Post-orchiectomy radiotherapy for stages I and II testicular seminoma

Long-Term Results in Patients Affected by Testicular Seminoma Treated with Radiotherapy: Risk of Second Malignancies

Aims

To report clinical results in patients with testicular seminoma treated with postoperative radiotherapy with regard to survival, acute and late toxicity, and risk of second malignancy.

Materials and methods

176 stage I-II testicular seminoma patients treated with radiotherapy from 1964 to 1994 at the Radiotherapy Division of Pisa University, using 60Co or Linac, were analyzed retrospectively. The follow-up ranged from 0.13 to 32.37 years, with a median of 12.1 years. The observed numbers of second malignancies were compared with those expected, taking into account age, sex, and incidence rates from the Tuscany Tumor Registry.

Results

Overall and specific survival at 10-15 years were 89-82% and 93-92%, respectively. Multivariate analysis revealed a significantly better survival in patients younger than 50 years and in those treated with Linac. Severe late sequelae occurred in 8% of the patients. Sixteen second malignancies were observed (14 solid tumors and 2 leukemias); median latency was 13 years (range, 3-27) and the observed/expected ratio 1.4 ( P not significant). Solid cancers were localized in the bladder (2), kidney (2), skin (2), stomach (1), prostate (1), lung (1), larynx (1), uvea (1) and contralateral testicle (1); 1 patient presented an intestinal carcinoid and 1 a metastasis from an unknown primary. The risk of a second malignancy was higher in the patient group receiving less than 4000 cGy (observed/expected, 2.8; P = 0.015).

Conclusions

The study confirmed the high cure rate in stage III seminomas after postoperative radiotherapy. Incidence of a second malignancy was higher than expected, but the difference was not statistically significant.

Stage I Seminoma of the Testis: Long Term Results and Toxicity with Adjuvant Radiotherapy

Aims and background

Pure testicular seminoma has historically been treated with post-orchidectomy radiation therapy with excellent results. Recently, several aspects of the treatment of stage I seminoma have been questioned. We assessed long-term results and toxicity of patients with pure testicular seminoma treated at the Department of Radiation Oncology of S. Chiara Hospital, Trento.

Methods

From 1953 to 1987, 102 patients with stage I pure testicular seminoma were given megavoltage irradiation with curative intent. All patients had a minimum follow-up of 3 years (maximum 37 years, median 13 years). They received a mean para-aortic/pelvic dose of 33.07 Gy (range 23.70-45.20 Gy) with different doses and fields reflecting the change in techniques over a long period of time.

Results

The cause-specific actuarial survival at 30 years was 99% and crude survival 67%. One patient had an out-field relapse (inguinal) after a few months and was cured with radiotherapy and chemotherapy. Another patient relapsed with widespared metastases and died after 1 year of progressive disease. Early toxycity was mild and the treatment was well tolerated. Late side effects were reported in 8/102 patients.

Conclusion

In our series adjuvant radiation therapy resulted in cure rates corresponding to those reported in the literature. The 30-year actuarial survival of 99% was extremely good and the toxicity of the treatment was mild. Post-orchidectomy radiation to the para-aortic and ipsilateral pelvic nodes is a safe and effective method of preventing recurrences and is currently to be considered the treatment of choice in stage I testicular seminoma.

Management of Low-Stage Testicular Seminoma

Management of testicular seminoma has benefited from numerous advances in imaging, radiotherapy, and chemotherapy over the last 50 years leading to nearly 100% disease-specific survival for low-stage seminoma. This article examines the evaluation and management of low-stage testicular seminoma, which includes clinical stage I and IIA disease. Excellent outcomes for stage I seminoma are achieved with active surveillance, adjuvant radiotherapy, and adjuvant single-agent carboplatin. Current areas of research focus on optimizing surveillance regimens and minimizing the morbidity and long-term complications of adjuvant treatment. Radiotherapy continues to be the primary treatment option for patients with clinical stage IIa disease.

