Staging, treatment, and results in testicular seminoma. A 12-year report

ACR Appropriateness Criteria® Staging and Surveillance of Testicular Cancer: 2021 Update

The staging and surveillance of testicular cancer is a complex topic, which integrates clinical, biochemical, and imaging components. The use of imaging for staging and surveillance of testicular cancer is individually tailored to each patient by considering tumor histology and prognosis. This document discusses the rationale for use of imaging by imaging modality during the initial staging of testicular seminoma and nonseminoma tumors and during the planned surveillance of stage IA and IB testicular cancer by histological subtype integrating clinical suspicion for disease recurrence in surveillance protocols. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Management preferences following radical inguinal orchidectomy for Stage I testicular seminoma in Australasia

A survey to evaluate the preferred patterns of management of Stage I seminoma was conducted during March 2001. The questionnaire was distributed by the Royal Australian and New Zealand College of Radiologists to all qualified radiation oncologists, 74 out of 170 responded. All performed a staging CT scan of the abdomen and pelvis. Thoracic imaging consisted of either chest X-ray (29%) or chest CT (38%) while 33% performed both. Fifty-four percent of radiation oncologists discussed surveillance with their patients but estimated that 5% or less would choose this option. The most commonly prescribed dose was 25 Gy in 15 or 20 fractions (79%). Sixty-five percent of respondents treated the para-aortic (PA) nodes alone. Forty-two of 48 clinicians treating the PA field reported a change in practice after publication of the Medical Research Council study in 1999. Of these, 40 and 23% perform CT scans of the pelvis annually and every 6 months. Thirty-one percent did no follow-up CT scan. Compared to a similar survey from North America, we are more likely to use PA fields and less likely to discuss surveillance. As in the USA, and in contrast to Canada, few patients choose surveillance. There is no consensus regarding the frequency of follow-up scans in either North America or Australasia.

Para-aortic irradiation only appears to be adequate treatment for patients with Stage I seminoma of the testis

PURPOSE

Results of treatment of patients with Stage I seminoma with orchiectomy and radiotherapy are excellent. Even without adjuvant radiotherapy, the relapse rate is only 15-20%; most of the patients fail in the retroperitoneum, with rare failures observed in the pelvis (0.5-2%). In 1991, we began a prospective study evaluating para-aortic lymph node radiation as the only adjuvant treatment for such patients. This paper reports our preliminary results.

MATERIALS & METHODS

Between March 1991 and January 1996, 35 patients with histologically proven Stage I seminoma were entered in the study. Median age was 37.9 years (range: 27-65 years). A radical inguinal orchiectomy was performed in all patients. Staging workup consisted of a chest X-ray; B-HCG, alpha-fetoprotein, and CT scan of the abdomen and pelvis in all patients. Lymphangiogram was done in 23 (66%) of 35 patients for further evaluation of the retroperitoneal lymph nodes. Radiotherapy consisted of treatment to the para-aortic region only. Parallel opposed fields extending from the top of T11 to the bottom of L5 were used. The median field size was 8.7 x 21.8 cm (range: 7-11 x 18-26 cm). The median total dose, prescribed at midpoint, was 25 Gy given in 15 daily fractions of 1.66 Gy. Follow-up was performed every 3 months for the first year, every 4-5 months for the second and third years, and every 6 months thereafter. Chest X-ray, tumor markers, and CT scan of the pelvis were performed routinely as part of the follow-up investigation.

RESULTS

At a median follow-up of 39.7 months (range: 16-74 months), 34 (97.1%) of 35 patients are alive with no evidence of disease for an overall actuarial survival rate of 97.1% at 5 years and a cause-specific actuarial survival rate of 100%. Treatment morbidity was limited to Grade I-II acute side effects in 18 (51.4%) of 35 patients. No late side effects were seen.

CONCLUSION

From our preliminary results, adjuvant radiation treatment limited to the para-aortic lymph node region, without ipsilateral pelvic irradiation, appears to be adequate treatment for Stage I seminoma. Such an approach in our patients resulted in minimal toxicity and excellent disease-free survival.

