Gastrointestinal morbidity of adjuvant radiotherapy in stage I malignant teratoma of the testis

Epigenetic Factors and ncRNAs in Testicular Cancer

Testicular cancer is the most prevalent tumor among males aged 15 to 35, resulting in a significant number of newly diagnosed cases and fatalities annually. Non-coding RNAs (ncRNAs) have emerged as key regulators in various cellular processes and pathologies, including testicular cancer. Their involvement in gene regulation, coding, decoding, and overall gene expression control suggests their potential as targets for alternative treatment approaches for this type of cancer. Furthermore, epigenetic modifications, such as histone modifications, DNA methylation, and the regulation by microRNA (miRNA), have been implicated in testicular tumor progression and treatment response. Epigenetics may also offer critical insights for prognostic evaluation and targeted therapies in patients with testicular germ cell tumors (TGCT). This comprehensive review aims to present the latest discoveries regarding the involvement of some proteins and ncRNAs, mainly miRNAs and lncRNA, in the epigenetic aspect of testicular cancer, emphasizing their relevance in pathogenesis and their potential, given the fact that their specific expression holds promise for prognostic evaluation and targeted therapies.

Pathobiology, irradiation dosimetric parameters and therapy of radiation-induced gastric damage: a narrative review

OBJECTIVE

To review the pathobiology, irradiation dosimetric parameters and other risk factors, and therapy of radiation-induced gastric damage (RIGD).

BACKGROUND

RIGD is a side-effect of upper abdominal radiotherapy. Acute toxicities are usually mild and self-limiting. Late toxicities are potentially life-threatening and include bleeding, perforation or stenosis. The data on RIGD is mainly historical and derived from neoplasms and treatments where the role of radiotherapy is contracting, such as para-aortic nodal irradiation for testis and cervical cancer and Hodgkin's Disease. On the other hand, the role of radiotherapy is expanding, especially with stereotactic body radiotherapy (SBRT) treatments evolving for both primary and secondary upper gastrointestinal neoplasms, which might be expected to increase the frequency of RIGD. Pathoclinical and radiation dosimetric data which might predict the risk of RIGD are evaluated.

METHODS

English language articles between 1945 and December 2020, using PubMed and Embase, searching titles for keywords including: radiation; ionizing; radiotherapy; gastritis and 65 articles were selected for review. There may have been a risk of bias in the studies evaluated, since the majority of reports were retrospective, largely descriptive and qualitative.

CONCLUSIONS

A common pathoclinical theme in RIGD is inflammation. Numerous factors predict for a greater likelihood of RIGD, including radiation fraction size and dose, concurrent chemotherapy and previous abdominal surgery. Therapy is pathology-dependent and comprises pharmacological, interventional and in the most severe cases, surgical approaches. It is timely to review the topic of RIGD, discuss the limitations of the data and highlight the need for future research directions.

Modelling duodenum radiotherapy toxicity using cohort dose-volume-histogram data

Background and purpose

Gastro-intestinal toxicity is dose-limiting in abdominal radiotherapy and correlated with duodenum dose-volume parameters. We aimed to derive updated NTCP model parameters using published data and prospective radiotherapy quality-assured cohort data.

Material and methods

A systematic search identified publications providing duodenum dose-volume histogram (DVH) statistics for clinical studies of conventionally-fractionated radiotherapy. Values for the Lyman-Kutcher-Burman (LKB) NTCP model were derived through sum-squared-error minimisation and using leave-one-out cross-validation. Data were corrected for fraction size and weighted according to patient numbers, and the model refined using individual patient DVH data for two further cohorts from prospective clinical trials.

Results

Six studies with published DVH data were utilised, and with individual patient data included outcomes for 531 patients in total (median follow-up 16 months). Observed gastro-intestinal toxicity rates ranged from 0% to 14% (median 8%). LKB parameter values for unconstrained fit to published data were: n = 0.070, m = 0.46, TD₅₀₍₁₎ [Gy] = 183.8, while the values for the model incorporating the individual patient data were n = 0.193, m = 0.51, TD₅₀₍₁₎ [Gy] = 299.1.

Conclusions

LKB parameters derived using published data are shown to be consistent to those previously obtained using individual patient data, supporting a small volume-effect and dependence on exposure to high threshold dose.

Upper gastrointestinal complications associated with gemcitabine-concurrent proton radiotherapy for inoperable pancreatic cancer

BACKGROUND

Little is known about acute upper gastrointestinal (GI) complications associated with gemcitabine-concurrent proton radiotherapy (GPT) for inoperable pancreatic cancer. We investigated acute GI complications following GPT in patients with inoperable pancreatic cancer using small-bowel endoscopy.