A 55-Year-Old Man with Stage IV Squamous Cell Carcinoma of the Right Groin after External Beam Radiation for Testicular Cancer

Treating testicular cancer with adjuvant radiation has been associated with a number of second malignancies affecting the genitourinary tract and retroperitoneal structures; however, there have been few reported cases of cutaneous second malignancies. We report the case of a man who developed stage IV squamous cell carcinoma (SCC) of a condyloma after orchiectomy and adjuvant radiation for testicular cancer. We also review relevant literature available to date. A 55-year-old Caucasian man presented to the hospital with a large growth at the right groin which had grown into his right thigh preventing ambulation. His past medical history was significant for right testicular cancer of unknown pathology treated with orchiectomy and adjuvant radiation twenty years ago. Punch biopsy of the lesion revealed superficially invasive squamous cell carcinoma. He underwent excision of the growth with subsequent Cisplatin, radiation boost, and Paclitaxel regimens. Despite an aggressive treatment regimen and an initial good response, the patient's cancer progressed requiring palliative care. It is unclear whether or not therapeutic radiation in this case promoted the conversion of the patient's condyloma to a malignant lesion. Further studies are required at this time to clarify the clinical implications of these findings.

Management options for stage I seminoma

Stage I seminoma is the most common clinical scenario among patients with testicular cancer. Following orchiectomy, various treatment alternatives (adjuvant radiotherapy, surveillance, chemotherapy) can be offered that yield similar efficacy results and definitive cure is the rule. However, there is no consensus on the optimal management choice and considerable debate has been raised in recent years. The pros and the cons associated with each therapy, as well as their long-term outcomes are discussed in this review. Overall burden of treatment needed, therapy-related morbidity, economic costs, quality of life issues and patient preferences should all be considered. Refinement in the knowledge of predictive factors for relapse and mounting experience with both surveillance and adjuvant chemotherapy have led to consideration of risk-adapted treatment strategies as an alternative to standard radiotherapy. Although this model needs to be improved and validated, active close surveillance for low-risk patients and adjuvant therapy for those uncompliant or at higher risk of relapse seem to be acceptable options for patients with stage I seminoma.

[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.

Management of Low-Stage Testicular Seminoma

Testicular seminoma represents a modern model of a multidisciplinary approach to a curable neoplasm. Surgeons, radiation oncologists, and medical oncologists play an important role in disease detection, diagnosis, treatment, and follow-up. This article focuses on the management of men who have early-stage seminoma, which represents stage I and IIa (minimal retroperitoneal spread). In stage I disease, the major controversies continue to revolve around surveillance versus adjuvant treatment and more recently adjuvant radiotherapy or carboplatin-based chemotherapy. Focus on long-term complications, such as cardiovascular disease, gastrointestinal disease, and secondary cancers, has led to the concept of increased surveillance with therapy for those who relapse. Radiation therapy remains the mainstay of therapy for patients who have stage IIa disease.

Germ cell tumors of the testis

Testicular cancer is the most common malignancy in men aged 20 to 35 years and accounts for approximately 1% of all male malignancies. Through the appropriate utilization of clinical trials, effective treatment paradigms have been developed for the management of all stages of testicular cancer. The multidisciplinary approach to the management of germ cell tumors of the testis has resulted in survival rates of > 90% overall. This review summarizes the principal management of germ cell tumors of the testis, highlighting the indications for surgery, controversies surrounding the integration of surgery, and alternative management strategies.

The management and outcome of patients with germ-cell tumours treated in the Edinburgh Cancer Centre between 1988 and 2002

AIMS

The aim of this retrospective analysis was to review the outcome of patients with germ-cell tumours treated in the Edinburgh Cancer Centre over the past 15 years, and to see whether there had been any changes over three 5-year cohorts.

MATERIALS AND METHODS

Patients referred with gonadal and extra-gonadal primary germ-cell tumours, between 1988 and 2002, were identified from the departmental database, and survival by stage and prognostic group was analysed.

RESULTS AND CONCLUSIONS

The proportion of patients with stage I seminoma has significantly increased. The good prognosis of patients with early stage disease is confirmed, with the outcome for some groups of patients being better than expected. There is a non-significant trend to improved results over the three 5-year cohorts. The outcome for patients with stage IV seminoma is worse than would be expected, but numbers are small. The poor prognosis of patients with non-seminomatous germ-cell tumours who fall into the International Germ Cell Consensus Classification (IGCCC) poor-prognostic group is confirmed. Failure of patients with metastatic non-seminomatous germ-cell tumours to achieve a complete response to initial therapy is shown to be a poor prognostic indicator.

Pelvic recurrence in stage I seminoma: A new phenomenon that questions modern protocols for radiotherapy and follow-up

OBJECTIVE

To highlight the increased risk for pelvic relapse in patients with stage 1 seminoma treated with adjuvant radiotherapy limited to para-aortic template alone.

