Adjuvant treatment of clinical stage I seminoma: is a single course of carboplatin sufficient?

A Systematic Review Investigating the Difference between 1 Cycle versus 2 Cycles of Adjuvant Chemotherapy in Stage I Testicular Germ Cell Cancers

Standard care for stage I testicular germ cell cancers (seminomatous-STC or non-seminomatous-NSTC) is orchiectomy followed by active surveillance, 1 or 2 cycles of adjuvant chemotherapy, surgery or radiotherapy. The decision on the adjuvant therapeutic approach is guided by the associated risk factors of the patient and the potential related toxicity of the treatment. Currently, there is no consensus regarding the optimal number of adjuvant chemotherapy cycles. Although in terms of overall survival, there is no proven inconsistency regarding the number of cycles of adjuvant chemotherapy, and the rate of relapse may vary.

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.

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.

Recommendations for followup of stage I and II seminoma: The Princess Margaret Cancer Centre approach

Testicular seminoma most commonly affects young men and is associated with favourable prognosis. Various followup schedules and imaging protocols for testicular seminoma have been described without overall consensus. We reviewed the literature together with our experience at the Princess Margaret Cancer Centre and present an evidence-based followup approach for patients with stage I and II seminoma.

Clinical Characteristics and Outcomes of Late Relapse in Stage I Testicular Seminoma

AIMS

To identify the characteristics and outcomes associated with late relapse in stage I seminoma.

MATERIALS AND METHODS

A retrospective review was carried out of all patients with stage I seminoma managed at our institution between 1981 and 2011. Data were obtained from a prospectively maintained database. Late relapse was defined as tumour recurrence > 2 years after orchiectomy.

RESULTS

Overall, 1060 stage I seminoma patients were managed with active surveillance (n=766) or adjuvant radiotherapy (n=294). At a median follow-up of 10.6 years (range 1.2-30), 142 patients relapsed at a median (range) of 14 (3-129) months; 128 on active surveillance and 14 after adjuvant radiotherapy. The late relapse rate for the active surveillance and adjuvant radiotherapy groups was 4% and 1%, respectively. There was no specific clinicopathological factor associated with late relapse. Isolated para-aortic node(s) was the most common relapse site in active surveillance patients either in late (88%) or early relapse (82%). Among the active surveillance group, no patients with late relapse subsequently developed a second relapse after either salvage radiotherapy (n=25) or chemotherapy (n=6), whereas in early relapse patients a second relapse was reported in seven (10%) of 72 patients treated with salvage radiotherapy and one (4%) of 23 patients who received chemotherapy; all second relapses were subsequently salvaged with chemotherapy. No patient in the adjuvant radiotherapy group developed a second relapse after salvage chemotherapy (n=10) or inguinal radiotherapy/surgery (n=4). Of seven deaths, only one was related to seminoma. Among active surveillance patients, the 10 year overall survival for late and early relapse groups were 100% and 96% (P = 0.2), whereas the 10 year cancer-specific survival rates were 100% and 99% (P = 0.3), respectively.

CONCLUSIONS

In stage I seminoma, the extent and pattern of late relapse is similar to that for early relapse. For active surveillance patients, selective use of salvage radiotherapy/chemotherapy for relapse results in excellent outcomes regardless of the timing of relapse, whereas salvage radiotherapy for late relapse seems to be associated with a minimal risk of second relapse.

Testicular seminoma clinical stage 1: treatment outcome on a routine care level

Purpose

Clinical stage 1 (CS1) testicular seminoma involves an almost 100 % disease-specific survival in controlled clinical trials. We aimed to find out whether these results can be matched in patients managed on the routine care level.

Patients, methods

In total, 725 patients with seminoma CS1 were prospectively enrolled from 130 institutions. Adjuvant management as decided by local physicians involved surveillance (n = 256), radiotherapy (41), 1× Carboplatin (362), and 2× Carboplatin (66). We registered type of management, age, duration of follow-up (F/U), relapse, rete testis invasion (RTI), and tumor size. Actuarial relapse-free survival curves were calculated for treatment modalities and stratified for tumor sizes and RTI. A Cox regression model was calculated to explore for factors influencing relapses.

Results

Disease-specific survival was 100 %. Crude relapse rates were 8.2, 2.4, 5.0, and 1.5 % for surveillance, radiotherapy, 1× Carboplatin, and 2× Carboplatin after a median F/U of 30 months. RTI and tumor size were not associated with progression in surveillance patients. One course Carboplatin caused relapses in 6.8 % in tumor sizes >4 cm and 9.3 % (actuarial 13 %) in sizes >5 cm. The Cox model revealed the association of tumor size with recurrence in the entire seminoma population (Hazard ratio 1.17; 95 % confidence intervals 1.03–1.33).