METHODS

This prospective single center observational study was conducted at the Hyogo Ion Beam Medical Center from January 2010 to January 2012. Ninety-one patients who had clinically and medically inoperable pancreatic cancer treated by GPT were analyzed. Endoscopic examinations were performed before and after GPT to clarify the incidence rates of radiation-induced ulcers, GI hemorrhage, and GI perforation associated with GPT.

RESULTS

Post-treatment endoscopic examinations revealed that 45 (49.4 %) patients had radiation-induced ulcers in the stomach and duodenum. Of those, many ulcerative lesions were found in the lower stomach (51 %) and horizontal part of the duodenum (39 %), regardless of the primary tumor site in the pancreas. Neither GI hemorrhage, nor perforation, was found in post-treatment endoscopy examinations.

CONCLUSION

Approximately half of the patients treated with GPT for inoperable pancreatic cancer exhibited radiation-induced ulcers in the stomach and duodenum.

Acute radiation enteritis caused by dose-dependent radiation exposure in dogs: experimental research

Accidental or intended radiation exposure in mass casualty settings presents a serious and on-going threat. The development of mitigating and treating agents requires appropriate animal models. Unfortunately, the majority of research on radiation enteritis in animals has lacked specific assessments and targeted therapy. Our study showed beagle dogs, treated by intensity-modulated radiation therapy (IMRT) for abdominal irradiation, were administered single X-ray doses of 8-30 Gy. The degree of intestinal tract injury for all of the animals after radiation exposure was evaluated with regard to clinical syndrome, endoscopic findings, histological features, and intestinal function. The range of single doses (8 Gy, 10-14 Gy, and 16-30 Gy) represented the degree of injury (mild, moderate, and severe, respectively). Acute radiation enteritis included clinical syndrome with fever, vomiting, diarrhea, hemafecia, and weight loss; typical endoscopic findings included edema, bleeding, mucosal abrasions, and ulcers; and intestinal biopsy results revealed mucosal necrosis, erosion, and loss, inflammatory cell infiltration, hemorrhage, and congestion. Changes in serum diamine oxides (DAOs) and d-xylose represented intestinal barrier function and absorption function, respectively, and correlated with the extent of damage (P < 0.05 and P < 0.05, respectively). We successfully developed a dog model of acute radiation enteritis, thus obtaining a relatively objective evaluation of intestinal tract injury based on clinical performance and laboratory examination. The method of assessment of the degree of intestinal tract injury after abdominal irradiation could be beneficial in the development of novel and effective therapeutic strategies for acute radiation enteritis.

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.

[Stage 1 testicular seminoma]

Testicular cancer is rare, representing only 1 % of malignant tumors, but the most common cancer in young men, 15 to 35 years. Adjuvant radiotherapy after orchidectomy in testicular seminoma stage I, reduces risk of relapse. It aims to eradicate micro-metastatic disease in lymph drainage territories. In the case of adjuvant radiotherapy, the relapse-free survival of 96 % with an overall survival of 98 % at 5 years. The irradiation volume is made up of lymph nodes paraaortic which it is possible to add the ipsilateral renal hilum to the testicular lesion. The current recommended dose is 20 Gy in 10 fractions and 2 weeks, usually delivered by two antero-posterior beams. The acute toxicities, mainly represented by nausea and diarrhea are usually quickly resolved to the end of irradiation. Regarding toxicities long-term, preservation of semen should be considered after surgery because of fear of infertility post-treatment. The risk of second cancer associated with exposure to ionizing radiation, albeit small, is especially important to consider these patients to significant life expectancy. Nevertheless, developments in radiotherapy techniques and lower doses and irradiated volumes can probably reduce this risk further.

Gastroduodenal complications after concurrent chemoradiation therapy in patients with hepatocellular carcinoma: endoscopic findings and risk factors

PURPOSE

Concurrent chemoradiation therapy (CCRT) is useful in advanced hepatocellular carcinoma (HCC), but little is known about radiation-induced gastroduodenal complications following therapy. To determine risk factors, we investigated the prevalence and patterns of gastroduodenal complications following CCRT using endoscopy.

METHODS AND MATERIALS

Enrolled in the study were 123 patients treated with CCRT for unresectable HCC between January 1998 and December 2005. Radiation-induced gastroduodenal complications were defined as radiation gastritis/duodenitis, radiation gastric/duodenal ulcer, or other gastroduodenal toxicity associated with radiation, based on Common Terminology Criteria for Adverse Events (CTCAE 3.0). Serious gastroduodenal complications were defined as events occurring within 12 months from completion of CCRT, those requiring prompt therapeutic intervention, or symptoms equivalent to Grade 3 or 4 radiation-related gastroduodenal toxicity, including nausea or vomiting, based on CTCAE 3.0.