Radiotherapy in stage IIA and IIB testicular seminoma with reduced portals: a prospective multicenter study

PURPOSE

A prospective multicenter study was carried out to estimate the treatment outcome of radiotherapy in Stage II seminoma after the application of modern staging and radiotherapy techniques. The lower margin of the iliac field was positioned on the upper rim of the acetabulum to reduce the amount of scattered irradiation to the remaining testicle.

METHODS AND MATERIALS

The study was carried out in 25 centers in Germany. Patients with pure seminoma, negative AFP-values, and retroperitoneal lymph node metastases of less than 5 cm in diameter were entered into the study. All patients received a ventrodorsal opposed field irradiation of the para-aortic and the ipsilateral iliac lymph nodes. The fields extended from the top of the 11th thoracic vertebra to the top of the acetabulum. Patients in Stage IIA (lymph nodes <2 cm ) received 30 Gy, and patients with Stage IIB (lymph nodes between 2 and 5 cm) 36 Gy total dose.

RESULTS

39 patients in Stage IIA and 19 patients in Stage IIB were evaluated. After a median observation time of 37 months all patients are alive and disease free. Recurrence free survival in stage IIA was 100%. Two patients in Stage IIB experienced a recurrence 10 and 17 months after the end of radiotherapy. The actuarial recurrence free survival estimate in Stage IIB was 94.1% for 1 year and 87.4% for 2 years. One recurrence in Stage IIB occurred in the mediastinum, one in the mediastinum, and one the lung. Both patients could be salvaged by chemotherapy. There were no pelvic recurrences. The treatment was well tolerated, with nausea being the most common side effect (56.9% Grade 1, 15.5% Grade 2, and 8.6% Grade 3). Diarrhea occurred in 15.5% (Grade 1), 15.5% (Grade 2), and 5.2% (Grade 3) of the patients.

CONCLUSIONS

The outcome of para-aortic and ipsilateral iliac irradiation in Stage IIA/B testicular seminoma is excellent with the currently available staging methods and treatment facilities. The treatment is well tolerated. The lower margin of the iliacal field can be placed at the acetabulum.

Relapses in early-stage testicular seminoma: radiation therapy versus retroperitoneal lymphadenectomy

Being among the most radiosensitive tumours, radiation therapy has replaced retroperitoneal lymphadenectomy in the treatment of early-stage testicular seminoma. One hundred and sixty-one patients who were treated from 1975 through to 1991 with histologically confirmed testicular seminoma of stages I and II were analyses retrospectively. After high semicastration, 98 patients were treated by radiation therapy of regional lymph nodes and 63 patients received retroperitoneal lymphadenectomy. Until 1985 retroperitoneal lymphadenectomy was preferred, but after 1985 radiotherapy outweighed retroperitoneal lymphadenectomy. The follow-up ranged from 11 months to 13.5 years, with a median of 79 months. Retroperitoneally, in-field relapses occurred in 9.5% (6/63 patients) after retroperitoneal lymphadenectomy and in 2.0% (2/98 patients) after radiation therapy (Fisher exact test, p = 0.057). A trend to a higher frequency of retroperitoneal relapses after retroperitoneal lymphadenectomy seemed to be apparent. Relapses outside the operation site or radiation fields were registered with non-significantly different frequencies (p = 0.741) of 4.8% (3/63 patients) and 7.1% (7/98 patients), respectively. Relapses increased from 4.1% for stage I (5/121 patients) up to 58.3% for stage IIC (7/12 patients).

Contribution of cell proliferative activity to malignancy potential in testicular seminoma

Testicular anaplastic seminoma, which has a high mitotic activity, is regarded as more malignant than typical seminoma, although its prognosis is still unclear. To determine whether seminoma with relatively greater malignancy potential can be identified based on the cell proliferative activity, the mitotic rate (MR; mitotic count per high-power field), mitotic index (MI; mitotic count per 1000 cells), Ki-67 labeling index (Ki-67 LI; the percentage of positive cells) and proliferating cell nuclear antigen LI (PCNA LI; the percentage of positive cells) were histologically examined in 44 patients. The MI, Ki-67 LI and PCNA LI in patients with metastatic disease were significantly higher than those in patients without metastatic disease, and the MI in patients with fatal disease was significantly higher than those in patients cured of the disease. However, these distributions of the MI, Ki-67 LI and PCNA LI values overlapped for both pairs of groups. There were no significant differences in the MR. These results suggest that the cell proliferative activity makes a small contribution to the malignancy potential in testicular seminoma, with the activity being not necessarily indicative of metastasis and prognosis.

