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

Late recurrence of Seminoma in the pelvis: A case report

Recurrence of pure seminoma in atypical lymph node sites, such as the pelvis are rare masses that show clinical signs late in disease progression. We report a case of a 73-year-old male that presented with urinary retention and pain in his left lower extremity with a history of right radical orchiectomy and adjuvant radiation for a stage 1 pure seminoma 30 years prior. CT showed a left pelvic mass concerning for malignancy. Patient subsequently underwent surgical excision of mass that pathology identified as recurrence of pure seminoma. This case report emphasizes etiology of pure seminoma and late, contralateral pelvic recurrence.

IGG* Practice Guidelines on Germ Cell Tumor in Adult Male Patients

Germ cell tumors are rare neoplasms that affect young males. Nearly 99% of patients with localized stage I disease and nearly 80% of patients with metastatic disease can be cured. Even patients who relapse following chemotherapy can achieve a long-term survival in approximately 30–40% of cases. The main objective in early stages and in good prognosis patients has changed in recent years, and it has become of major importance to reduce treatment-related morbidity without compromising the excellent long-term survival rate. In poor prognosis patients, there is a correlation between the experience of the treating institution and the long-term clinical outcome of the patients, particularly when the most sophisticated therapies are needed. So far, of utmost importance is the information from updated practice guidelines for the diagnosis and treatment of germ cell tumors. The Italian Germ cell cancer Group (IGG) has developed the following clinical recommendations, which identify the current standards in diagnosis and treatment of germ cell tumors in adult males.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Management of stage I seminomatous testicular cancer: a systematic review

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

Posttreatment surveillance after paraaortic radiotherapy for stage I seminoma: a systematic analysis

CONTEXT

The extent and duration of routine follow-up after paraaortic (PA) radiotherapy for stage I seminoma remain controversial in terms of efficacy, costs of technical investigations and long-term morbidity.

OBJECTIVE

To analyze the current literature assessing routine follow-up after PA radiotherapy for stage I seminoma.

EVIDENCE ACQUISITION

We identified all published reports on PA radiotherapy for stage I seminoma (1986-2005). We analyzed time patterns of recurrence, sites and methods of detection of relapse, and follow-up programs used.

EVIDENCE SYNTHESIS

We identified 11 publications reporting outcome in 2,280 patients. Median time to recurrence in 80 relapsing patients was 15.5 months. Less than 10% of recurrences were diagnosed beyond the third year of follow-up. Isolated locoregional or distant recurrence was observed in 52 and 20 patients, respectively, without significant difference in median time to relapse. 19 out of 43 recurrences with reported method of detection of relapse were diagnosed by routine technical investigations. There was no significant difference in time to relapse between those patients followed with low volume as compared to high-volume imaging protocols.

CONCLUSIONS

Our data suggest that technical investigations in posttreatment surveillance should be restricted to the first 3 years of follow-up. Furthermore, surveillance programs with a high volume of imaging apparently do not lead to earlier detection or less advanced stage at the time of relapse as compared to protocols with low volume imaging.

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.

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.