Postoperative radiotherapy for Stage I/II seminoma: results for 212 patients

The role of primary retroperitoneal lymph node dissection in the treatment of stage II seminoma

PURPOSE OF REVIEW

Stage II seminoma is responsive to chemo- or radiotherapy with a progression-free survival of 87-95% at 5 years but at the cost of short- and long-term toxicity. After evidence about these long-term morbidities emerged, four surgical cohorts investigating the role of retroperitoneal lymph node dissection (RPLND) as a treatment option for stage II disease were initiated.

RECENT FINDINGS

Currently, two RPLND series have been published as a complete report, while data from other series have only been published as congress abstracts. In series without adjuvant chemotherapy, recurrence rates ranged from 13% to 30% after follow-ups of 21-32 months. In those receiving RPLND and adjuvant chemotherapy, the recurrence rate was 6% after a mean follow-up of 51 months. Across all trials, recurrent disease was treated with systemic chemotherapy (22/25), surgery (2/25), and radiotherapy (1/25). The rate of pN0 disease after RPLND varied between 4% and 19%. Postoperative complications were reported in 2-12%, while antegrade ejaculation was maintained in 88-95% of patients. Median length of stay ranged from 1 to 6 days.

SUMMARY

In men with clinical stage II seminoma, RPLND is a safe and promising treatment option. Further research is needed to determine the risk of relapse and to personalize treatment options based on patient-specific risk factors.

Late recurrence of localized pure seminoma in prostate gland: A case report

BACKGROUND

Late relapses of early-stage germ cell tumors are rare. Most patients (-85%) with stage I seminoma are cured by radical orchiectomy. The detection of late relapse is challenging given the relative rarity of this phenomenon, and the fact that patients who have completed surveillance are usually not undergoing regular oncologic workup nor imaging. While many treatment options do exist for a patient with late relapse of seminoma, surgery is typically the mainstay as these tumors are generally thought to be more chemo-resistant.

CASE SUMMARY

In this article, we describe the management of a patient with an early-stage pure seminoma who was subsequently identified to have a recurrence two decades later. We provide a review of the literature not only focused on clinical factors and biology, but also the management of late recurrences specifically in pure seminoma and in prostate gland.

CONCLUSION

There is a paucity of data and treatment recommendations for this clinical entity, and a multidisciplinary approach emphasizing subspecialty expert consultation and patient education is imperative.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

DNA damage measured in blood cells predicts overall and progression-free survival in germ cell tumour patients

Germ cell tumour (GCT) patients who fail to respond to chemotherapy or who relapse have a poor prognosis. Timely and accurately stratifying such patients could optimise their therapy. We identified endogenous DNA damage levels as a prognostic marker for progression-free (PFS) and overall (OS) survival in chemotherapy-naïve GCT patients. In the present study, we have extended our previous results and reviewed the prognostic power of DNA damage level in GCTs. Endogenous DNA damage levels were measured with the comet assay. Receiver operator characteristic analysis was applied to determine the optimal cut-off value and to evaluate its prognostic accuracy. PFS and OS were estimated by the Kaplan-Meier method and compared using the log-rank test. Hazard ratio (HR) estimates were calculated by Cox regression analysis. A cut-off value of 6.34 provided the highest sensitivity and specificity, with area under curve values of 0.813 and 0.814 for disease progression and mortality, respectively. A % DNA in tail > 6.34 was significantly associated with shorter PFS (HR = 9.54, 95 % confidence interval [CI]: 3.43-26.55, p < 0.001) and OS (HR = 14.62, 95 % CI: 3.14-67.95, p = 0.001) by univariate analysis. The prognostic value of DNA damage measurement was confirmed by multivariate models (HR = 6.45, 95 % CI: 2.22-18.75, p = 0.001 for PFS and HR = 9.40, 95 % CI: 1.70-52.09, p = 0.010 for OS), when HR was adjusted for relevant clinical categories. The added prognostic value of DNA damage in combination with International Germ Cell Cancer Collaborative Group (IGCCCG) risk groups has been revealed. Endogenous DNA damage is an independent prognosticator for PFS and OS in GCT patients and its clinical use, particularly in combination with IGCCCG risk groups, may help in stratifying these patients.

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

Aim

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

Method

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

Results

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

Conclusion

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

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.

[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.

[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.