Cisplatin-based chemotherapy in advanced seminoma: experience of the Northern Israel Oncology Center: 1981-1994

BACKGROUND

The efficacy of cisplatinum combined chemotherapy modalities was investigated in a variety of trials for patients with advanced seminoma. Results regarding remission rates and survival are encouraging.

METHODS

Between December 1981 and January 1994, 13 patients with either relapsed (following radiotherapy failure) or primarily advanced seminoma were treated with cisplatin-based chemotherapy at the Northern Israel Oncology Center.

RESULTS

Eleven (84%) patients achieved complete clearance of all sites of disease. One patient demonstrated clinically and radiographically remarkable shrinkage of an abdominal mass, and laparotomy revealed fibrotic/necrotic tissue without viable tumor cells. After a mean follow-up of 58 months (range 4-168), 12 patients (92%) are alive and well without evidence of malignancy. One patient, in whom a 2-cm abdominal mass is stable radiographically, is under observation with no sign of tumor activity. Side effects were tolerable; no patient developed chemotherapy-induced sepsis. One patient developed spontaneous pneumothorax a few days after completion of his first chemotherapy cycle, which resolved with treatment.

CONCLUSIONS

Our results confirm the efficacy and safety of cisplatin-based chemotherapy in the treatment of advanced seminoma, even in pre-irradiated patients.

External beam abdominal radiotherapy in patients with seminoma stage I: field type, testicular dose, and spermatogenesis

PURPOSE

To establish a predictive model for the estimation of the gonadal dose during adjuvant para-aortic (PA) or dog leg (DL: PA plus ipsilateral iliac) field radiotherapy in patients with testicular seminoma.

METHODS AND MATERIALS

The surface gonadal dose was measured in patients with seminoma Stage I receiving PA or DL radiotherapy. Sperm cell analysis was performed before and 1 year after irradiation. PA and DL radiotherapy were simulated in the Alderson phantom while we measured the dose to the surface and middle of an artificial testicle, varying its position within realistic anatomical constraints. The symphysis-to-testicle distance (STD), field length, and thickness of the patient were experimental variables. The developed mathematical model was validated in subsequent patients.

RESULTS

The mean gonadal dose in patients was 0.09 and 0.32 Gy after PA and DL irradiation, respectively (p < 0.001). DL radiotherapy, but not PA irradiation led to significant reduction of the sperm count 1 year after irradiation. The gonadal dose-reducing effect of PA irradiation was confirmed in the Alderson phantom. A significant correlation was found between the STD and the gonadal dose during DL irradiation. A mathematical model was established for calculation of the gonadal dose and confirmed by measurements in patients.

CONCLUSIONS

During radiotherapy of seminoma, the gonadal dose decreases with increasing STD. It is possible to predict the individual gonadal dose based on delivered midplane dose and STD.

Long-term evaluation of postorchiectomy radiotherapy for stage II seminoma

PURPOSE

To determine survival, long-term tumor control, and the effects of irradiation for stage II seminoma.

MATERIALS AND METHODS

Forty-five patients with stage II testicular seminoma were treated between 1966 and 1989. There were 31 patients with stage IIA disease and 14 with stage IIB disease. All patients underwent orchiectomy followed by iliac and paraaortic irradiation (median dose: 30 Gy), with 37 patients receiving prophylactic mediastinal and supraclavicular irradiation (median dose: 30 Gy). Follow-up ranged from 6 months to 20.6 years, with a median of 9.4 years.

RESULTS

Uncorrected survival was 98% at 5 years, 84% at 10 years, and 79% at 15 years. Survival corrected for intercurrent disease was 98% at 5, 10, and 15 years. Five patients developed recurrences with four successfully salvaged by chemotherapy and/or irradiation. There were no serious acute toxicities, and no late complications have developed from infradiaphragmatic irradiation. Supradiaphragmatic irradiation was associated with an increased risk of coronary artery disease compared to the age-matched general population.