Conclusions

The overall outcome of CS1 seminoma managed on the routine care level mirrors that of controlled trials. Unexpectedly, the risk factors in surveillance patients were not confirmed, but tumor size proved to be a risk indicator in the entire group of seminoma. Importantly, one course Carboplatin involved low efficacy to control the disease in large tumors.

Electronic supplementary material

The online version of this article (doi:10.1007/s00432-016-2162-z) contains supplementary material, which is available to authorized users.

Two cycles of adjuvant carboplatin in stage I seminoma: 8-year experience by the Hellenic Cooperative Oncology Group (HECOG)

PURPOSE

Following the establishment of adjuvant carboplatin in stage I testicular seminoma as a standard, we adopted this treatment for all stage I seminoma patients. We report our 8-year experience and compare these results with our previous adjuvant etoposide/cisplatin (EP) strategy.

PATIENTS AND METHODS

Patients with stage I seminoma, treated with adjuvant carboplatin and with a minimum follow-up of 1 year, were included. Two cycles of carboplatin [area under the curve (AUC) 6] were administered.

RESULTS

A total of 138 patients with median age of 34 years, treated from September 2003 to December 2011, were selected. There were 5 relapses [5-year relapse-free rate (RFR) 96.8 % (95 % confidence interval 91.6-98.8)]: 3 relapses at retroperitoneal lymph nodes, 1 relapse at the adrenal gland, and 1 isolated brain metastasis. Four patients with relapse were cured with salvage chemotherapy. All patients with relapse had tumor diameter ≥4 cm and/or age ≤34 years. Patients with at least 1 of the above risk factors (n = 111) had a significantly higher relapse rate compared with a similar population (n = 64) treated with 2 cycles of adjuvant EP: 5-year RFR was 95 % (SE 2 %) versus 100 % (SE 0 %), (p = 0.067).

CONCLUSIONS

Age and tumor diameter were associated with relapse in stage I seminoma treated with adjuvant carboplatin. Although adjuvant carboplatin in patients with age ≤34 and/or tumor diameter ≥4 cm is associated with higher relapse rates than EP, the prognosis of these patients is excellent, and therefore, the use of less toxic treatment is justified.

[Seminona of stage I: strategies compared]

Testicular cancer is an infrequent disease, accounting for 1% to 2% of all malignant 
neoplasms in men. However, it represents the most common solid malignancy among men between 15 and 35 years old.
The standard initial treatment for stage I seminoma is radical inguinal orchiectomy. Since the mid-20th century, the traditional treatment after surgery had consisted in external photon beam radiotherapy directed to the para-aortic and pelvic lymph nodes. Patients receiving radiotherapy achieve cause-specific survival rates approaching 100%, with virtually no relapses within the radiation portal.
At the moment, the options for the management of stage I seminoma consist of surveillance, adjuvant radiation therapy and adjuvant chemotherapy usually done with carboplatin. Patients should be informed of all treatment options and of potential benefits and side effects of each choice.
Significant treatment-related morbidities following radiotherapy have been reported. Acute toxicities are generally mild and self-timing, but patients treated with adjuvant radiotherapy alone had a significantly increased risk of second primary malignances (SPMs) and gonadal toxicity.
The Medical Research Council (MRC) TE10 and TE18 randomized trials have investigated the reduction of the treatment volume and total dose to decrease the risk of radiation-related side effects.
The MRC TE19 randomized trial compared radiotherapy and a single course of carboplatin AUC7. The preliminary results, reported in 2005, and also the updated results, reported in 2008 and 2011, confirm the non inferiority of single-dose carboplatin.

Risk-Adapted Treatment in Clinical Stage I Testicular Seminoma: The Third Spanish Germ Cell Cancer Group Study

Purpose

To confirm the efficacy of a risk-adapted treatment approach for patients with clinical stage I seminoma. The aim was to reduce both the risk of relapse and the proportion of patients receiving adjuvant chemotherapy while maintaining a high cure rate.

Patients and Methods

From 2004 to 2008, 227 patients were included after orchiectomy in a multicenter study. Eighty-four patients (37%) presented no local risk factors, 44 patients (19%) had tumors larger than 4 cm, 25 patients (11%) had rete testis involvement, and 74 patients (33%) had both criteria. Only the latter group received two courses of adjuvant carboplatin, whereas the rest were managed by surveillance.

Results

After a median follow-up time of 34 months, 16 relapses (7%) have been documented (15 [9.8%] among patients on surveillance and one [1.4%] among those treated with carboplatin). All relapses occurred in retroperitoneal lymph nodes, except for one case in pelvic nodes. Median node size was 25 mm, and median time to recurrence was 14 months. All patients were rendered disease-free with chemotherapy. The actuarial 3-year disease-free survival rate was 88.1% (95% CI, 82.3% to 93.9%) for patients on surveillance and 98.0% (95% CI, 94.0% to 100%) for those treated with adjuvant chemotherapy. Overall 3-year survival was 100%.