The most common, clinically significant misdiagnoses in testicular tumor pathology, and how to avoid them

Testicular tumors are both increasing in frequency and disproportionately occur in young men; furthermore, different forms of neoplasm require different treatments. These considerations make the accurate diagnosis of testicular tumors especially important. Many of the critical distinctions involve the differentiation of seminoma from one or more potential mimics because seminoma is not only the most common testicular neoplasm but it is also the only malignant testicular tumor that is commonly treated with radiation, which is ineffective in other malignancies of the testis. For the most part, accurate diagnosis can be achieved by careful light microscopic evaluation, although appropriate immunostains can provide diagnostic assistance if doubt persists. This article discusses a number of clinically important differential diagnoses in the testis that are common sources of misinterpretations. These include: seminoma versus embryonal carcinoma, seminoma versus yolk sac tumor, seminoma versus Sertoli cell tumor, seminoma with syncytiotrophoblast cells versus choriocarcinoma, granulomatous seminoma versus granulomatous orchitis, intertubular seminoma versus orchitis, lymphoma versus seminoma or embryonal carcinoma, dermoid cyst versus teratoma, scar versus regressed germ cell tumor, and "anaplastic" spermatocytic seminoma versus usual seminoma or embryonal carcinoma.

Squamous cell carcinoma of the renal pelvis after curative retroperitoneal radiotherapy for seminoma

We report the case of a 71-year-old male who presented with squamous cell carcinoma of the renal pelvis in a solitary functioning kidney, 34 years after orchidectomy and adjuvant retroperitoneal radiotherapy for stage II seminoma. This rare second malignancy occurred in the radiation treatment field. Second malignancies are an uncommon but serious sequela of radiotherapy, with potential for significant health problems in patients with complete remission of primary disease. To our knowledge, this is the first report of squamous cell carcinoma of the renal pelvis occurring after radiation treatment.

Low-dose radiotherapy for Stage I seminoma—long-term results

PURPOSE

The aim of this study was to review retrospectively the results of low-dose radiotherapy for Stage I seminoma using four different fractionation schedules and target volume definitions.

METHODS AND MATERIALS

A total of 191 patients underwent irradiation for histologically proven Stage I seminoma after undergoing an inguinal orchiectomy. Fractionation schedules were used one after another as follows: Total dose 30 Gy (dose/fraction 1.5 Gy, 16 patients), total dose 25.5 Gy (dose/fraction 1.5 Gy, 62 patients), total dose 20 Gy (dose/fraction 2 Gy, 69 patients), total dose 26 Gy (dose/fraction 2 Gy, 29 patients). The remaining 12 patients were excluded from this study. In the same period the target volume was gradually reduced. In 1983 the paraaortic, pelvic and inguinal regions were irradiated; later the target volume was reduced to the paraaortic region exclusively.

RESULTS

Overall survival and event-free survival were identical in all groups ranging from 95% to 100% /5 years. Three patients experienced a lymph node metastasis during follow-up, 3 patients a distant metastasis to the lung and the bones. Mild acute side effects were noted in 8% to 15% of the patients, and very mild long-term side effects in 1% to 5% of patients. Multivariate analysis showed no prognostic significance of total dose, dose per fraction, or target volume. In univariate analysis, a higher frequency of acute side effects to the skin and the bowel was related to a higher total dose, and an elevated frequency of nausea was related to a higher daily dose per fraction.

CONCLUSION

Using lower doses and limiting the target volume to the paraaortic region exclusively did not result in a worse prognosis in our patient series.

Data required for testicular dose calculation during radiotherapy of seminoma

The purpose of this study was to provide the required data for the direct calculation of testicular dose resulting from radiotherapy in patients with seminoma. Paraortic (PA) treatment fields and dog-leg (DL) portals including paraortic and ipsilateral pelvic nodes were simulated on a male anthropomorphic phantom equipped with an artificial testicle. Anterior and posterior irradiations were performed for five different PA and DL field dimensions. Dose measurements were carried out using a calibrated ionization chamber. The dependence of testicular dose upon the distance separating the testicle from the treatment volume and upon the tissue thickness at the entrance point of the beam was investigated. A clamshell lead shield was used to reduce testicular dose. The scattered dose to testicle was measured in nine patients using thermoluminescent dosimeters. Phantom and patient exposures were generated with a 6 MV x-ray beam. Linear and nonlinear regression analysis was employed to obtain formulas describing the relation between the radiation dose to an unshielded and/or shielded testicle with the field size and the distance from the inferior field edge. Correction factors showing the variation of testicular dose with the patient thickness along beam axis were found. Bland-Altman statistical analysis showed that testicular dose obtained by the proposed calculation method may differ from the measured dose value by less than 25%. The current study presents a method providing reasonable estimations of testicular dose for individual patients undergoing PA or DL radiotherapy.