RESULTS

A month after completion of CCRT, 65 (52.8%) patients displayed endoscopic evidence of radiation-induced gastroduodenal complications. Radiation gastric and duodenal ulcers were found in 32 (26.0%) and 20 (16.3%) patients, respectively; radiation gastritis and duodenitis were found in 50 (40.7%) and 42 (34.1%) patients, respectively. Radiation-related bleeding was observed in 13 patients (10.6%). Serious gastroduodenal complications occurred in 18 patients (14.6%) and were significantly more frequent in patients with liver cirrhosis than in those without cirrhosis (p=0.043). There were no radiation-related deaths.

CONCLUSIONS

Endoscopically detectable radiation-induced gastroduodenal complications were common in HCC following CCRT. Although serious complications were uncommon, the frequency was higher in patients with liver cirrhosis; thus, these patients should be closely monitored when receiving CCRT.

Radiation dose-volume effects in the stomach and small bowel

Published data suggest that the risk of moderately severe (>or=Grade 3) radiation-induced acute small-bowel toxicity can be predicted with a threshold model whereby for a given dose level, D, if the volume receiving that dose or greater (VD) exceeds a threshold quantity, the risk of toxicity escalates. Estimates of VD depend on the means of structure segmenting (e.g., V15 = 120 cc if individual bowel loops are outlined or V45 = 195 cc if entire peritoneal potential space of bowel is outlined). A similar predictive model of acute toxicity is not available for stomach. Late small-bowel/stomach toxicity is likely related to maximum dose and/or volume threshold parameters qualitatively similar to those related to acute toxicity risk. Concurrent chemotherapy has been associated with a higher risk of acute toxicity, and a history of abdominal surgery has been associated with a higher risk of late toxicity.

[Stage I seminoma and radiotherapy: to bury it or not?]

Postorchidectomy management of stage I testis seminoma has evolved for many years. Three treatment options should be discussed after surgery. Surveillance tends toward taking a more significant place to avoid overtreatment, adjuvant chemotherapy with carboplatin has demonstrated its efficiency, and for some, preventive radiotherapy, the historical reference treatment, is losing momentum. Whatever the chosen orientation, long-term prognosis is excellent with overall survival closed to 100%. In this context, this review underlines the advantages and the drawbacks of the three attitudes but also the unknowns relative to each. Indeed, their knowledge is crucial for informing clearly and with an objective way. Without gold-standard, but with three therapeutic options available, informing our patients is the key so they make an informed choice in dialogue with the oncologist.

Retroperitoneal lymph node dissection for high-risk stage I and stage IIA seminoma

INTRODUCTION

The clinical results of radiotherapy in low-stage seminoma are excellent with negligible early morbidity. However, in a long-term follow-up various complications may occur. On the other hand, experience in nonseminomas shows that surgical morbidity has decreased markedly after invention of a nerve-sparing technique. These issues served as a rationale for us to perform the primary retroperitoneal lymph node dissection (RPLND) in seminoma patients.

MATERIALS AND METHODS

Fourteen pure seminoma patients (10 high-risk stage I and four with clinical stage IIA) underwent nerve-sparing RPLND from September, 1997 to December, 2002.

RESULTS

Pathological evaluation revealed lymph node involvement in three out of 10 clinical stage I and in all four stage IIA cases. The patients' acceptance of the surgery was good. Minor intra- and early postoperative complications were observed in two cases. Antegrade ejaculation was preserved in all patients. No retroperitoneal or distant recurrences have been observed. All patients were free of disease with the mean follow-up period of 56 months.

CONCLUSION

The excellent results and minimum morbidity of nerve-sparing RPLND together with the increased concerns on late complications of radiotherapy may turn the preference of surgery in low-stage seminoma into the subject of future discussion.

Noncancer Causes of Death in Survivors of Testicular Cancer

BACKGROUND

Although modern treatments for testicular cancer are associated with increased survival, the long-term health effects of these treatments are unclear. We conducted a population-based study to quantify the long-term risks of mortality from noncancer causes among men with testicular cancer.

METHODS

We identified 38,907 one-year survivors of testicular cancer within 14 population-based cancer registries in North America and Europe (from 1943 through 2002). We used data from these registries to calculate standardized mortality ratios (SMRs) for noncancer deaths and to evaluate associations between histology, age at testicular cancer diagnosis, calendar year of diagnosis, and initial treatment and the risk of noncancer mortality. All statistical tests were two-sided.

