Clinical Stage IIA-IIC Seminoma: Radiation Therapy versus Systemic Chemotherapy versus Retroperitoneal Lymph Node Dissection

Iodine‑125 seeds combined with carboplatin in the treatment of retroperitoneal metastatic seminoma: A case report and literature review

Testicular seminoma is a relatively rare malignant tumor, with the most common site of recurrence and metastasis being the retroperitoneal lymph nodes. Since seminoma is highly sensitive to radiotherapy and chemotherapy, even if it metastasizes, its cure rate is still >95%. However, the long-term toxicity and side effects of radiotherapy and chemotherapy cannot be ignored. Iodine-125 seeds represent a low-energy radioactive source that kills tumor cells while protecting the surrounding normal tissues, and brachytherapy using iodine-125 seeds has been widely used for the treatment of various malignancies. In addition, carboplatin can be used as an alternative to cisplatin-based combination chemotherapy to reduce the incidence of pulmonary toxicity, neurological damage and renal toxicity. In the present study, a case in which iodine-125 seeds were implanted for the treatment of retroperitoneal metastatic seminoma is reported. The patient was diagnosed with postoperative recurrence of seminoma that metastasized to the retroperitoneal lymph nodes. Since the tumor was large and surrounded blood vessels, surgical intervention and external radiotherapy were not considered. Moreover, considering the potential long-term toxic side effects of standard chemotherapy, a treatment plan for the patient using iodine-125 seed implantation combined with carboplatin (AUC7) therapy was finally formulated. No disease recurrence or toxic reactions occurred during the 3-year follow-up after treatment. The present case therefore demonstrated the antitumor efficacy and reduced toxicity of iodine-125 seeds combined with carboplatin for treating seminoma.

Retroperitoneal Lymph Node Dissection in Clinical Stage IIA/B Metastatic Seminoma: Results of the COlogne Trial of Retroperitoneal Lymphadenectomy In Metastatic Seminoma (COTRIMS)

BACKGROUND

Radiation therapy and systemic chemotherapy are recommended treatment options in marker-negative clinical stage (CS) IIA/B seminoma. Despite high cure rates of 82-94%, both therapeutic options are associated with significant long-term toxicities.

OBJECTIVE

To evaluate the feasibility, oncological efficacy, and treatment-associated morbidity of primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) in CS IIA/B seminoma.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, single-arm, clinical phase 2 trial including CS IIA/B seminoma patients was conducted.

INTERVENTION

Primary nerve-sparing retroperitoneal lymphadenectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relapse-free and overall survival, surgery-associated complications according to the Clavien-Dindo classification, and Kaplan-Meier methods for survival calculation were assessed.

RESULTS AND LIMITATIONS

Thirty patients at a mean age of 39.1 (34-52) yr with marker-negative CS IIA and IIB seminomas were recruited. The median follow-up was 22 (8-30) mo. Nineteen (63%) and 11 (36%) patients were diagnosed with stages IIA and B, respectively, at the time of primary diagnosis. Fourteen (47%) and 16 (53%) patients were diagnosed with CS IIA and IIB, respectively, at the time of nsRPLND. Twenty-seven and three patients underwent open and robot-assisted nsRPLND, respectively. The median operating room time was 125 (115-145) min, median blood loss was <150 ml, and median time of hospitalization was 4.5 (3-9) d. Four (13%) patients experienced Clavien-Dindo grade 3a complications. Lymph node histology revealed seminoma in 25 (80%) patients; two and three patients demonstrated embryonal carcinoma and benign disease, respectively. Sixteen patients underwent a serum analysis of miR371 preoperatively, which predicted metastatic disease in 12/13 and benign histology in 3/3 patients. Three of 30 (10%) patients developed an outfield relapse 4, 6, and 9 mo postoperatively and were salvaged by systemic chemotherapy. Limitations are the low patient number and length of follow-up.

CONCLUSIONS

The nsRPLND approach results in a high cure rate at midterm follow-up and is associated with a low frequency of treatment-associated morbidities, making this approach a feasible alternative to radiation therapy or systemic chemotherapy.

PATIENT SUMMARY

The standard treatment of clinical stage IIA/B seminomas is radiation therapy or chemotherapy, which results in a significantly increased frequency of long-term toxicity and secondary neoplasms. In this trial, we demonstrate that nerve-sparing retroperitoneal lymph node dissection is a feasible therapeutic approach with low morbidity and high oncological efficacy.

[French ccAFU guidelines - update 2020-2022: testicular germ cell tumors]

OBJECTIVE

- To update French guidelines concerning testicular germ cell cancer.

MATERIALS AND METHODS

- Comprehensive Medline search between 2018 and 2020 upon diagnosis, treatment and follow-up of testicular germ cell cancer and treatments toxicities. Level of evidence was evaluated.

RESULTS

- Testicular Germ cell tumor diagnosis is based on physical examination, biology tests (serum tumor markers AFP, hCGt, LDH) and radiological assessment (scrotal ultrasound and chest, abdomen and pelvis computerized tomography). Total inguinal orchiectomy is the first-line treatment allowing characterization of the histological type, local staging and identification of risk factors for micrometastases. In case of several therapeutic options, one must inform his patient balancing risks and benefits. Surveillance is usually chosen in stage I seminoma compliant patients as the evolution rate is low between 15 to 20%. Carboplatin AUC7 is an alternative option. Radiotherapy indication should be avoided. In stage I non seminomatous patients, either surveillance or risk-adapted strategy can be applied. Staging retroperitoneal lymphadenectomy has restricted indications. Metastatic germ cell tumors are usually treated by PEB chemotherapy according to IGCCCG prognostic classification. Lombo-aortic radiotherapy is still a standard treatment for stage IIA. Residual masses should be evaluated by biological and radiological assessment 3 to 4 weeks after the end of chemotherapy. Retroperitoneal lymphadenectomy is advocated for every non seminomatous residual mass more than one cm. 18FDG uptake should be evaluated for each seminoma residual mass more than 3 cm.

CONCLUSIONS

- A rigorous use of classifications is mandatory to define staging since initial diagnosis. Applying treatments based on these classifications leads to excellent survival rates (99% in CSI, 85% in CSII+).