Conclusion

With the limitations of the short follow-up duration, we confirm that a risk-adapted approach is effective for stage I seminoma. Adjuvant carboplatin seems adequate treatment for patients with 2 risk criteria, as is active surveillance for those with 0 to one risk factors. More reliable predictive factors are needed to improve the applicability of this model.

Management of stage I testicular seminoma over a period of 49 years

BACKGROUND

The aim of this study was to review the treatment, toxicity, and outcomes in patients with stage I seminoma after orchidectomy.

PATIENTS AND METHODS

A retrospective chart review of all patients with stage I seminoma referred for initial treatment during the last 49 years was performed. Initial treatment approaches, toxicity, and outcomes were analyzed.

RESULTS

A total of 320 patients were seen between 1960 and 2009. Median age at diagnosis was 37 years (range: 20-72), with a median follow-up of 22.7 years (range: 1-48). All patients but 12 were treated with adjuvant radiotherapy. Acute toxicity was mainly gastrointestinal, with 7.6% classified as grade 2. The 10-year disease-specific survival and relapse-free survival were 97.7 and 97.6%, respectively. 8 patients (2.7%) developed a relapse and were managed with chemotherapy. 10 patients died, 6 of the disease and 4 from other causes (disease-free at time of death).

CONCLUSION

In the management of stage I seminoma, 3 treatment options are available; currently in the European Consensus, surveillance is the first choice, considering the overall comparable outcome and the low acute and late toxicity. Adjuvant radiotherapy and adjuvant chemotherapy should be considered as alternative options only if the patient declines the surveillance strategy.

Management of stage I testicular seminoma

Adjuvant treatment options for stage I seminoma include surveillance, radiation, and hemotherapy. Despite excellent results for both adjuvant chemotherapy and radiotherapy, many concerns have been raised in regards to the potential long-term toxicities of these treatments. To minimize the burden of treatment, there has been a shift away from adjuvant treatments for stage I testicular seminomas toward surveillance protocols for seminoma survivors. This article reviews the evidence for all adjuvant treatment options for stage I testicular seminomas with a particular focus on surveillance.

Late relapse of germ cell tumors

This article highlights relevant aspects of the rare late relapses of malignant germ cell tumors (MGCTs), which by definition occur at least 2 years after successful treatment. In most reports, 1% to 6% of patients with MGCT experience a late relapse. Surgery is the most important part in the treatment of late relapses. Viable MGCT or teratoma with malignant transformation may require multimodal treatment with chemotherapy, radiotherapy, and/or surgery. Salvage chemotherapy should be based on a representative biopsy. Referring patients with late relapse to high-volume institutions ensures the best chances of cure and enables multimodal treatment.

Side Effects of Adjuvant Radiotherapy in Men with Testicular Seminoma Stage I

In this study we followed up the side effects of adjuvant radiotherapy in patients with testicular seminoma stage I over a period from 13 to 84 months (median 28 months). The most frequent side effects during radiotherapy were gastrointestinal (nausea/vomiting), psychological, cognitive, and minor sexual problems.

The reported side effects were treated by antiemetics and anxiolytics. After radiotherapy, the side effects persisted in 6 % of patients, but only a few of them required additional treatment. Healthy children were born to 76 % of patients in the 18 to 39 years age group. This study shows that adjuvant radiotherapy of the para-aortic lymph nodes with the total dosage of 24 Gy in 16 daily fractions administered to testicular seminoma patients causes acceptable side effects, does not adversely affect quality of life and fertility, if the approach to treatment is individual and family consulting is provided. This makes adjuvant radiotherapy of the para-aortic lymph nodes an acceptable treatment for testicular seminoma stage I patients.

Pure seminoma: a review and update

Pure seminoma is a rare pathology of the young adult, often discovered in the early stages. Its prognosis is generally excellent and many therapeutic options are available, especially in stage I tumors. High cure rates can be achieved in several ways: standard treatment with radiotherapy is challenged by surveillance and chemotherapy. Toxicity issues and the patients' preferences should be considered when management decisions are made. This paper describes firstly the management of primary seminoma and its nodal involvement and, secondly, the various therapeutic options according to stage.

Late relapses (>2 years) in patients with stage I testicular germ cell tumors: predictive factors and survival

OBJECTIVES

Late relapses (>2 years) after completion of chemotherapy are rare and often platinum-resistant. There are limited data concerning late relapses in chemotherapy-naïve patients with stage I germ cell tumors. This retrospective analysis was performed to compare the outcome between patients with stage I germ cell tumors, who had late (≥2 years) and early (≥3 months and <2 years) relapse after orchiectomy.