PATIENTS AND METHODS

Over a four-year period, three patients presented with early pelvic recurrence after radical orchidectomy and adjuvant irradiation for stage 1 seminoma. In each case, radiotherapy had been limited to the para-aortic region with omission of the ipsilateral hemi pelvis.

RESULTS

Pelvic recurrences occurred on the ipsilateral tumor side. Durable complete remission was achieved in each case; however, treatment was complex and there was associated morbidity.

CONCLUSION

This significant incidence of pelvic recurrence questions the validity of modern radiotherapy protocol which excludes the ipsilateral pelvis from the radiation field.

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.

Mortality after cure of testicular seminoma

PURPOSE

To determine the incidence of potentially treatment-related mortality in long-term survivors of testicular seminoma treated by orchiectomy and radiation therapy (XRT).

PATIENTS AND METHODS

From all 477 men with stage I or II testicular seminoma treated at The University of Texas M.D. Anderson Cancer Center (Houston, TX) with post-orchiectomy megavoltage XRT between 1951 and 1999, 453 never sustained relapse of their disease. Long-term survival for these 453 men was evaluated with the person-years method to determine the standardized mortality ratio (SMR). SMRs were calculated for all causes of death, cardiac deaths, and cancer deaths using standard US data for males.

RESULTS

After a median follow-up of 13.3 years, the 10-, 20-, 30-, and 40-year actuarial survival rates were 93%, 79%, 59%, and 26%, respectively. The all-cause SMR over the entire observation interval was 1.59 (99% CI, 1.21 to 2.04). The SMR was not excessive for the first 15 years of follow-up: SMR, 1.30 (95% CI, 0.93 to 1.77); but beyond 15 years the SMR was 1.85 (99% CI, 1.30 to 2.55). The overall cardiac-specific SMR was 1.61 (95% CI, 1.21 to 2.24). The cardiac SMR was significantly elevated only beyond 15 years (P <.01). The overall cancer-specific SMR was 1.91 (99% CI, 1.14 to 2.98). The cancer SMR was also significant only after 15 years of follow-up (P <.01). An increased mortality was evident in patients treated with and without mediastinal XRT.

CONCLUSION

Long-term survivors of seminoma treated with post-orchiectomy XRT are at significant excess risk of death as a result of cardiac disease or second cancer. Management strategies that minimize these risks but maintain the excellent hitherto observed cure rates need to be actively pursued.

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.

Treatment outcome, body image, and sexual functioning after orchiectomy and radiotherapy for Stage I-II testicular seminoma

PURPOSE

Orchiectomy followed by infradiaphragmatic irradiation is the standard treatment for Stage I-II testicular seminoma in The Netherlands. Because body image and sexual functioning can be affected by treatment, a retrospective study was carried out to assess treatment outcome, body image, and changes in sexuality after orchiectomy and radiotherapy.

METHODS AND MATERIALS

The medical charts of 166 patients with Stage I-II testicular seminoma were reviewed. A questionnaire on body image and current sexual functioning regarding the frequency and quality of erections, sexual activity, significance of sex, and changes in sexuality was sent to 157 patients (at a mean of 51 months after treatment).

RESULTS

Seventy-eight percent (n = 123, mean age 42 years) completed the questionnaire. During irradiation, almost half of patients experienced nausea and 19% nausea and vomiting. Only 3 patients had disease relapse. After treatment, about 20% reported less interest and pleasure in sex and less sexual activity. Interest in sex, erectile difficulties, and satisfaction with sexual life did not differ from age-matched healthy controls. At the time of the survey, 17% of patients had erectile difficulties, a figure that was significantly higher than before treatment, but which correlated also with age. Twenty percent expressed concerns about fertility, and 52% found their body had changed after treatment. Cancer treatment had negatively influenced sexual life in 32% of the patients.

CONCLUSIONS

Orchiectomy with radiotherapy is an effective and well-tolerated treatment for Stage I-II testicular seminoma. Treatment-induced changes in body image and concerns about fertility were detected, but the sexual problems encountered did not seem to differ from those of healthy controls, although baseline data are lacking.

Radiotherapy for stage II testicular seminoma

PURPOSE

To compare the outcome of patients with Stage II seminoma treated with prophylactic mediastinal irradiation, without any supradiaphragmatic irradiation, and with prophylactic left supraclavicular irradiation (PLSCI).

