Management of Stage II testicular seminoma over a period of 40 years

Therapy of clinical stage IIA and IIB seminoma: a systematic review

PURPOSE

The optimal treatment for clinical stage (CS) IIA/IIB seminomas is still controversial. We evaluated current treatment options.

METHODS

A systematic review was performed. Only randomized clinical trials and comparative studies published from January 2010 until February 2021 were included. Search items included: seminoma, CS IIA, CS IIB and therapy. Outcome parameters were relapse rate (RR), relapse-free (RFS), overall and cancer-specific survival (OS, CSS). Additionally, acute and long-term side effects including secondary malignancies (SMs) were analyzed.

RESULTS

Seven comparative studies (one prospective and six retrospective) were identified with a total of 5049 patients (CS IIA: 2840, CS IIB: 2209). The applied treatment modalities were radiotherapy (RT) (n = 3049; CS IIA: 1888, CSIIB: 1006, unknown: 155) and chemotherapy (CT) or no RT (n = 2000; CS IIA: 797, CS IIB: 1074, unknown: 129). In CS IIA, RRs ranged from 0% to 4.8% for RT and 0% for CT. Concerning CS IIB RRs of 9.5%-21.1% for RT and of 0%-14.2% for CT have been reported. 5-year OS ranged from 90 to 100%. Only two studies reported on treatment-related toxicities.

CONCLUSIONS

RT and CT are the most commonly applied treatments in CS IIA/B seminoma. In CS IIA seminomas, RRs after RT and CT are similar. However, in CS IIB, CT seems to be more effective. Survival rates of CS IIA/B seminomas are excellent. Consequently, long-term toxicities and SMs are important survivorship issues. Alternative treatment approaches, e.g., retroperitoneal lymph node dissection (RPLND) or dose-reduced sequential CT/RT are currently under prospective investigation.

Clinical dilemmas in local and regional testis cancer

At the Canadian Testis Cancer Workshop, the multidisciplinary management of testis cancer care was discussed. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician's assistants, residents, fellows, nurses, patients, and patient advocacy group members.This review summarizes the discussion regarding clinical dilemmas in local and regional testis cancer. We present cases that highlight the need for a coordinated approach to individualize care. Overarching themes include the importance of a multidisciplinary approach to testis cancer, willingness to involve a high-volume experienced center, and given that the oncological outcomes are excellent, a reminder that clinical decisions need to prioritize selecting a strategy with the least treatment-related morbidity when safe.

Systemic therapy for primary and extragonadal germ cell tumors: prognosis and nuances of treatment

Testicular germ cell tumors are the most common solid tumors in young men. These cancers represent a success story of modern medicine in our ability to cure young patients and offer decades of life, with a 5-year survival rate of approximately 95%. This review outlines the staging and risk classification of testicular cancers, and reviews the current state of knowledge and standard of care for the systemic treatment of testicular germ cell tumors with chemotherapy, focusing on the relevant clinical data supporting each treatment regimen. This review also briefly highlights current areas of active investigation, notably in the relapsed and refractory setting, including ongoing clinical trials.

Stage IIA and IIB testicular seminoma treated postorchiectomy with radiation therapy versus other approaches: a population-based analysis of 241 patients

Objectives

To evaluate post-orchiectomy utilization of radiation therapy (RT) versus other management approaches in stage IIA and IIB testicular seminoma patients.

Materials and Methods

Two hundred and forty-one patients with stage IIA and IIB testicular seminoma were identified between 1988 and 2003 using the Surveillance, Epidemiology, and End Results (SEER) database.

Results

Median follow-up was 10 years. Patients with stage IIA disease underwent RT more frequently than those with stage IIB disease (72% vs. 46%, respectively; P<0.001). There was no significant change in RT utilization for stage IIA or IIB disease between 1988 and 2003 (P = 0.89).

Conclusions

Between 1988 and 2003, stage IIA patients underwent RT more often than stage IIB patients in the United States. There was no significant change in RT utilization for stage IIA or IIB disease during this time period. Based on reports describing excellent progression-free survival with cisplatin-based chemotherapy, this approach has increased in popularity since 2003 and may eventually become the most popular treatment approach for both stage IIA and IIB testicular seminoma.

Retroperitoneal Lymph Node Dissection as First-Line Treatment of Node-Positive Seminoma

INTRODUCTION

The long-term morbidity associated with treating advanced seminoma can be significant. Retroperitoneal lymph node dissection (RPLND) has established oncologic efficacy in treating germ cell tumors with minimal long-term toxicity. We describe our experience with RPLND as a front-line treatment of lymph node-positive seminoma.

MATERIALS AND METHODS

We reviewed our institutional review board-approved testicular cancer database to find the patients with pure seminoma and isolated retroperitoneal lymph node disease who had undergone primary RPLND. The clinical and pathologic variables were obtained. The follow-up data were used to determine recurrence and death.