METHODS AND MATERIALS

We analyzed data of 1,069 chemotherapy-naïve patients with advanced germ cell tumors of testis treated in our department from 1986 to 2008. All patients had cisplatin- and etoposide-based chemotherapy. We identified 169 (15.8%) patients with prior stage I disease, who had not received adjuvant treatment: 140 and 29 patients had early and late relapse, respectively. Among patients with late relapse, pure seminoma was revealed in 14 patients, and nonseminoma in 15 patients. Median follow-up time for 169 patients was 35 (range, 2-218) months.

RESULTS

Patients with late relapse were older, 35 years (23-57) and had more frequent pure seminoma in primary tumor, 14/29 (48.3%), than patients with early relapse, 30 years (16-63) (P = 0.0008) and 46/140 (32,8%, P = 0.08), respectively. At the time of disease progression, both groups were very similar according to well-known prognostic factors including IGCCCG classification. The only difference was larger size of retroperitoneal lymph nodes in late (9 cm) than in early relapse (4 cm, P < 0.0001). The outcome in patients with late relapse was significantly worse than in patients with early relapse: complete response rate after induction chemotherapy was 20.7% (6/29) vs. 42.1% (59/140) (P = 0.01), 3-year progression-free survival 66% vs. 84% (P = 0.02, HR = 2.4, 95% CI 1.2-8.8) and 3-year overall survival, 72% vs. 88% (P = 0.04, HR = 2.4, 95% CI 1.05-10.25), respectively. In patients with pure seminoma, this difference in overall survival was even more significant: 65% vs. 91% (P = 0.04, HR = 3.8, 95% CI 1.06-32.4).

CONCLUSIONS

Late relapses following stage I germ cell tumors were associated with seminoma, older age, and worse outcome after induction chemotherapy.

Update on management of seminoma

Testicular germ cell tumors and, in particular, seminomas are exquisitely radiation and chemotherapy-sensitive and most presentations are highly curable. In recent years the management focus has been on reducing late sequelae of treatment. For Stage I disease surveillance and adjuvant carboplatin, chemotherapy has become an option. The efficacy of combination chemotherapy has been established for advanced metastatic disease. Through a review of the available literature this article outlines the recent changes in the management of seminoma.

[What's new in the treatment of seminomas?]

Pure testicular seminoma is a rare disease with an excellent prognosis. Its management is controversial. In stage I disease, several treatment options are considered. Those are radiation therapy alone, chemotherapy alone or active surveillance, which is becoming increasingly popular. For more advanced stages, treatment is based on chemotherapy with or without radiation therapy. In this article, we review thoroughly the existing literature and recent recommendations the various treatment options, their advantages and disadvantages in different stages of the disease.

Randomized trial of carboplatin versus radiotherapy for stage I seminoma: mature results on relapse and contralateral testis cancer rates in MRC TE19/EORTC 30982 study (ISRCTN27163214)

PURPOSE

Initial results of a randomized trial comparing carboplatin with radiotherapy (RT) as adjuvant treatment for stage I seminoma found carboplatin had a noninferior relapse-free rate (RFR) and had reduced contralateral germ cell tumors (GCTs) in the short-term. Updated results with a median follow-up of 6.5 years are now reported.

PATIENTS AND METHODS

Random assignment was between RT and one infusion of carboplatin dosed at 7 × (glomerular filtration rate + 25) on the basis of EDTA (n = 357) and 90% of this dose if determined on the basis of creatinine clearance (n = 202). The trial was powered to exclude a doubling in RFRs assuming a 96-97% 2-year RFR after radiotherapy (hazard ratio [HR], approximately 2.0).

RESULTS

Overall, 1,447 patients were randomly assigned in a 3-to-5 ratio (carboplatin, n = 573; RT, n = 904). RFRs at 5 years were 94.7% for carboplatin and 96.0% for RT (RT-C 90% CI, 0.7% to 3.5%; HR, 1.25; 90% CI, 0.83 to 1.89). One death as a result of seminoma (in RT arm) occurred. Patients receiving at least 99% of the 7 × AUC dose had a 5-year RFR of 96.1% (95% CI, 93.4% to 97.7%) compared with 92.6% (95% CI, 88.0% to 95.5%) in those who received lower doses (HR, 0.51; 95% CI, 0.24 to 1.07; P = .08). There was a clear reduction in the rate of contralateral GCTs (carboplatin, n = 2; RT, n = 15; HR, 0.22; 95% CI, 0.05 to 0.95; P = .03), and elevated pretreatment follicle-stimulating hormone (FSH) levels (> 12 IU/L) was a strong predictor (HR, 8.57; 95% CI, 1.82 to 40.38).