METHODS AND MATERIALS

Between 1960 and 1999, 73 men with Stage II seminoma received postorchiectomy radiotherapy. Before 1984, 36 received prophylactic mediastinal irradiation (Series I); between 1984 and 1992, 17 received no supradiaphragmatic irradiation (Series II); and after 1992, 20 received PLSCI (Series III). The outcomes in these series were compared.

RESULTS

The abdominal tumor sizes were as follows: Series I, <or=2 cm, n = 4; >2 and <or=5 cm, n = 12; >5 and <or=10 cm, n = 16; Series II, <or=2 cm, n = 1; >2 and <or=5 cm, n = 12; >5 and <or=10 cm, n = 4; and Series III, <or=2 cm, n = 1; >2 and <or=5 cm, n = 14; >5 and <or=10 cm, n = 5 (p = 0.75). The median duration of follow-up was 14.4, 9.3, and 4.5 years for Series I, II, and III, respectively. The 6-year freedom from relapse was 94%, 71%, and 95% for Series I, II, and III, respectively. The differences between Series I and II (p = 0.014) and between II and III (p = 0.042) were significant. Three patients in Series II had a relapse in their left supraclavicular fossa-a failure pattern abrogated by PLSCI.

CONCLUSIONS

PLSCI significantly diminishes the likelihood of relapse for Stage IIA, IIB, and IIC seminoma (mass <or=10 cm).

Surveillance for stage I testicular seminoma. a review

There is good evidence that patients with stage I seminoma can be managed equally well after orchidectomy with surveillance and adjuvant retroperitoneal radiation therapy. There is considerable reluctance amongst many physicians to accept surveillance as a management option in stage I seminoma and this is largely based on the excellent results achieved with adjuvant retroperiteonal radiation for many years. However, patients with stage I seminoma have a long life span and it is possible that the long-term sequelae of radiation treatment could have a negative impact on quality of life and longevity. It is of utmost importance to continue the study of the long-term effects of all current treatment approaches, in particular the risk of induction of second malignancies. However, the psychosocial impact on patients of surveillance and other management strategies must also be assessed. Stage I testicular seminoma is highly curable with currently available management approaches and the current challenge for clinicians is to maintain these excellent results while minimizing toxicity and individualising treatment to the specific social, economic and emotional circumstances of each patient. Surveillance should be one of the management options offered to patients with stage I seminoma.

Combination carboplatin and radiotherapy in the management of stage II testicular seminoma: comparison with radiotherapy treatment alone

PURPOSE

To assess the results of treatment in 33 patients with stage IIA/B seminoma who were treated with carboplatin and radiotherapy (RT) between January 1989 and December 1996.

PATIENTS AND METHODS

Thirty patients received single course single agent carboplatin (400 mg/m2 or area under curve (AUC 7), two patients received two courses carboplatin, and one patient received single course carboplatin and etoposide, all 4-6 weeks prior to infra-diaphragmatic RT. Results were retrospectively compared with those obtained for 80 patients treated from 1970 to 1998 with radiotherapy alone.

RESULTS

There was minimal toxicity associated with the use of carboplatin prior to RT. With a median follow-up of 4 years (range 2-70 months) 2/33 patients treated with chemotherapy and RT have relapsed, 5-year relapse free survival (RFS) = 96.9% (95% confidence interval (CI) 72.9-99.4%), and one patient has died of progressive disease, 5-year overall survival (OS) = 96.7%. With a median follow-up of 11.2 years (range 6 months to 25.8 years) 15/80 patients treated with RT alone have relapsed, 5-year RFS = 80.7% (95% CI 70.1-87.9%), including 13/61 patients treated with infra-diaphragmatic RT, 5-year RFS = 77.9%, and 2/19 treated with additional supra-diaphragmatic RT, 5-year RFS = 89.5% (P = 0.277). Eleven out of 80 patients have died, 5-year OS = 94.7%. For stage IIA, 1/14 patients treated with chemotherapy and RT have relapsed, 5-year RFS = 92.3%, compared with 5/34 treated with infra-diaphragmatic RT alone 5-year, RFS = 84.9% (P = 0.527). For stage IIB, 1/19 patients relapsed (at 69 months) following chemotherapy and RT (5-year RFS = 100%), whereas 8/27 relapsed following infra-diaphragmatic RT alone, 5-year RFS = 69.4% (P = 0.0595).