RESULTS

Four patients with a mean age of 37 years were identified. All patients had normal tumor markers and retroperitoneal lymphadenopathy measuring 1.1, 1.5, 1.8, and 5.5 cm before RPLND. Of the 4 patients, 3 had had seminoma diagnosed at orchiectomy and 1 (with a 5.5-cm retroperitoneal lymphadenopathy and a burned out primary testicular mass) had had seminoma diagnosed at RPLND after 2 nondiagnostic retroperitoneal biopsies. All patients had undergone nerve-sparing, template, extraperitoneal RPLND and were discharged home after 3 days. An average of 3 positive lymph nodes were found. Of the 4 patients, 3 had pathologic stage IIA and 1 stage IIB disease, with no patient undergoing adjuvant therapy. At a mean follow-up period of 25 months, no patient had experienced disease recurrence, and none had died. All patients maintained antegrade ejaculation, and no long-term complications had developed.

CONCLUSION

Our small series has demonstrated encouraging oncologic efficacy for RPLND as a primary treatment of retroperitoneal lymph node-positive seminoma. A multi-institutional phase II trial of RPLND for stage IIA seminoma is being developed.

Clinical presentation features of testicular cancer in public hospitals in the Autonomous Community of Madrid, Spain

OBJECTIVE

To study the clinical features of the patients with germ cell tumor of testis in the Autonomous Community of Madrid, emphasizing on the different treatments used.

MATERIAL AND METHOD

Retrospective analysis of 536 patients with testicular cancer who were obtained from the Community of Madrid cancer registry, during a follow-up period of 15 years (1991-2010). Data analysis has been performed using SPSS 15.0 for Windows. Chi-square test has been used to determine possible relationships among variables. The level of significance was p ≤ 0.05 RESULTS: An increase in the incidence rate has been detected along study period. Mean age was 33.6±13.6 years. 89.7% of cases were germ cells tumors (46% seminoma and 43.6% nonseminomatous germ cell tumor [NSGCT]) and other histologic subtypes the remaining 10.3% of cases. 74% of patients were diagnosed with stage I disease, 8.2% with stage II and 16.2% with stage III; 54.3% of patients were treated with surgery plus adjuvant chemotherapy and in 5.6% of patients the treatment was surgery plus adjuvant radiotherapy. Surgery alone was used in 27.4% of cases: in 32.7% of stage I tumors, 13.6% of stage II and 9.2% of stage III. Radiotherapy was prescribed in 10% of stage I tumors, in 9% of stage II and in 3.4% of stage III. For the seminomas: the surgery-chemotherapy association was used in 49.8 of cases, surgery alone in 30% and surgery plus radiotherapy in 16.6% of cases. For the NSGCT, surgery plus chemotherapy was used in 70.5% of patients, surgery alone in 23.5% and surgery-radiotherapy association in 0.8% of cases.

CONCLUSION

Testicular cancer incidence is increasing. Adjuvant chemotherapy is the treatment used most frequently in the more advanced stages of both seminomas and NSGCT. The tendency to reduce the use of radiotherapy in the treatment of seminoma was confirmed.

Radiotherapy for Stage IIA seminoma: The Northern Israel Oncology Center Experience, 1971-2010

AIM

To evaluate treatment details, outcome, relapse rate and side-effects in Stage IIA seminoma irradiated and followed for a period of 39 years.

BACKGROUND

Seminoma is a very radiosensitive disease and radiation therapy alone is able to achieve long-term disease-free survival, even in advanced Stage disease. Due to the lack of long-term prospective studies, it is of value to follow patients and try to determine the appropriate volume to be irradiated and the dose which can achieve total cure with minimal acute and chronic side-effects.

PATIENTS AND METHODS

A retrospective review of 24 Stage IIA seminoma patients irradiated between 1971 and 2010 was performed. All patients underwent orchiectomy and meticulous clinical, biochemical and radiological staging.

RESULTS

Median age at diagnosis was 36 years and median follow-up was 84 months. A majority of patients received the "hockey-stick" irradiation schedule (para-aortic lymph nodes and hemi-pelvis) to a total dose of 2250-2500 cGy and a boost to radiologically involved nodes of 500-1000 cGy. Treatment was well-tolerated. Twenty-one (88%) patients are alive with no evidence of disease. Two patients died due to unknown causes, while one patient died due to head of the pancreas carcinoma, most probably radiation-induced.

CONCLUSIONS

In Stage II seminoma, radiotherapy can provide excellent results with low rates of toxicity. Reduction of total dose and size of fields without affecting the good results should be considered. Due to prolonged survival, awareness of second primary tumor is indicated.