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

Para-aortic irradiation for stage I testicular seminoma: results of a prospective study in 675 patients. A trial of the German testicular cancer study group (GTCSG)

A prospective nonrandomised trial was performed in order to evaluate tumour control and toxicity of low-dose adjuvant radiotherapy in stage I seminoma with treatment portals confined to the para-aortic lymph nodes. Between April 1991 and March 1994, 721 patients were enrolled for the trial by 48 centres in Germany. Patients with pure seminoma and no evidence of lymph node involvement or distant metastases received 26 Gy prophylactic limited para-aortic radiotherapy. Disease-free survival at 5 years was the primary end point. With a median follow-up of 61 months, 675 patients with follow-up investigations were evaluable for this analysis. Kaplan–Meier estimates of disease-free and disease-specific survival were 95.8% (95% CI: 94.2–97.4) and 99.6% (95% CI: 99.2–100%) at 5 years and 94.9% (95% CI: 92.5–97.4%) and 99.6% (95% CI: 99.2–100%) at 8 years, respectively. A total of 26 patients relapsed. All except two were salvaged from relapse. In all, 21 recurrences were located in infradiaphragmatic lymph nodes without any ‘in-field’ relapse. Nausea and diarrhoea grade 3 were observed in 4.0 and 1.0% of the patients, respectively. Grade 3 late effects have not been observed so far. The results of our trial lend further support to the concept of limited para-aortic irradiation as the recently defined new standard of radiotherapy in stage I seminoma. There is no obvious compromise in disease-specific or disease-free survival compared to more extensive hockey-stick portals, which were used as standard portals at the time this study was initiated.

[Radiotherapy in stage I testicular seminoma: retrospective study and review of literature]

INTRODUCTION

Seminoma accounts for about 40% of germ cell tumours of the testicle. In this retrospective analysis, we review literature concerning management of stage I seminoma.

MATERIALS AND METHODS

Between March 1987 and April 2001, 65 patients with stage I pure testicular seminoma received adjuvant radiotherapy with a 25 MV linear accelerator.

RESULTS

Median age was 33 years. Testicular tumour has been found on the right testis in 39 patients and on the left one in 24 patients. Patients have been treated using an anterior-posterior parallel pair and have received 20-25 Gy in 10-14 fractions. The target volume consisted of paraaortic, and paraaortic + homolateral iliac lymph nodes in 17 and 46 patients, respectively. Acute toxicity was mainly digestive, 38% of patients presenting nausea and vomiting. Median follow-up time was 37 months. All patients are alive in complete remission.

DISCUSSION

Because of good radio-sensitivity of seminoma, radiotherapy is regarded as standard adjuvant treatment (5 years relapse rate: 3-5%). Acute toxicity is dominated by moderate gastro-intestinal side effects. Secondary neoplasia represents one of the worst possible long-term complications of therapy. Waiting for ongoing randomised trials, the modern literature for seminoma reflects a trend toward lower radiation doses (20-25 Gy) and smaller treatment volumes (paraaortic field). Adjuvant chemotherapy with two courses of carboplatin, might be equivalent to radiotherapy but must be investigated in randomised trials. A surveillance policy is one of the other management options less recommended.

Management of recurrence and follow-up strategies for patients with seminoma and selected high-risk groups

Seminoma is characterized by high sensitivity to both radiation and chemotherapy. Localized recurrences in the retroperitoneum after surveillance for stage I can be treated with radiotherapy; however, multiple or large bulky retroperitoneal recurrences or systemic metastasis requires cisplatin-based chemotherapy. Salvage chemotherapy for those who recur after initial CR to induction chemotherapy is based on ifosfamide- and cisplatin-containing regimens. Incomplete response or failure after induction chemotherapy requires high-dose chemotherapy and stem cell rescue. Patients with seminoma need long-term follow-up because of the possibility of late recurrence and the risk of a second primary tumor.