CONCLUSION

Infradiaphragmatic RT alone cures the majority of patients with stage II seminoma, but the relapse rate remains high particularly for patients with stage IIB disease. As compared with historical controls, carboplatin with RT appears to reduce the relapse rate in stage II seminoma with minimal additional toxicity and the results approach statistical significance for stage IIB patients. Confirmation would require a phase III randomized comparison.

Twelve-year experience with two courses of adjuvant single-agent carboplatin therapy for clinical stage I seminoma

PURPOSE

During the past 30 years, radiation therapy with 28 to 30 Gy for para-aortic and ipsilateral iliac node areas was the standard adjuvant treatment for clinical stage I seminoma after orchiectomy. However, late effects of radiotherapy prompted a search for alternative adjuvant treatment approaches, including surveillance and application of carboplatin. In this retrospective analysis, we evaluated the efficacy and toxicity of two adjuvant single-agent carboplatin courses in 107 patients who were diagnosed with clinical stage I seminoma at our study centers between 1988 and 1999.

PATIENTS AND METHODS

All 107 patients (median age, 39 years; range, 24 to 63 years) received two postoperative adjuvant cycles of carboplatin (400 mg/m(2)). The pathologic tumor stage was pT1 in 84 patients, pT2 in 18 patients, and pT3 in five patients. Whole blood count and serum chemistry were evaluated weekly during treatment to assess hematologic and nonhematologic toxicity.

RESULTS

Six patients died from tumor-unrelated causes. The remaining 101 patients are currently alive and free of disease after a median follow-up of 74 months (range, 5 to 145 months). A detailed analysis of hematologic toxicity showed only World Health Organization (WHO) grade 1 leukocytopenia in 10.7% of all cycles and WHO grade 2 leukocytopenia in 2.1% of all cycles.

CONCLUSION

Regarding the absence of tumor recurrences in our retrospective analysis and the favorable toxicity profile with no episodes of long-term toxicity, we suggest that two adjuvant courses of single-agent carboplatin for clinical stage I seminoma patients might be equivalent to radiotherapy.

Minisatellite mutation frequency in human sperm following radiotherapy

Screening pedigrees for inherited minisatellite length changes provides an efficient means of monitoring repeat DNA instability but has given rise to apparently contradictory results regarding the effects of radiation on the human germline. To explore this further in individuals with known radiation doses and to potentially gain information on the timing of mutation induction, we have used an extremely sensitive single molecule approach to quantify the frequencies of mutation at the hypervariable minisatellites B6.7 and CEB1 in the sperm of three seminoma patients following hemipelvic radiotherapy. Scattered radiation doses to the testicles were monitored and pre-treatment sperm DNA was compared with sperm derived from irradiated pre-meiotic, meiotic and post-meiotic cells. We show no evidence for mutation induction in any of the patients and discuss this finding in the context of previous population studies using minisatellites as reporter systems, one of which provided evidence for radiation-induced germline mutation.

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.

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

PURPOSE

A retrospective review of patients with Stage I and II seminoma treated at a regional cancer center was performed to assess the long term efficacy and toxicity associated with post operative radiotherapy.

METHODS AND MATERIALS

Between 1950 and 1995, 212 patients seen at the London Regional Cancer Centre received adjuvant radiotherapy following orchiectomy for Stage I (169) and II (43) seminoma. Median follow-up for the group was 7.5 years.

RESULTS

Progression free, cause specific, and overall survival were 95%, 98%, and 95% at 5 years, and 94%, 98%, and 94% at 10 years respectively. An increased risk of failure was noted among patients with bulky Stage II disease. No other prognostic factors for relapse were identified. Late toxicity was uncommon with only 12/212 (6%) developing any late GI toxicity potentially attributable to radiotherapy. The incidence of second malignancies (excluding second testicular tumors) was 6/212 (actuarial:1%, 1%, 6% at 5,10,15 years respectively). There was a trend toward increased acute complications for patients treated with larger volumes of radiation. No prognostic factors associated with increased risk of late toxicity or second malignancy were identified, likely a consequence of the small number of these events.

CONCLUSION

Survival and toxicity were comparable to that reported in the literature. Post-operative radiotherapy remains a safe and efficacious adjuvant treatment for Stage I and early Stage II seminoma.

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

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

Testicular cancer

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

Cost-effectiveness of posttreatment surveillance after radiation therapy for early stage seminoma

BACKGROUND

This study evaluated the cost-effectiveness of posttreatment surveillance after radiation therapy for early stage seminoma.