RESULTS

A total of 2942 deaths from all noncancer causes were reported after a median follow-up of 10 years, exceeding the expected number of deaths from all noncancer causes in the general population by 6% (SMR = 1.06, 95% confidence interval [CI] = 1.02 to 1.10); the noncancer standardized mortality ratios did not differ statistically significantly between patients diagnosed before and after 1975, when cisplatin-based chemotherapy came into widespread use. Compared with the general population, testicular cancer survivors had higher mortality from infections (SMR = 1.28, 95% CI = 1.12 to 1.47) and from digestive diseases (SMR = 1.44, 95% CI = 1.26 to 1.64). Mortality from all circulatory diseases was statistically significantly elevated in men diagnosed with testicular cancer before age 35 years (1.23, 95% CI = 1.09 to 1.39) but not in men diagnosed at older ages (SMR = 0.94; 95% CI = 0.89 to 1.00). Men treated with chemotherapy (with or without radiotherapy) in 1975 or later had higher mortality from all noncancer causes (SMR = 1.34, 95% CI = 1.15 to 1.55), all circulatory diseases (SMR = 1.58, 95% CI = 1.25 to 2.01), all infections (SMR = 2.48, 95% CI = 1.70 to 3.50), and all respiratory diseases (SMR = 2.53, 95% CI = 1.26 to 4.53). Testicular cancer patients who were younger than 35 years at diagnosis and were treated with radiotherapy alone in 1975 or later had higher mortality from all circulatory diseases (SMR = 1.70, 95% CI = 1.21 to 2.31) compared with the general population.

CONCLUSION

Men who have survived for at least 1 year after being diagnosed with testicular cancer have a slightly higher risk of dying from noncancer causes, including infections, digestive diseases, and circulatory diseases, than the general population. Men treated with chemotherapy in 1975 or later may be at particularly high risk.

In vivo assessment of the gastric mucosal tolerance dose after single fraction, small volume irradiation of liver malignancies by computed tomography–guided, high-dose-rate brachytherapy

PURPOSE

The aim of this study was to assess the tolerance dose of gastric mucosa for single-fraction computed tomography (CT)-guided, high-dose-rate (HDR) brachytherapy of liver malignancies.

METHODS AND MATERIALS

A total of 33 patients treated by CT-guided HDR brachytherapy of liver malignancies in segments II and/or III were included. Dose planning was performed upon a three-dimensional CT data set acquired after percutaneous applicator positioning. All patients received gastric protection post-treatment. For further analysis, the contours of the gastric wall were defined in every CT slice using Brachyvision Software. Dose-volume histograms were calculated for each treatment and correlated with clinical data derived from questionnaires assessing Common Toxicity Criteria (CTC). All patients presenting symptoms of upper GI toxicity were examined endoscopically.

RESULTS

Summarizing all patients the minimum dose applied to 1 ml of the gastric wall (D(1 ml)) ranged from 6.3 to 34.2 Gy; median, 14.3 Gy. Toxicity was present in 18 patients (55%). We found nausea in 16 (69%), emesis in 9 (27%), cramping in 13 (39%), weight loss in 12 (36%), gastritis in 4 (12%), and ulceration in 5 patients (15%). We found a threshold dose D(1 ml) of 11 Gy for general gastric toxicity and 15.5 Gy for gastric ulceration verified by an univariate analysis (p = 0.01).

CONCLUSIONS

For a single fraction, small volume irradiation we found in the upper abdomen a threshold dose D(1 ml) of 15.5 Gy for the clinical endpoint ulceration of the gastric mucosa. This in vivo assessment is in accordance with previously published tolerance data.

Outcome of radiotherapy for gastric mucosa-associated lymphoid tissue lymphoma refractory to Helicobacter pylori eradication therapy

BACKGROUNDS AND AIMS

Most low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphomas respond to eradication of H. pylori, however, some are refractory. The effectiveness of radiotherapy for MALT lymphoma refractory to H. pylori eradication has been demonstrated. However, the long-term outcome and associated late radiation morbidity of radiotherapy for gastric MALT lymphoma are unclear. We evaluated the efficacy of radiotherapy and the radiation-associated adverse effects for gastric MALT lymphoma refractory to H. pylori eradication therapy.

METHODS

Eighteen patients with H. pylori-positive gastric MALT lymphoma received H. pylori eradication therapy, of which three patients refractory to eradication of H. pylori were subsequently treated with irradiation (median 39 Gy, range 36-40 Gy). Efficacy of radiotherapy and associated radiation morbidity were evaluated. Adverse events were evaluated according to RTOG and NCI-CTC criteria.

RESULTS

Radiation was well tolerated. All three patients treated with radiotherapy achieved complete remission, which was sustained for a median follow-up period of 42.0 months (range, 24-72 months). As acute radiation side effects, all patients experienced mild nausea (Grade 1 by RTOG and 1 point [1 category] in NCI-CTC). One patient had Grade 1 appetite loss. There were no severe late adverse events. One patient had left kidney atrophy of approximately 10%, but none had renal dysfunction.

CONCLUSIONS

Radiotherapy for patients with gastric MALT lymphoma refractory to H pylori eradication was effective without any critical acute or late adverse events.