CONCLUSION

Radiotherapy remains an effective treatment for stage II testicular seminoma, with a 98% adjusted survival rate at 15 years, without serious acute toxicity. Supradiaphragmatic irradiation should not be used in stage IIB patients for whom salvage chemotherapy is an option.

Adjuvant radiation therapy for low stage testicular seminoma: Diagnosis and therapy in evolution

We performed a retrospective study to evaluate the clinical outcome of patients with early stage testicular seminoma who received adjuvant radiation therapy after orchiectomy over the past 15 years. During the 15 year period, 61 patients were treated with adjuvant radiation therapy for stages I, IIA, and IIB testicular seminoma. Patients received from 2,000 to 4,000 cGy delivered by a Cobalt machine and later by a linear accelerator. Our standard treatment protocol was modified in 13 patients: 7 secondary to abnormal lymphangiography (LAG) parameters and 6 due to abnormal computed tomography findings. We analyzed each patient's outcome for survival, recurrence, and complications. We then compared outcomes, looking for differing trends based on evolving evaluation or treatment techniques. The average follow-up is 75 months, with an overall survival rate of 93%. The cause specific survival is 100%. Four patients died from intercurrent diseases; at time of autopsy, one of these patients was noted to have a small focus of seminoma in a lateral inguinal node. He died from widely disseminated Hodgkin's disease. Three patients, including the aforementioned one, had recurrent disease outside of the radiation field, yielding a recurrence rate of 5%. No significant long term treatment complications were reported, although 24% of patients had one or more complications from LAG. Regardless the various changes in patient evaluation and radiation treatment techniques over the past 15 years, adjuvant radiation therapy remains effective in patients with early stage testicular seminoma.

Low-dose radiotherapy for stage I seminoma: early results

One hundred and one patients with stage I seminoma were irradiated with total doses of 30, 25.5 and 20 Gy to gradually reduced target volumes (paraaortic, pelvic, and inguinal regions to paraaortic only). Low doses and small target volumes resulted in excellent survival and freedom of recurrence but in more frequent nausea.

Testicular seminoma: a failure analysis and literature review

PURPOSE

A retrospective analysis of 74 patients with pure seminoma, treated at the University of Florida between 1964 and 1989, was undertaken.

METHODS AND MATERIALS

All patients received megavoltage irradiation, with chemotherapy reserved for salvage. At 10 years, the probability of relapse-free survival was 91% for Stage I, 93% for Stage IIA, 83% for Stage IIB, and 75% for Stage III patients.

RESULTS

There were seven recurrences, none of which occurred in irradiated areas. Only two of seven patients (29%) with recurrence were salvaged.

CONCLUSION

A literature review revealed an increasing rate of mediastinal or supraclavicular recurrence, correlating with the size of the subdiaphragmatic disease, in Stage II patients who did not receive elective mediastinal irradiation. Recommendations are made regarding the role of elective mediastinal irradiation for Stage II disease. We conclude that patients with Stage I or II seminoma can have high cure rates when treated with radiotherapy alone. Patients with Stage III seminoma should be treated initially with cisplatin-based chemotherapy.

Has lymphography a role in early stage testicular germ cell tumours?

A retrospective study was performed of 183 newly diagnosed seminoma cases and 73 newly diagnosed non-seminomatous germ cell tumours (NSGCT) presenting from 1985 to 1989 to a tertiary referral cancer hospital. The purpose was to assess the contribution of bipedal lymphography (LG) to the management of these patients. As the main value of LG is in detecting small retroperitoneal lymph node (LN) metastases, analysis concentrated upon early stage disease, specifically N0 and N1a LN disease. Comparison between LG results, abdominopelvic computed tomography (APCT), final clinical stage and treatment outcome was performed. We found that with the LG and APCT criteria used (filling defects > 2 mm and LN diameter > 20 mm, respectively), LG was much more sensitive in disease detection. However, with modern techniques APCT can reliably detect disease 10 mm or greater. In addition, tumour marker status, primary tumour vascular invasion status and initial clinical examination were each more important in staging NSGCT disease than LG alone. Thus, LG is now rarely used in our institution but we will have to monitor our excellent survival data to confirm that this change in policy is warranted.