CONCLUSION

These updated results confirm the noninferiority of single dose carboplatin (at 7 × AUC dose) versus RT in terms of RFR and establish a statistically significant reduction in the medium term of risk of second GCT produced by this treatment.

Management options for stage I seminoma

Stage I seminoma is the most common clinical scenario among patients with testicular cancer. Following orchiectomy, various treatment alternatives (adjuvant radiotherapy, surveillance, chemotherapy) can be offered that yield similar efficacy results and definitive cure is the rule. However, there is no consensus on the optimal management choice and considerable debate has been raised in recent years. The pros and the cons associated with each therapy, as well as their long-term outcomes are discussed in this review. Overall burden of treatment needed, therapy-related morbidity, economic costs, quality of life issues and patient preferences should all be considered. Refinement in the knowledge of predictive factors for relapse and mounting experience with both surveillance and adjuvant chemotherapy have led to consideration of risk-adapted treatment strategies as an alternative to standard radiotherapy. Although this model needs to be improved and validated, active close surveillance for low-risk patients and adjuvant therapy for those uncompliant or at higher risk of relapse seem to be acceptable options for patients with stage I seminoma.

Management of stage I seminomatous testicular cancer: a systematic review

The treatment options available for the management of stage I seminoma consist of either a surveillance strategy or adjuvant therapy after orchidectomy. A systematic review was undertaken to identify the optimal management strategy. The MEDLINE and EMBASE databases, in addition to the American Society of Clinical Oncology Meeting Proceedings, were searched for the period 1981 to May 2007. Studies were eligible for inclusion if they discussed at least one of survival, recurrence, second malignancy, cardiac toxicity, or quality of life for patients with stage I seminoma. A search update was carried out in June 2009. Fifty-four reports satisfied the eligibility criteria, including seven clinical practice guidelines, one systematic review, three randomised controlled trials focused on treatment options, 26 non-randomised studies of treatment options, and 15 non-randomised long-term toxicity studies. The existing data suggest that virtually all patients with stage I testicular seminoma are cured regardless of the post-orchidectomy management. The 5-year survival reported in all the studies identified in this systematic review was over 95%, regardless of the management strategy, including surveillance alone with no adjuvant therapy. In conclusion, to date, the optimal management of stage I seminoma remains to be defined. Surveillance seems to be the preferable option, as this strategy minimises the toxicity that might be associated with adjuvant treatment, while preserving high long-term cure rates. The currently available evidence should be presented to patients in order to select the most appropriate option for the individual.

Adjuvant radiotherapy in stage I seminoma: is there a role for further reduction of treatment volume?

An analysis was performed to determine whether a cranial reduction of the portals to the T11/T12 junction instead of the common T10/T11 junction would alter the outcome of patients with stage I seminoma. Of 163 consecutive patients with newly diagnosed testicular seminoma referred to the authors' institution between April 1992 and April 1999, 80 patients with stage I seminoma were treated with cranially reduced para-aortic treatment fields reaching from the top of T12 to the bottom of L4. Median total dose was 20.0 Gy (range, 19.8-27.2 Gy). Patients were followed-up by the use of CT in regular intervals. After a median follow-up of 7.1 years (range, 4.1-11.1 years), four patients (5%) had relapsed resulting in an actuarial 5-year relapse-free survival of 95%. No patients relapsed within the cranially reduced treatment volume above the top of T12. The cranial reduction of the para-aortic treatment fields resulted in a median reduction of treatment volume of 16% (range, 13-21%). The achieved median reduction in treatment volume of 16% appears to be relevant and is not associated with an increased relapse rate. This approach is recommended in analogy to the surgical approach in NSGCT to further minimize the risk of radiation-related late effects.

The treatment of stage A testicular seminoma by carboplatin monochemotherapy

BACKGROUND/AIM

Although radiotherapy is considered to be a standard treatment of stage A testicular seminoma, an increasing number of studies have reported encouraging results of the treatment by carboplatin monochemotherapy (CBDCA). The aim of this study was to analyse the treatment results of patients with clinical stage A seminoma treated by CBDCA on daily basis in the period June 1999 to September 2008.

METHODS

A total of 124 patients, mean age 36.63 years (20-62 years), with stage A testicular seminoma were treated, upon radical orchiectomy, by adjuvant CBDCA (400 mg/m2 on day 1 and 22).

RESULTS

Chemotherapy was well tolerated, except moderate nausea on the day of the drug administration and the following day. No patient had any serious disorders in blood cells count requiring substitutional treatment. During the mean follow-up period of 37.5 (range 6-111) months, three relapses were noted (2.41%) and none neoplasm of contralateral testicle or any other organ.

CONCLUSION

Simple and easy carboplatin administration with excellent treatment results, along with good tolerance and absence of comorbidity, poses itself as a new "gold standard" of treatment for stage A testicular seminoma.