Quality of life in survivors of testicular cancer

The objective of this review was to give an overview of findings concerning quality of life (QOL) in general as well as its domains in survivors of testicular cancer. QOL on the group level was equal to that of men of the same age in the general population. Treatment strategies hardly influenced the QOL. The anxiety level, but not depression, was higher among survivors, while sexual functioning hardly differed from the male population norm. Patients to be treated for testicular cancer should be told about the outlook for good QOL, and the low risk of mental and physical long-term effects.

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.

Management of testicular seminoma

Testicular seminoma is highly curable with currently available treatments. Today, there is good evidence that patients with Stage I disease can be treated equally well with either immediate adjuvant para-aortic and ipsilateral pelvic radiotherapy or close surveillance with treatment at the time of relapse. The decision as to which of these management strategies is adopted in an individual case is a complex function of physician preference, and the emotional, social, and economic circumstances of the patient. Ongoing research in Stage I seminoma is focused at reducing the side-effects of treatment either by modifying the radiation treatment plan or by using adjuvant chemotherapy in lieu of radiation. Stage II patients with small bulk retroperitoneal lymphadenopathy have a high probability of long-term disease control with radiotherapy. Patients with bulky Stage II disease or Stage III disease should be treated with cisplatin-based chemotherapy.

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.

Surveillance for stage I testicular seminoma. Is it a good option?

Postorchidectomy treatment options in patients with stage I seminoma include surveillance (reserving treatment for patients who relapse), adjuvant radiation therapy (RT), and adjuvant chemotherapy. Adjuvant retroperitoneal RT remains the treatment of choice in most centers; however, the success of surveillance in stage I nonseminomatous germ cell testis tumors, the establishment of curative chemotherapy for advanced disease, and the improvements in CT have led to re-examination of the standard treatment approach. The available data from the surveillance and adjuvant RT series suggest that almost 100% of patients with stage I testicular seminoma are cured, whichever approach is chosen. This article presents an overview of the available information on all treatment options, the pros and cons of each approach, and indications for where surveillance fits into the armamentarium of clinicians dealing with this disease.

Testicular cancer

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

Current concepts about testicular cancer

In the past 20 years, testicular cancer, which occurs in the young, has become a curable malignancy; 90% of the patients treated will achieve long-term survival. However, there is a significant morbidity associated with the management of the disease process. The literature was reviewed concerning the current treatment strategies and prognosis, as well as the long-term sequelae of the various diagnostic and therapeutic procedures. Surveillance has become a key element in the management of patients with a primary (stage I) testicular non-seminoma. Although approximately 25% of these patients will relapse, 100% survival can be achieved with cisplatin in combination with etoposide and bleomycin (BEP). Patients with a disseminated non-seminoma are usually treated with 4 courses of BEP; an 80% survival rate can be achieved. The long-term effects of chemotherapy include Raynaud's phenomenon, acral paraesthesia, hyperlipidaemia, nephrotoxicity, infertility and hormonal disturbances. Retroperitoneal lymph node dissection or resection of residual disease following chemotherapy are associated with a low mortality and morbidity rate, ejaculatory dysfunction excepted. However, with specific modifications in technique (e.g. nerve-sparing) antegrade ejaculation can be preserved in the majority of patients. Radiotherapy is used in stage I and II seminoma. With the conventional dose of 25-30 Gy to the retroperitoneal and ipsilateral iliac lymph nodes, temporary dysfunction of the germ and Leydig cells of the remaining testis may occur by scatter radiation. Patients with advanced seminoma are treated with cisplatin-based chemotherapy. To date, testicular cancer patients can receive appropriate curative treatment with acceptable acute toxicity, depending on the therapy given. The detrimental effects of late toxicities require careful study and follow-up. However, little attention is paid currently to quality of life aspects, in particular the impact of the disease and its treatment on general well-being, including sexual function.

An analysis of surveillance for stage I combined teratoma--seminoma of the testis

We analysed 973 patients with stage I testicular tumours presenting between 1983 and 1994. The median ages at presentation for non-seminomatous germ cell tumour (teratoma) were 27 years, seminoma 36 years and combined tumour 33 years. These differences were statistically significant (Mann-Whitney P < 0.05), suggesting that combined tumours may have a separate natural history. We, therefore, analysed all stage I patients managed with surveillance (530 in total) post orchidectomy. The actuarial 5 year relapse-free survival and anatomical patterns of relapse were identical for non-seminomatous germ cell tumour (NSGCT) and combined tumour and both were statistically distinct from seminoma (P = 0.01, log-rank test, chi-square test P = 0.001). The association of seminoma within a histologically confirmed NSGCT has no influence on the clinical outcome.