Two secondary malignancies after radiotherapy for seminoma: case report and review of the literature

We report a case of a 50-year-old man with two synchronous second malignancies 25 years after orchiectomy and adjuvant radiotherapy for seminoma. An annual health examination revealed an elevated prostate-specific antigen level. A biopsy was performed revealing Gleason score 9 adenocarcinoma of the prostate. Computed tomography of the abdomen revealed a 2-cm solid mass in the right kidney consistent with renal cell carcinoma. Both of these lesions were within the nonstandard radiation field for seminoma with which this patient was treated. Second malignancies, including prostate cancer, are a very uncommon occurrence but an important consideration in long-term survivors of seminoma treated with radiotherapy.

Appropriate radiation volume for stage IIA/B testicular seminoma

PURPOSE

Prophylactic left supraclavicular fossa irradiation has been suggested to reduce relapse rates in patients treated for Stage IIA/B testicular seminoma. To address this issue, we reviewed patterns of failure and treatment outcome in patients treated with radiation therapy at our institution.

METHODS AND MATERIALS

Between 1981 and 1999, 79 men with Stage II seminoma (IIA, 49; IIB, 30) were treated with radiation therapy (RT) to the para-aortic and ipsilateral (+/- contralateral) pelvic lymph nodes (dose: 25-35 Gy).

RESULTS

With a median follow-up of 8.5 years, the 5-year relapse-free rate was 91% (standard error: 3%), and 2 patients have died of seminoma, giving a 5-year cause-specific survival of 97%. A total of 7 patients have relapsed with 2 isolated to the left supraclavicular fossa. Five of 7 patients have been successfully salvaged.

CONCLUSIONS

Prophylactic left supraclavicular fossa irradiation might have prevented relapse in 2 of 79 patients in Stage IIA/B seminoma. However, 97% of patients would have received unnecessary left neck RT, so we continue to recommend, as standard treatment, infradiaphragmatic RT only.

Long-term experience with carboplatin monotherapy for clinical stage I seminoma: a retrospective single-center study

OBJECTIVES

To evaluate the long-term oncologic efficacy and morbidity of carboplatin monotherapy, which was introduced at our department 11 years ago for the treatment of Stage I seminoma. Radiotherapy is the standard treatment of patients with clinical Stage I seminoma. Carboplatin has been advocated as a treatment alternative to avoid the late side effects of radiotherapy and the high recurrence rate of surveillance strategies.

METHODS

From February 1990 until August 2001, 108 patients received two adjuvant cycles of single-agent carboplatin (400 mg/m2 body surface on days 1 and 22) 2 weeks after high inguinal orchiectomy. To assess for myelosuppression, complete blood counts were performed at least once a week until the nadir occurred after the second treatment cycle.

RESULTS

During a mean follow-up period of 59.8 months (range 6 to 134), 2 patients (1.85%) developed a recurrence (retroperitoneal tumor) within the first year. Both patients received cisplatin-based salvage chemotherapy. At last follow-up, all patients were alive without any evidence of disease. Carboplatin treatment was well tolerated by all patients and was associated with only mild gastrointestinal side effects. Leukopenia was noted in 32 patients (29.6%); 21 (19.4%) of these patients had World Health Organization (WHO) grade 1, 8 (7.4%) had grade 2, 3 (2.8%) had grade 3, and none had grade 4. No patient developed neutropenic fever. Thrombocytopenia was observed in 48 patients (44.4%); of these patients, 38 (35.2%) had WHO grade 1, 5 (4.6%) had grade 2, 2 (1.9%) had grade 3, and 3 (2.8%) had grade 4.

CONCLUSIONS

From an oncologic standpoint, two cycles of carboplatin monotherapy was highly effective and very well tolerated by all patients.

Late recurrence in 1263 men with testicular germ cell tumors. Multivariate analysis of risk factors and implications for management

BACKGROUND

Testicular germ cell tumors are highly curable. However, 10-30% of patients have recurrence after initial treatment. The time-course of recurrence has implications for the duration of follow-up. This study was undertaken to assess the risk and time-course of recurrence and to identify patients at higher risk of late recurrence.