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)

Combined single course carboplatin with radiotherapy in treatment of stage IIA,B seminoma--a preliminary report

Twenty-one patients with Stage IIA or B seminoma have been treated post orchidectomy by a single course of carboplatin prior to conventional radiotherapy in either the Royal Marsden Hospital or the Norwegian Radium Hospital during 1989-1993. Follow-up ranged from 8 months to 51 months with a mean of 36 months and median 34 months. All patients achieved complete remission and remain disease free. The main side-effects were nausea and vomiting while haematological toxicity was slight. There was no symptomatic peripheral neuropathy, ototoxicity or deterioration of renal function. This combined modality approach is rational, feasible, and effective, although a larger number of patients with longer term follow-up are needed for reasonable comparison with the use of infradiaphragmatic radiotherapy alone.

Testicular cancer in blacks. A multicenter experience

BACKGROUND

The rarity of testis tumor in black patients has made the study of a large series difficult. Much of the epidemiologic and clinical information regarding this neoplasm in this population is in dispute, including data on incidence, prognosis, histologic distribution, age and stage at presentation, and side distribution.

METHODS

A retrospective review of 66 blacks with testicular tumors from seven military medical centers was performed.

RESULTS

Similar results were found for blacks with testis tumor to those of the general testis cancer population regarding prognosis, side distribution, and age of onset for nonseminoma and interstitial tumors. There is a slight increase in the expected number of interstitial tumors in blacks, but the distribution between seminoma and nonseminoma is similar to the general population. The mean age of presentation for seminoma in blacks was younger than that of the general testis cancer population. For testis tumor treated at the same institution, there was an increased delay of diagnosis in blacks compared with whites. The number of new cases of testicular cancer between 1979 and 1991 at one major center was increased for whites but not for blacks. The availability of cisplatin-based combination chemotherapy has resulted in an improved prognosis for blacks, as has already been demonstrated for white populations.

CONCLUSIONS

Testis tumor in blacks behaves similarly to testis tumor in the general population except that in blacks there are more interstitial tumors and the mean age of presentation for seminoma is younger. Further, there is an increased delay in diagnosis for blacks compared with whites, but the incidence of this tumor in this population does not appear to be increasing. Cisplatin-based chemotherapy has significantly improved survival in this population.

Testicular seminoma stage I: treatment results and long-term follow-up (1968-1988)

Sixty-nine patients with stage I testicular seminoma were referred to the Northern Israel Oncology Center between 1968 and 1987. Sixty-four patients were irradiated postoperatively and five patients had surveillance alone. Complete follow-up was available for all patients, with a median follow-up of 86 months (range 9-239 months). The last follow-up was in December 1988. Actuarial survival was 94% to 5, 10, 15, and 20 years. Six patients relapsed following completion of irradiation. All the recurrences occurred outside the radiation field. Three of the relapsed patients could be salvaged with cisplatinum-based chemotherapy and are alive at 4, 7, and 10 years following second-line treatment. Acute or chronic side effects were mild and manageable. Seven patients developed second primary cancers, two within and six outside the radiation field. While surveillance policy alone in stage I testicular seminoma may be successful in terms of patient outcome, it requires prolonged observation, good compliance of patients, and intensive use of resources. Thus, until proved otherwise, infradiaphragmatic radiotherapy should further remain the optimal routine treatment in seminoma patients with stage I disease.

Post-orchiectomy radiotherapy for stages I and II testicular seminoma

PURPOSE

In 1984 the following changes were made in the management of testicular seminoma at The University of Texas M.D. Anderson Cancer Center: (1) abdominopelvic computerized tomography replaced the bipedal lymph-angiogram for evaluating retroperitoneal nodes; (2) elective mediastinal radiation was totally abandoned; (3) patients with abdominal adenopathy < 10 cm were classified as having Stage IIA disease. This report evaluates the impact of these management policy changes on disease outcome.

METHODS AND MATERIALS

Between 1960 and 1991, 350 patients with Stages I or II testicular seminoma received post-orchiectomy radiation. The 241 patients treated prior to 1984 constitute our old series, and the 109 patients treated since then are our new series. The outcomes in the new series were compared to those in the old series.