The role of blood flow in chronic duodenal ulcer

BACKGROUND

Changes in gastroduodenal blood flow have been implicated in the pathogenesis of duodenal ulcer. We have studied duodenal blood flow during the development of an acute to chronic duodenal ulcer by using the abscopal model, in which ulcers are generated as an indirect effect of lower mediastinal irradiation.

METHODS

Female CFLP mice (n = 108) weighing 25-40 g were randomly allocated to one of three groups. Controls were not irradiated. Irradiated 'controls' received 18 Gy 250 kV X-rays to the upper mediastinum (which does not cause duodenal ulceration). The lower mediastinum group received the same dose of irradiation, which has been shown to induce typical chronic duodenal ulcers in 45% of animals so treated. Animals were studied by means of radiolabelled microspheres 3 or 7 days later (that is, during and at the end of the lag period for ulcer induction).

RESULTS

Proximal duodenal blood flow specifically was reduced by 32% in the lower mediastinum group compared with irradiated controls at 7 days (4.3 versus 6.3 ml/g tissue/min; P = 0.025 by ANOVA with contrast); there was no significant difference in blood flow to the stomach and to the distal duodenum. The decrease in proximal duodenal blood flow in the lower mediastinum group did not differ in the five animals that developed ulcer compared with the seven that did not.

CONCLUSION

Although there is an overall decrease in duodenal blood flow associated with chronic duodenal ulcer, reduced blood flow may not explain individual susceptibility to ulceration.

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)

Quality of life in long-term survivors of nonseminomatous germ cell testicular tumors

A total of 109 survivors of curative therapy for nonseminomatous germ cell testicular tumor was interviewed an average of 9 years after treatment to assess long-term physical, emotional and sexual sequelae. An age-matched group of healthy men were interviewed similarly as controls. Of the physical sequelae loss of ejaculation was prominent (30% of the patients) and appeared directly related to retroperitoneal lymph node dissection surgery (p < 0.01). Hypofertility was apparent among patients during the posttreatment period compared to controls (p < 0.01). Other physical complications were present in 35% of the patients and 8% were severe. Laparotomy was associated with incisional hernia and radiotherapy with gastrointestinal complications (p < 0.001). Psychoemotional status was similar among patients and controls before cancer diagnosis but 60% of the patients had obvious emotional problems during the treatment period, which were more severe in those who had a history of such problems. Anxiety, often with insomnia, affected 49% of the patients, while irritability and depression were noted in 34%. At the interview 30% of the patients versus 5% of the controls had psychoemotional dysfunction (p < 0.001) but half of the affected patients had a history of problems preexisting the diagnosis of cancer. Sexual complaints were encountered in 19% of the patients before cancer diagnosis compared to only 7% of the controls (p < 0.02). During cancer therapy 57% of the patients had sexual symptoms, primarily loss of erection and decreased frequency of intercourse. Residual problems were more prevalent among patients (38%) than controls (11%, p < 0.001). Sexual impairment was associated with direct treatment effects and persisted more often when symptoms developed during the treatment period. Although direct treatment related effects should decrease with modern single modality therapy, appropriate attention should be placed on counseling to help avoid long-term psychoemotional and sexual complications of the disease process and its treatment.

Short duration radiotherapy in stage I seminoma of the testis: preliminary results of a prospective study

Ninety-four patients with Stage I seminoma of the testis, treated between November 1989 and December 1991, received short duration radiotherapy (2000 cGy in 8 fractions) to the para-aortic area only. The treatment was well tolerated and, after a median follow-up time of 34 months (minimum 15 months), no patient has relapsed in the abdomen. One patient developed an apparently solitary distant metastasis from a latent teratoma and is disease free after chemotherapy. This form of radiotherapy would appear to be well-tolerated with a low relapse rate. It offers the advantage of a simpler and shorter technique compared with conventional therapy and avoids the necessity of intensive surveillance to detect relapse.

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.

Duodenal ulcer: a model of impaired mucosal defence

There is a new model of chronic duodenal ulcer in which the ulcer is generated by irradiating the lower mediastinum of mice with a single dose of 18 Gy 250 kV x rays. Single ulcers develop in the proximal duodenum of about half the animals. Previous studies have shown a remarkable morphological and behavioural similarity to duodenal ulcer in man. Ulceration occurs because of an imbalance between aggressive and defensive forces within the duodenum and an attempt has been made to elucidate the pathomechanism of this ulcer by determining acid and pepsin secretion. The basal and pentagastrin stimulated secretion of acid, pepsin, and histamine were measured and no changes in acid or pepsin secretion were shown to occur (risk of type II error < 1%). It is therefore concluded that this chronic ulcer is a model of impaired duodenal defence.