Late relapse of germ cell tumors

OBJECTIVE

To assess the main characteristics of late relapsing malignant germ cell tumors (MGCTs). These tumors are rare and occur by definition 2 years or later after successful treatment.

METHODS

We present relevant literature on relapsing MGCT in order to highlight the following issues: incidence, impact of initial treatment on the subsequent risk of late relapse, treatment, and survival.

RESULTS

A pooled analysis of 5,880 patients with MGCT revealed late relapses in 119 of 3,704 (3.2%) and in 31 of 2,176 (1.4%) patients with non-seminoma and seminoma, respectively. The retroperitoneal space is the predominant site of relapse in both histological types. The initial treatment is important for the risk and localization of late relapses. Patients with single site teratoma are usually cured by surgery alone, whereas viable MGCT or teratoma with malignant transformation may require multimodal treatment with chemo- and/or radiotherapy as well as surgery. Surgery is the most important part in the treatment of late relapses. Salvage chemotherapy should, if feasible, be based on a representative biopsy. Five-year cancer-specific survival is above 50% in the recent large series and reaches 100% in case of single site teratoma.

CONCLUSIONS

Treatment of late relapsing MGCT patients is challenging and should be performed in experienced centers only. Referral of late relapsing patients to high-volume institutions ensures the best chances of cure and enables multimodal treatment, and contributes to increased knowledge of tumor biology as well experience with the clinical course of these patients.

Controversies in the management of early-stage germ cell tumors

The optimal management of clinical stage I testicular germ cell tumors remains controversial despite a cure rate of 99%. Alternatives for stage I nonseminomas include close surveillance, retroperitoneal lymph node dissection, and chemotherapy. For pure seminomas, the options are surveillance, chemotherapy, and radiation. Understanding the pros and cons of each approach may help in choosing a management plan.

Stage I testicular seminoma: management and controversies

Seminomas constitute more than half of testicular germ-cell tumours and 70-80% of patients with seminoma present with clinical stage I disease. Post-orchiectomy, management options include irradiation, surveillance or chemotherapy. Adjuvant irradiation to the infradiaphragmatic lymph nodes is the standard of care with relapse rates of 3-4%. Long-term follow-up data have shown association with late complications (cardiotoxicity, second malignancy, fertility impairment). Surveillance is an attractive alternative but relapse rates are higher ranging between 15 and 20%. Single agent carboplatin chemotherapy has demonstrated survival data equivalent to radiotherapy but long-term relapse and toxicity data are yet to be confirmed. Routine follow-up after irradiation and the role of risk stratification also remain unclear. Highly curative rates can be attained by all three modalities. Standard treatment with radiotherapy is challenged by surveillance and chemotherapy. Toxicity issues and patients' preferences are considered when management decisions are made.

Contemporary management of stage I testicular seminoma: a survey of Canadian radiation oncologists

Recently published studies clearly indicate that there are now several acceptable options for managing stage i testicular seminoma patients after orchiectomy. We therefore decided to survey Canadian radiation oncologists to determine how they currently manage such patients and to compare the results with previous surveys.

Our results demonstrate that adjuvant single-agent chemotherapy is being considered as an option by an increasing proportion of radiation oncologists (although it is not considered the preferred option), the routine use of radiotherapy is declining, and surveillance is becoming increasingly popular and is recommended most often.

Evidence-based pragmatic guidelines for the follow-up of testicular cancer: optimising the detection of relapse

Testicular germ cell tumours (TGCTs) are the most common cause of cancer in men between the ages of 15 and 40 years, and, overall, the majority of patients should expect to be cured. The European Germ Cell Cancer Consensus Group has provided clear guidelines for the primary treatment of both seminoma and nonseminomatous germ cell tumours. There is, however, no international consensus on how best to follow patients after their initial management. This must promptly and reliably identify relapses without causing further harm. The standardising of follow-up would result in optimising risk-benefit ratios for individual patients, while ensuring economic use of resources. We have identified the seven common scenarios in managing seminomas and nonseminomas of the various stages and discuss the pertinent issues around relapse and follow-up. We review the available literature and present our comprehensive TGCT follow-up guidelines. Our protocols provide a pragmatic, easily accessible user-friendly basis for other centres to use or to adapt to suit their needs. Furthermore, this should enable future trials to address specific issues around follow-up giving meaningful and useful results.

Germ cell tumors of the ovary

PURPOSE

Malignant ovarian germ cell tumors (MOGCTS) are rare but curable at all stages of disease. This review gives an outline of the management of this disease.

METHODS

We performed a literature search in the PubMed of almost all relevant articles concerning MOGCTs on pathology, prognostic factors, surgery, post-operative therapy and late effects of therapy. The available literature is mainly composed of retrospective reviews and articles.