METHODS

The records of 1263 patients with primary testicular germ cell tumors presenting to the Royal Marsden Hospital between December 1979 and December 1993 were reviewed. In all, 255 episodes of recurrence were documented (including 44 patients with multiple recurrences) and used to calculate recurrence-free survivals.

RESULTS

Fifty-three patients (15 seminomas; 38 nonseminomatous germ cell tumors [NSGCT]) had recurrence more than 2 years after initial presentation. A multivariate analysis of risk of recurrence after 2 years identified positive markers at presentation and the presence of differentiated teratomas in postchemotherapy surgical specimens as significant predictors. Very late recurrence (> 5 years) occurred mainly in patients with metastatic NSGCT (12 of 14 patients) with a 1% annual risk of recurrence between 5 and 10 years. Very late recurrence was also seen in one case of metastatic seminoma and one case of Stage I NSGCT managed by surveillance. Most late recurrences (n = 9) were detected at routine annual follow-up visits but five had recurrences with symptoms leading to an unscheduled clinic visit.

CONCLUSION

Late recurrences are rare in patients with testicular germ cell tumors and follow-up to detect recurrence may not be needed after 5 years, except in those presenting with metastatic NSGCTs.

Malignant Sertoli cell tumors of the testis: a study of 13 examples of a neoplasm frequently misinterpreted as seminoma

The distinction of Sertoli cell tumors from seminoma is critical to ensure proper treatment. Although usually straightforward, we highlight herein 13 malignant Sertoli cell tumors of the testis with light microscopic features that mimicked seminoma. All of the cases were received in consultation, 10 with submitting diagnoses of seminoma, usually of classic type, but three cases of spermatocytic type. Patients ranged from 15 to 80 years of age (median 37 years); all presented with testicular masses. The tumors were typically firm, white to yellow-tan, and often had foci of hemorrhage. The dominant microscopic pattern was nested or sheet-like, with some tumors having secondary patterns of trabeculae-solid tubules, hollow tubules, and pseudofollicles. Tumor cells were polygonal with conspicuous clear cytoplasm in 12 cases; the cytoplasm was focally eosinophilic in 10 cases, but this was never conspicuous. Nine tumors had cytoplasmic vacuoles, and three of four that were investigated stained for intracytoplasmic glycogen. Nuclei were small (5) to medium-sized (8), round-to-oval (13), and vesicular with irregular contours (11). Nucleoli were present in 11 tumors (six small; five large). Stromal fibrosis (12) and lymphoid infiltrates (10) were conspicuous, and tumor necrosis (11) and vascular invasion (8) also were seen. Mitotic figures ranged from <1 to 21/10 high power fields (HPF) (median 1/10 HPF). Staining for inhibin-alpha, epithelial membrane antigen, and cytokeratin (AE1/AE3) was positive in four of four, six of six, and three of six cases, respectively; placental alkaline phosphatase was negative in all five tumors investigated. The nested growth pattern, prominence of clear cells, lymphoid infiltrate, inconspicuous tubular differentiation, cytoplasmic glycogen, and prominent nucleoli caused these tumors to be mistaken for seminomas. The smaller, less pleomorphic nuclei of Sertoli cell tumors, their lower mitotic rate, and the absence of intratubular germ cell neoplasia are helpful differential features. Immunohistochemistry is a useful adjunct in confirming the diagnosis of Sertoli cell tumor, but only if the overlapping features are appreciated by conventional microscopy and the diagnosis of Sertoli cell tumor included in the differential.

The location of contralateral breast cancers after radiation therapy

Radiation therapy following conservative surgery results in scattered radiation to the contralateral breast, with higher doses to the medial breast and lower doses laterally. The purpose of the current study is to determine whether the location of contralateral breast cancers developing following breast conserving surgery and radiation is indicative of radiation-induced malignancies. The charts of 1,755 patients treated with conservative surgery and radiation therapy between 1970 and 1998 were reviewed. Fifty-nine patients who developed a contralateral malignancy following conservative surgery and radiation therapy and who had complete information and documentation of the location of the second lesion served as the primary focus of the current study. The location of the contralateral malignancy was compared with the location of the primary tumors of the overall patient population. The location of breast cancers developing in the contralateral breast following breast conserving therapy and radiation was not consistent with radiation-induced malignancies. Specifically, there was not a preponderance of medially located tumors in patients developing contralateral breast cancers following radiation. There was a slight excess of central lesions that cannot be explained by higher doses of radiation. The location of breast cancers in the contralateral breast following conservative surgery and radiation is not indicative of radiation-induced lesions. These data should be reassuring to women considering breast conserving surgery and radiation.