Surveillance following orchidectomy for stage I testicular seminoma

An analysis of the primary tumour histopathology was performed on 103 patients managed by orchidectomy and surveillance for stage I seminoma. Patients have been followed for 14-141 months (median 62 months) after orchidectomy. Seventeen patients relapsed, the probability of remaining relapse free at 5 years being 82% (95% confidence intervals, 74%-88%). No patients died of progressive germ cell tumours. The only significant histological factor predicting relapse was the presence of lymphatic and vascular invasion. Four of 42 patients with neither lymphatic or vascular invasion recurred, nine of 53 patients with either lymphatic or vascular invasion recurred and three of eight cases with both lymphatic and vascular invasion recurred (P = 0.05-trend). Though initial recurrence was usually of moderate volume and confined to para-aortic nodes, eight patients were treated with chemotherapy either because of the extent of their initial relapse (four cases), or because of subsequent relapse (four cases). In view of the difficulties of identifying patients at risk and of detecting early relapse, surveillance for stage I seminoma should remain a research protocol.

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.

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.

Psychosocial well-being in testicular cancer patients

149 testicular cancer patients with no evidence of disease for 3 or more years filled in a questionnaire which covered the following subjects: psychosocial well-being, working ability and use of analgesics/tranquilisers. The questions were chosen to compare cancer patients' morbidity with that of age-matched controls. The patients had been treated with surgery (32 patients), radiotherapy (39 patients), cisplatin-based chemotherapy plus surgery (46 patients) or chemotherapy plus radiotherapy with or without surgery (32 patients). Since no systematic differences between the treatment groups were found, the analyses were undertaken with all patients combined. The patients felt significantly less exhausted after a working day, were more satisfied with life and felt stronger and more fit than the controls. On the other hand, the patients reported a significantly higher incidence of anxiety and depression than the normal population. The results indicate that patients treated for a malignant disease may have greater fluctuations in mood and affect than the general population.

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.

Low-dose preoperative radiation postpones recurrences in operable rectal cancer. Results of a randomized multicenter trial in western Norway

A randomized, multicenter clinical trial was conducted in Western Norway to study the effectiveness of preoperative radiation therapy in operable rectal cancer, given at a dosage of 3150 cGy in 18 fractions, 2 to 3 weeks before radical surgery. Three hundred nine patients were entered into the trial between May 1976 and December 1985. After radiation no tumor was seen in 4.5% of the patients. There was no increased morbidity or mortality at surgery. The 5-year survival for evaluable patients was 57.5% in the control group and 56.7% in the radiotherapy group. For patients operated on for cure the 5-year survival was 60.9% and 64.2% in the control group and radiotherapy group, respectively. Radiation significantly delayed both local and distant recurrences in patients in the radiation group who had curative resection from 13.3 months in controls to 27.1 months. The local recurrence rate in the corresponding groups was 21.1% and 13.7%, respectively. We conclude that higher preoperative radiation doses should be used in new trials as a higher dosage may transform the observed positive effects into a survival benefit.

Long-term somatic side-effects and morbidity in testicular cancer patients

In order to evaluate long-term somatic morbidity after treatment for testicular cancer 149 patients with NED greater than or equal to 3 years answered a questionnaire. The patients had been treated with surgery only (32 patients, radiotherapy only (39 patients), cisplatin-based chemotherapy plus surgery (46 patients) or chemotherapy plus radiotherapy with or without surgery (32 patients). Raynaud-like phenomena were the most frequent side-effect occurring significantly more often after cisplatin-based chemotherapy than after surgery or radiotherapy (33/72 patients versus 5/68 patients). Peripheral sensory 'neuropathy' was reported by 18% of all the patients. Seventeen per cent and 11% complained of pulmonary symptoms and auditory symptoms, respectively. Gastrointestinal side-effects were more frequent after any type of cytotoxic therapy than after surgery only (34/47 patients versus 5/22 patients). Twenty-six patients had fathered children after treatment. About 80% of the patients were in full time wage-earning activity when they answered the questionnaire. In conclusion, 3-7 years after treatment for testicular cancer, 30-50% of the patients had minor somatic complaints whereas serious side-effects seldom occurred.

Long-term morbidity after infradiaphragmatic radiotherapy in young men with testicular cancer

Long-term morbidity was evaluated in 357 patients with testicular cancer who were treated by infradiaphragmatic radiotherapy between 1970 and 1982. Myelopathy developed in four patients, radiation osteomyelitis in one, and radiation hepatitis in another after treatment. Posttreatment gastrointestinal symptoms were recorded in the medical records of 4% of patients but were mentioned by 41% of 199 who answered a questionnaire. The moderate gastrointestinal problems were recorded by 17% of the patients compared with 6% in a control group of healthy men. Postirradiation peptic ulcer occurred in 9%. A dose relationship existed, the risk of posttreatment gastrointestinal problems being less when the midplane dose was less than 40 Gy. Forty-one of 63 men who wished to do so fathered at least one child after their radiotherapy. The overall posttreatment quality of life was comparable to that of the control group. The authors conclude that the risk of major posttreatment morbidity is minimal for testicular cancer patients who undergo infradiaphragmatic radiotherapy after orchiectomy. Slight gastrointestinal symptoms are relatively common without major impact on quality of life. Gonadal toxicity is not a significant complication. Infradiaphragmatic radiotherapy is a safe, routine adjuvant treatment of seminoma in orchiectomized patients with Stage I seminoma. The midplane dose should not exceed 36 Gy in these patients.