RESULTS

Prognostic factors include stage, amount of residual tumor, histologic type and raised tumor markers. For patients with early stage disease, cure rates approach 100%, while for those with advanced-stage disease are at least 75%. Appropriate surgical treatment for patients where fertility needs to be preserved consists in laparotomy with unilateral salpingo-oophorectomy (USO) and resection of all visible disease. For patients with advanced-stage disease, the role and the extent of debulking surgery remain controversial despite its routine use. However, it is suggested a benefit from minimal residual disease at completion of primary surgical cytoreduction with both non-platinum and platinum-based chemotherapy regimens. Second-look surgery clearly is not indicated in patients with early stage non-dysgerminoma or in all patients with dysgerminoma. However, teratoma patients may benefit from secondary cytoreduction. Three courses of bleomycin, etoposide and cisplatin (BEP) is the current standard adjuvant chemotherapy and four courses of BEP are recommended in case of bulky residual tumor after surgery. More evidence is required to show that surveillance is a safe option. There is a hint that high-dose chemotherapy may play a role in relapsed patients. The majority of MOGCTs patients who undergo fertility-sparing surgery and chemotherapy retain their gonadal and reproductive function. There is an increasing concern about life-threatening long-term effects of treatment.

CONCLUSION

MOGCTs are rare neoplasms that affect girls and young women and have excellent prognosis at all stages of disease with optimal therapy. The majority of MOGCTs patients retain their reproductive function.

Two cycles of etoposide/cisplatin cured all patients with stage I testicular seminoma: risk-adapted protocol of the Hellenic Cooperative Oncology Group

OBJECTIVES

Adjuvant carboplatin is used as adjuvant therapy in Stage I testicular seminoma. Although cure is the rule, relapses still occur, especially in high-risk populations. We report the results of a risk-adapted strategy by the Hellenic Cooperative Oncology Group.

METHODS

From 1996 to 2003, 64 patients with Stage I seminoma and one of two risk factors (maximal tumor diameter greater than 4 cm and/or age younger than 34 years) were prospectively included in a protocol of adjuvant chemotherapy. Treatment consisted of two 3-week courses of etoposide 120 mg/m2 and cisplatin 40 mg/m2 for three consecutive days with granulocyte colony-stimulating factor support.

RESULTS

Of the 64 patients, 43 (67%) were younger than 34 years and 55 (86%) had a tumor diameter greater than 4 cm. Neutropenia and nausea and vomiting were the most frequent grade 3 or 4 toxicities (16.5% and 9.5%, respectively), apart from alopecia. After a median follow-up of 60 months (range 7 to 118), no disease relapses have occurred. A metachronous testicular carcinoma has been reported. One patient died of causes unrelated to his disease.

CONCLUSIONS

The results of our study have shown that two cycles of etoposide and cisplatin is an effective and safe form of adjuvant therapy for Stage I testicular seminoma. Risk factors can be used to identify patients who could benefit from etoposide and cisplatin treatment.

A comprehensive systematic review of testicular germ cell tumor surveillance

BACKGROUND

Testicular cancer is the most common malignancy in men aged 15-34, and its incidence has been increasing over the past half-century. Survival for stage I testis cancer approaches 100% regardless of management strategy which is often dictated by other factors such as perceived morbidity. Advances in treatment have attempted to decrease morbidity and surveillance is thought to achieve this goal.

METHODS

An English language literature search of MEDLINE from 1966 to December 2005 and CINAHL from 1982 to December 2005 was conducted using a broad search strategy. Comparative and descriptive original articles on outcomes of seminoma or NSGCT surveillance would be deemed eligible and review articles containing no original data were omitted. One hundred and thirty-eight articles were selected for formal review, during which a database was compiled that documented the first author, publication year, tumor histologic type, study purpose or topic(s), methodology, sample size, median follow-up, and relevant results.

RESULTS

Most evidence for the efficacy of surveillance is from descriptive series or non-experimental comparative studies. Relapse occurs in approximately 28% and 17% of surveillance patients in NSGCT and seminoma, respectively, and cause-specific survival is approximately 98% and 100%, respectively. Compliance with surveillance ranges from poor to adequate, however there is no evidence that compliance impacts clinical outcome. Cost analyses have yielded inconsistent results when comparing treatment modalities. There is scant literature on quality of life and psychosocial issues and results are inconsistent. Active surveillance appears to be appropriate and perhaps optimal first line management of clinical stage I seminoma and non-seminomatous germ cell tumors. Further quantitative and qualitative research is warranted to deepen understanding of these issues that may impact treatment decision-making.