Quality of life after radiotherapy for early-stage testicular seminoma

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The effect of radiotherapy treatment changes on sites of relapse in stage I testicular seminoma

AIM

To evaluate relapse patterns in stage I testicular seminoma related to changes in radiotherapy practice.

METHOD

Four hundred and six patients with stage I testicular seminoma were treated with adjuvant radiotherapy following orchidectomy: 338 patients received para-aortic radiotherapy only and 68 patients with added risk factors had radiotherapy extended to include the pelvis. Computed tomograms of relapsed patients were reviewed and sites of relapse were documented with correlation to the radiotherapy field.

RESULTS

Thirteen relapses were identified; 10 occurring in the para-aortic radiotherapy group (3.0% relapse rate) and three in the extended radiotherapy field group (4.4% relapse rate). Sites of relapse were; five pelvis, three mediastinum, one lung, one scapula, one scrotum, while one patient had multiple relapse sites including the pelvis and one had a tumour marker relapse with no site identified. All the pelvic relapses occurred in the para-aortic radiotherapy group.

CONCLUSION

Pelvic relapse only occurred when radiotherapy had been confined to the para-aortic region. Since para-aortic radiotherapy achieves equivalent outcome to wider field radiotherapy with reduced toxicity, it is likely to become standard practice in stage I seminoma and pelvic relapses will therefore increase in frequency. It is therefore important to include pelvic imaging when relapse is suspected.

Second malignancies after treatment of early-stage breast cancer: lumpectomy and radiation therapy versus mastectomy

PURPOSE

To determine the risk of second malignancies after lumpectomy and radiation therapy (LRT), and to compare it with that in a similar cohort of early-stage breast cancer patients undergoing mastectomy without radiation (MAST).

PATIENTS AND METHODS

Between January 1970 and December 1990, 1,029 breast cancer patients at our institution underwent LRT. A cohort of 1,387 breast cancer patients who underwent surgical treatment by mastectomy (MAST), and who did not receive postoperative radiation during the same time period, served as a comparison group. Second malignancies were categorized as contralateral breast versus nonbreast. In the cohort of patients undergoing LRT, a detailed analysis was carried out with respect to age, disease stage, smoking history, radiation therapy technique, dose, the use of chemotherapy or hormone therapy, and other clinical and/or pathologic characteristics.

RESULTS

As of March 1999, the median follow-up was 14.6 years for the LRT group and 16 years for the MAST group. The 15-year risk of any second malignancy was nearly identical for both cohorts (17.5% v 19%, respectively). The second breast malignancy rate at 15 years was 10% for both the MAST and LRT groups. The 15-year risk of a second nonbreast malignancy was 11% for the LRT and 10% for the MAST group. In the subset of patients 45 years of age or younger at the time of treatment, the second breast and nonbreast malignancy rates at 15 years were 10% and 5% for patients undergoing LRT versus 7% and 4% for patients undergoing mastectomy (P, not statistically significant). In the detailed analysis of LRT patients, second lung malignancies were associated with a history of tobacco use. There were fewer contralateral breast tumors in patients undergoing adjuvant hormone therapy, although this did not reach statistical significance. The adjuvant use of chemotherapy did not significantly affect the risk of second malignancies.

CONCLUSION

There seems to be no increased risk of second malignancies in patients undergoing LRT using modern techniques, compared with MAST. Continued monitoring of these patient cohorts will be required in order to document that these findings are maintained with even longer follow-up periods. With nearly 15 years median follow-up periods, however, these data should be reassuring to women who are considering LRT as a treatment option.