Radiotherapy for testicular seminoma stage I: treatment results and long-term post-irradiation morbidity in 365 patients

After infradiaphragmatic radiotherapy the cancer-related 10 year survival was 99% in 365 patients with seminoma Stage I referred to the Norwegian Radium Hospital between 1970 and 1982. Thirteen patients relapsed, 11 of them within the first 3 years after treatment. Nine of the recurrent patients were cured by radiotherapy alone (4) or in combination with chemotherapy (5). There is no need to include the inguinal lymph nodes into the irradiation field or to give scrotal irradiation, not even to patients with tumor infiltration beyond the testicular tissue, or to those with prior scrotal or inguinal surgery. At least 1 year after radiotherapy moderate or more severe dyspepsia was observed in 16 patients. Nine patients developed a peptic ulcer. In general, there was no increased risk for development of a second non-germ cell cancer after radiotherapy. However, 4 patients developed a pulmonary cancer indicating a border-line significance of increased risk for this type of malignancy. (p:0.05). In conclusion, infradiaphragmatic radiotherapy remains the optimal routine treatment in seminoma patients with Stage I.

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

There are only infrequent complications from intermediate dose infradiaphragmatic radiation to the para-aortics or para-aortic and iliac nodal regions as given in Hodgkin's disease or seminoma. Nonetheless, such complications can cause significant debility and may be lifelong. Treatment related factors associated with such complications should be identified and where possible, avoided. We have analyzed the records of 1,026 patients treated nationwide in the Patterns of Care Outcome. Studies including the Hodgkin's national practice survey (387 patients), Hodgkin's large facility survey (253 patients), and Seminoma national practice survey (386 patients). There were 883 patients who received infradiaphragmatic radiation to the para-aortics or para-aortic and iliac regions. Complications which occurred in these patients included gastrointestinal injury, hepatitis, nephritis, gonadal injury, hematopoietic injury, second malignancy, and miscellaneous others. There were 139 complications of any severity and 35 major complications requiring hospitalization for management. The 3-year actuarial complication rates were 14% and 4% for any and major complications, respectively. There was a statistically significant increase in both any complications and major complications with dose (p less than .01). The most frequent complications were those related to gastrointestinal injury such as peptic ulceration, hemorrhage, chronic diarrhea, and intestinal obstruction. Major bowel complications comprised 60% (21/35) of major complications and increased with dose from 1% for doses less than 3,500 cGy to 3% for doses greater than or equal to 3,500 cGy (p = .03). This study indicates that total dose is an important factor in determining complications, particularly gastrointestinal injury, in patients receiving infradiaphragmatic radiation in Hodgkin's disease and seminoma and that prior G.I. disease is associated with an increased risk of radiation related bowel complication. The radiotherapist should seek to optimize the therapeutic ratio in these diseases where gross disease can be controlled with 3500 cGy or less with few exceptions.

Testicular cancer

Testicular cancer, which predominantly occurs in young men, has become increasingly common; it is presently the most common malignancy in men aged 20-34. Despite a lack of knowledge of aetiology, empirical advances, particularly in the management of patients with advanced disease, have been dramatic. Prior to the development of effective chemotherapy in the 1970s, less than 10% of men with metastatic non-seminomatous germ cell tumours were cured; nowadays approximately 90% of patients are potentially curable. The introduction of effective chemotherapy has led to a reappraisal of surgery and radiotherapy in the management of early stage disease and the introduction of a policy of surveillance in patients without evidence of metastases at the time of removal of the primary tumour. Following chemotherapy, surgery is required in approximately 25% of patients with advanced disease to excise residual masses, which in one-fifth of cases will show evidence of residual malignancy. In a proportion of patients, testicular cancer develops on a background of long-standing infertility, whereas in many men there is temporary oligospermia, despite a previous history of fertility. The majority of patients with prior evidence of spermatogenesis recover this function following chemotherapy and there is no evidence that children fathered by such patients have an increased risk of malformation. Despite physician optimism and excellent prospects for cure, significant psycho-social morbidity is associated with the diagnosis and treatment of testicular cancer. Factors contributing to this are being identified and will lead, hopefully, to the minimisation of such problems by appropriate intervention.