 96.3%, respectively. No severe acute and late complications were recorded. Overall 5.9% of patients had a second unrelated malignancy.

Conclusion

Adjuvant RT is an efficacious and safe treatment in stage I seminoma.

Seminoma Metastatic to the Orbit

PURPOSE

Seminomas are solid tumors in young men, but which rarely metastasize to the orbit. The authors review the known literature on seminoma metastatic to the orbit, and describe an additional case in a 33-year-old man.

METHODS

A literature search was performed on the MEDLINE database using keywords "seminoma," "testicular germ-cell tumors," "testicular cancer," "testicular neoplasm," "orbital metastasis," and "germ-cell neoplasms."

RESULTS

Malignant neoplasms of the testis account for only 1% of cancers in men. None-the-less, testicular germ cell seminoma is the most common solid tumor found in young men between the ages of 15 and 39. Only seven previous cases have been mentioned in the literature. The pathogenesis remains unclear although genetic, environmental, and maternal factors may play a role. The number of cases is too few to determine the best treatment options, but surgical excision and adjunctive orbital radiotherapy appear to be most appropriate.

CONCLUSIONS

Although metastases to the orbit are rare, seminoma should be considered in the differential diagnosis of all young men with proptosis.

Radiotherapy in testicular germ cell tumours - a literature review

Testicular germ cell tumours (GCT) represent about 1-2% of malignant in men. The essential therapeutic option for early-stage GCT is radical orchiectomy (RO), except in situations that require immediate chemotherapy in patients with a massive dissemination and unequivocally elevated levels of tumour markers. Postoperative radiotherapy (PORT) in patients with testicular seminoma in Clinical Stage I (CS I) is one of the treatment options next to active surveillance (AS) and chemotherapy (CHTH). Regardless of the procedure, five-year survival in this group of patients ranges between 97% and 100%. In the article, we present the literature review pertinent to therapeutic options, with a focus on radiotherapy. We have searched MEDLINE (PubMed) for all studies on patients with GCT treated with radiation therapy during the last 20 years, and the current therapeutic recommendations. We used the following keywords: germ cell tumours, testis, seminoma, non-seminoma, radiotherapy, outcome.

Adjuvant Therapy for High Risk Localized Kidney Cancer: Emerging Evidence and Future Clinical Trials

PURPOSE

We reviewed the literature on adjuvant therapies for patients with high risk localized kidney cancer following surgical resection. In this analysis we merge 2 recently published prospective trials with conflicting results within the context of their respective designs. In addition, we spotlight upcoming trials that use novel immunotherapy based checkpoint inhibitors and have the potential to establish a new standard of care.

MATERIALS AND METHODS

We searched PubMed^® for English language articles published through January 2017 using the keywords "renal cell carcinoma," "kidney cancer," "immunotherapy," "targeted therapy" and "adjuvant therapy." ClinicalTrials.gov was queried for ongoing studies. Relevant data recently presented at major urology and medical oncology meetings are also included.

RESULTS

Adjuvant therapies for high risk localized kidney cancer can be grouped into the categories of 1) traditional immunotherapy, 2) inhibitors of the vascular endothelial growth factor and mTOR (mammalian target of rapamycin) pathways, 3) vaccines and antibody dependent cytotoxic agents, and 4) immune checkpoint inhibitors. Several trials of traditional immunotherapy, such as interferon-α and high dose interleukin-2, failed to demonstrate benefit as adjuvant treatment and were associated with significant adverse events. Vascular endothelial growth factor and mTOR inhibitors have less severe toxicity in metastatic disease and, therefore, are natural considerations for adjuvant trials. However, current data are conflicting. The ASSURE (Sunitinib Malate or Sorafenib Tosylate in Treating Patients with Kidney Cancer that was Removed by Surgery, NCT00326898) trial found no recurrence-free survival benefit of sorafenib or sunitinib over placebo, while S-TRAC (Clinical Trial Comparing Efficacy and Safety of Sunitinib versus Placebo for the Treatment of Patients at High Risk of Recurrent Renal Cell Cancer, NCT00375674) revealed that 1 year of sunitinib improved recurrence-free survival by 1.2 years. Vaccine based treatments and antibody dependent cytotoxic agents have had mixed results. New trials evaluating immune checkpoint inhibitors are planned, given the impressive efficacy and tolerability as second line agents in metastatic disease. Future adjuvant trials are likely to be guided by molecular signatures to treat patients most likely to benefit.

CONCLUSIONS

Based on the available data, there appears to be no role for traditional immunotherapy as adjuvant treatment in patients with high risk localized kidney cancer following surgical resection. S-TRAC provides evidence that 1 year of adjuvant sunitinib in patients with higher risk locoregional disease increases the median time to recurrence. However, the data on overall survival are immature and adverse effects are common. Results from trials investigating immune checkpoint inhibitors are highly anticipated.