Current opinion in germ cell cancer 2000

Despite its relative rarity compared with the common adult cancers, scientific and clinical interest in germ cell cancer is increasing. From the point of view of epidemiology, the controversy about the relative importance of intrauterine versus postpubertal risk factors has continued. Evidence to support the importance of intrauterine factors comes from reports from Norway, Canada, and the US, confirming the Danish observation that the rising incidence of germ cell cancer is linked to a birth cohort effect; evidence in support of the importance of postpubertal risk comes from three case/control studies demonstrating increased risk linked to postpubertal exposures such as pesticides, plastics, electromagnetic radiation, trauma, and infections. There has been increasing interest in human endogenous retrovirus K10 as a possible factor explaining genetic susceptibility and providing a linkage between the two groups of risk factors. In cytogenetics, progress was reported in identifying the deletion point of the suspected tumor suppressor gene responsible for the i12p marker chromosome abnormality and development of FISH probes for diagnostic purposes. In molecular biology, the importance of DNA repair deficiency in normal germ cells as a factor in the exquisite chemosensitivity of germ cell cancer has been high-lighted by a report demonstrating a low level of the xeroderma pigmentosa group A (XPA) protein and induction of resistance in vitro by adding XPA. In the clinic, progress in positron emission tomography scanning and laparoscopic lymph node staging are leading to changes in outlook on management of stage 1 cases and patients with small residual masses postchemotherapy. Salvage chemotherapy regimens integrating dose dense and vertical dose intensification strategies reported 60% progression-free survival. New drugs such as gemcitabine demonstrated continued therapeutic potential for chemotherapy in these tumors. A report demonstrating the inadequacies of hormone replacement after bilateral orchidectomy and a report of the first child born after testis-conserving therapy highlight the need for more attention to testis conservation as a quality of life issue. With the cure rates so high, the need for central referral is once again debated both for stage 1 and metastatic disease. With new ways of defining poor risk stage 1 patients and reports on impact of experience highlighting the worse outcome of patients treated in centers treating small numbers, views on this issue remain clearcut.

Radiotherapy for stages I and IIA/B testicular seminoma

Radiotherapy is generally accepted as a standard treatment for early-stage testicular seminoma. Relapse rates of 2% to 5% in clinical stage I and 10% to 20% in stage IIA/B (according to the Royal Marsden classification) can be achieved. Disease-specific survival reaches 100%. With such excellent cure rates, treatment-related side effects gain particular importance. Therefore, a prospective multicenter trial was initiated for radiotherapy of testicular seminoma with limited treatment portals and low total doses of irradiation. In clinical stage I, 483 patients were treated with 26 Gy to the para-aortic region only. In stage IIA, 42 patients and, in stage IIB, 18 patients received irradiation to the para-aortic and high iliac lymph nodes with 30 and 36 Gy, respectively. With a median time to follow-up of 55 months for stage I and 55.5 months for stage IIA/B, there were 18 (3.7%) and 4 (6.7%) cases of relapse in both treatment groups. Disease-specific survival was 99.6% in stage I and 100% in stage IIA/B. Acute toxicity was dominated by moderate gastro-intestinal side effects. No major late toxicity has been observed to date. Limited volume pure para-aortic treatment for stage I and para-aortic/high iliac irradiation for stage IIA/B with 26, 30 and 36 Gy, respectively, yields excellent cure rates with only moderate acute toxicity and is therefore recommended as standard treatment.

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.

Treatment of testicular tumours based on risk factors

Germ cell cancer is highly sensitive to cisplatinum-based chemotherapy, resulting in cure rates of over 90% for patients with minimal metastatic disease or low tumour markers, 70% for patients with intermediate prognosis features, and 50% for patients with poor prognosis criteria. Whereas current clinical studies aim to improve the survival of patients with poor prognosis by means of high-dose chemotherapy, or the survival of intermediate prognosis patients by more intensive chemotherapy, for patients with good prognosis the reduction of doses, number of drugs or cycles is investigated to reduce the short-term and, in particular, long-term treatment sequelae. However, apart from these clinical studies, the current treatment standard of three cycles of platinum/etoposide/bleomycin for good prognosis patients and four cycles for intermediate and poor prognosis patients with advanced germ cell cancer has not been changed by recent trial results. The excellent cure rate with cisplatinum-based chemotherapy in the case of early metastatic disease with three cycles of platinum/etoposide/bleomycin as well as the high efficacy of adjuvant chemotherapy with two cycles of platinum/etoposide/bleomycin in the case of microscopic disease did change the treatment standards in stage I and II non-seminomatous germ cell cancer, with defined treatment options depending on prognostic factors. The treatment of testicular cancer based on prognostic factors is mandatory in all stages of seminoma and non-seminoma; however, molecular biological factors might make a major contribution to a more precise determination of prognosis and therefore enable a tailored selection of an individual treatment in the future.