RESULTS

The distribution of patients by stage was Stage I, 282 (old series, 190; new series, 92); Stage IIA, 55 (old series, 39; new series, 16); Stage IIB, 13 (old series, 12; new series, 1). The freedom-from-relapse at 5 years correlated with stage: Stage I, 97%; Stage IIA, 87%; Stage IIB, 69%. Elevated post-orchiectomy chorionic gonadotropin levels or involvement of the spermatic cord were adverse for disease relapse in Stage I but not Stage II disease. Patients with Stage I disease fared extremely well in both series (freedom-from-relapse 97%); the outcome for patients with Stage IIA was significantly worse in the new series (5-year freedom-from-relapse 73% vs. 92%) because of a 20% actuarial incidence of apparently solitary left supraclavicular nodal relapse. Although elective mediastinal radiation in the old series prevented this failure pattern, such treatment appeared to significantly decrease the survival of patients older than 40 years.

CONCLUSIONS

(1) Abdominopelvic computerized tomography scanning is adequate for the evaluation of abdominal lymph nodes in patients with seminoma; (2) Post-orchiectomy radiation to the para-aortic and ipsilateral hemipelvic regions remains the treatment of choice for patients with Stage I disease; (3) Patients with Stage IIA disease experience a 20% relapse rate especially in the left supraclavicular fossa and we recommend elective radiation to this site delivered concomitantly with para-aortic irradiation.

Post-orchiectomy management in stage I testicular seminoma: elective irradiation or surveillance?

Fifty-six patients with stage I testicular seminoma were treated at this institute between January 1982 and December 1988. Post-orchiectomy elective radiotherapy to ipsilateral iliac-inguinal and para-aortic lymph nodes was delivered in 54 cases. An overall 3 year survival rate of 96% was observed in this series. Four patients (7%) relapsed (one junctional recurrence in iliac node region, two mediastinal/hilar nodes and one skeletal metastasis). Salvage chemotherapy proved successful in two out of three cases with nodal relapse. No dose limiting acute or late radiation related complications were noticed. No definite correlation was found between the patients who relapsed and various known adverse prognostic factors. We recommend elective irradiation of the draining lymph nodes in stage I seminoma, particularly at centres where surveillance is not feasible.

Second cancer in patients treated for testicular seminoma

The exact risk of developing a second primary cancer following radiotherapy for testicular seminoma is not known. At the Northern Israel Oncology Center, between the years 1968-1988, 75 patients with early stage (I,IIA) testicular seminoma were treated by orchiectomy followed by radiation therapy. The overall 10- and 20-year survival probability was 95% and 90%, respectively. Eight patients (11%) developed nine second cancers, with a cumulative rate of one case per 1,000 years of follow-up. The second primary cancers were: two bronchogenic carcinomas, one contralateral seminoma, one thymoma, one papillary carcinoma of the thyroid, one carcinoma of the stomach, one transitional cell carcinoma of the urinary bladder, one carcinoma of the colon, and one malignant melanoma. Three of these tumors developed within the irradiated field. Five of these eight patients are alive with no evidence of recurrent cancer. We conclude that patients treated for seminoma have an increased risk of developing a second cancer. There is a need for greater awareness of this possibility. The overall prognosis remains favorable.

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.

Role of lymphangiography in staging testicular seminoma

Bipedal lymphangiography (LAG) and abdominal/pelvic computerized tomography (CT) are both useful in evaluating retroperitoneal lymph nodes in early-stage testicular seminoma. Fifty-four patients who had both radiologic studies performed between 1982 and 1986 were identified, and their films were reviewed. Four patients had evidence of retroperitoneal lymph node metastases on both CT and LAG. Of the 50 patients who had normal findings on CT scan, 39 (78%) had a normal LAG and 11 (22%) had a positive LAG. All 11 patients had architectural abnormalities within normal-sized nodes. No patient had positive findings on CT with negative LAG. In addition to aiding in staging, LAG is very useful in designing radiation treatment portals. Therefore, we believe that LAG can continue to play an important role in the accurate staging and treatment of patients with testicular seminoma.