Management of Low-Stage Testicular Seminoma

Testicular seminoma represents a modern model of a multidisciplinary approach to a curable neoplasm. Surgeons, radiation oncologists, and medical oncologists play an important role in disease detection, diagnosis, treatment, and follow-up. This article focuses on the management of men who have early-stage seminoma, which represents stage I and IIa (minimal retroperitoneal spread). In stage I disease, the major controversies continue to revolve around surveillance versus adjuvant treatment and more recently adjuvant radiotherapy or carboplatin-based chemotherapy. Focus on long-term complications, such as cardiovascular disease, gastrointestinal disease, and secondary cancers, has led to the concept of increased surveillance with therapy for those who relapse. Radiation therapy remains the mainstay of therapy for patients who have stage IIa disease.

Evidence-based guidelines for following stage 1 seminoma

BACKGROUND

The authors developed evidence-based guidelines for a follow-up schedule after orchiectomy for stage 1 seminoma. Required investigations, frequency of assessment, overall duration of follow-up, and management strategies were identified.

METHODS

A systematic review of the literature was performed of prospective studies in stage 1 seminoma. Studies published after 1980 were considered eligible for inclusion. Data extracted included relapse-free rates, number of patients at risk, and relapse locations. Five strategies were identified: Surveillance, Extended-Field Radiotherapy, Para-aortic Radiotherapy, and either 1 or 2 cycles of Carboplatin Chemotherapy. For each strategy, Kaplan-Meier relapse-free estimates were used to calculate weighted-mean cumulative hazards of relapse over time. These were used to calculate semiannual weighted-mean relapse hazards.

RESULTS

Seventeen prospective studies with a total of 5561 patients were identified. Actuarial data on relapse was available in 5013 (90.1%) patients, and 92.9% of all relapses had location data reported. Annual hazard rates for relapse were determined.

CONCLUSIONS

Evidence-based recommendations for follow-up frequency based on risk of relapse were formulated. The authors suggested 3 times per year when the risk is >5%, 2 times per year when the risk is 1% to 5%, and annually until the risk is <0.3%. Investigations should reflect location(s) at risk of relapse and include computed tomography of the abdomen and pelvis for surveillance and adjuvant carboplatin, whereas for para-aortic radiotherapy, pelvic computed tomography alone is required. These recommendations offer the possibility of maximal patient convenience and optimal healthcare resource allocation without compromising disease control.

Management of Stage I Testis Cancer

OBJECTIVE

Over the last 5 years the management of stage I testis cancer has changed tremendously. This review focuses on the latest changes in diagnostics and treatment of clinical stage I non-seminomatous and seminomatous germ cell tumors.

METHODS

A non-structured literature search (MEDLINE) was performed, including recently published papers (up to March 2006) on the subject.

RESULTS

Organ-sparing surgery has become an accepted approach to treat malignant and nonmalignant tumours in a solitary testis. With certain precautions and adjuvant radiotherapy, this approach has proven to be as effective as orchidectomy. Prognostic factors strongly influence the decision for or against adjuvant treatment in seminoma and non-seminoma. With the help of a risk-adapted approach, about 50% of patients with clinical stage I testis cancer will favour close surveillance instead of immediate adjuvant treatment. Several well-conducted trials have helped to substantiate the management. Surgical staging by retroperitoneal lymph node dissection became an exception. Patients with non-seminoma with high risk for occult metastatic disease will favour adjuvant chemotherapy and in patients with seminoma radiotherapy with reduced dosage will be challenged by carboplatin monotherapy.

CONCLUSION

With adequate diagnostics and treatment, 100% of patients with stage I testis cancer will survive. Future research will focus on quality control, adherence to guideline recommendations, and further reduction of treatment to diminish the risk of late sequalae for patients with adjuvant radiotherapy or chemotherapy.

Treatment Options, Prognostic Factors and Selection of Treatment in Stage I Seminoma

Treatment options in patients with stage I seminoma include radiotherapy (RT), surveillance, and adjuvant chemotherapy. This patient population has virtually a 100% cure rate whichever approach is taken. While adjuvant retroperitoneal RT has been the standard of care for the past 50-60 years, there is increasingly persuasive data that adjuvant RT in this setting is associated with a small but definite increased risk of second malignancy and cardiovascular death. The long-term data from surveillance series have documented the safety of this approach, and it is now accepted that a policy of surveillance is the optimal management approach. This gives a relapse rate of 15%, and most patients can be successfully salvaged with RT. Second relapse after salvage RT occurs in a small proportion of cases, and these patients are cured with chemotherapy. Adjuvant chemotherapy using carboplatin has been investigated as an alternative strategy but has not lived up to its initial promise. If used, then 2 courses of treatment should probably be given. It must be remembered that 80-85% of patients with testicular seminoma require no treatment after orchiectomy, and the long-term side effects of any adjuvant treatment approach must be carefully considered.