METHODS

From 1988-1995, 47 patients with Stage I, and 11 patients with Stage II seminoma (based on the Royal Marsden staging system) received paraaortic and pelvic lymph node radiation after radical orchiectomy. Patient records were reviewed and patients surveyed to determine the tests ordered for posttreatment surveillance.

RESULTS

With a median follow-up of 55 months, there were 2 recurrences among the 58 patients. Eight-year actuarial disease free survival was 93%, with 100% overall survival. Information concerning follow-up screening was available for 56 patients. The follow-up tests ordered included 842 physical examinations, 815 chest X-rays, 839 serum markers, 250 computerized tomography scans, and 112 abdominal plain films. The total cost of these examinations according to 1996 private sector charges and 1996 Medicare reimbursement rates, respectively, was $602,673.01 (average $10,762.02 per patient) and $282,746.52 (average $5049.05 per patient). The two patients who experienced recurrence were diagnosed independently of their posttreatment screening program. One patient recurred 7.5 months after his original diagnosis with an isolated spinal cord compression. The second patient had a mediastinum recurrence > 6 years after treatment. At last follow-up, both patients were disease free after salvage treatment.

CONCLUSIONS

Patients with early stage seminoma treated with orchiectomy and radiation have excellent disease free survival rates. The cost of the surveillance program studied does not appear to be justifiable.

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).

Seminoma arising in corrected and uncorrected inguinal cryptorchidism: treatment and prognosis in 66 patients

PURPOSE

The purpose of this study was to analyze prognosis and treatment results for seminoma arising in corrected and uncorrected inguinal cryptorchidism (SCIC and SUIC).

METHODS AND MATERIALS

We reviewed 66 patients with inguinal seminomas between June 1958 and December 1991 at the Cancer Hospital and Institute of Chinese Academy of Medical Sciences. Of these patients, 23 had prior orchiopexy and 43 presented with an inguinal form of cryptorchidism. At presentation, 17 of 66 (26%) patients had nodal metastases. This nodal involvement was 30% (7 of 23) for SCIC and 23% (10 of 43) for SUIC, respectively. These numbers are comparable with those in a series of patients treated for scrotal seminoma at our institution (26% vs. 20%). However, 3 of 23 (13%) patients who had prior orchiopexy presented with inguinal nodal metastasis as compared with 0 of 43 patients with SUIC or 4 of 237 patients with scrotal seminoma (p < .05). There were 49 stage I, 5 stage IIA, 8 stage IIB, 3 stage III, and 1 stage IV patients. All patients underwent radical orchiectomy and received further radiotherapy, chemotherapy, or both. Patients with stage I and stage II disease were treated primarily with radiotherapy, whereas patients with stage III and IV disease were treated with chemotherapy.

RESULTS

The overall and disease-free survival at 5 and 10 years was 94% and 92%, 89% and 87%, respectively. The overall 5- and 10-year survival by stage was 100% and 100% for stage I, and 77% and 68% for stage II, respectively (p < .05). There was no significant difference in survival between SUIC and SCIC (93% vs. 96% at 5 years). Four patients developed relapse. Two of these four patients experienced relapse at the inguinal area, due to a marginal miss. Three of four patients with relapse were successfully salvaged, and one died of disease.

CONCLUSION

Our results indicate that prognosis for inguinal seminoma is excellent and similar to that of scrotal seminoma. Postorchiectomy radiotherapy can be considered as the standard treatment for stage I and IIA inguinal seminoma. We recommend routinely including the para-aortic and ipsilateral pelvic nodes.

Clinical characteristics, prognosis, and treatment of pelvic cryptorchid seminoma

PURPOSE

To analyze the clinical characteristics, prognosis, and treatment outcome of pelvic cryptorchid seminoma (PCS), and to determine whether whole abdominal-pelvic irradiation for Stage I disease is necessary.

METHODS AND MATERIALS

From 1958 to 1991, 60 patients with PCS were treated at the Cancer Hospital of Chinese Academy of Medical Sciences, Beijing. They presented with a lower abdominal mass and showed a predominance for the right side. A high proportion of patients with PCS [26 of 60 (43%)] had metastatic disease, compared to 20% of those with scrotal seminoma, and there was a tendency toward a higher frequency of pelvic nodal metastases. There were 34 Stage I, 6 Stage IIA, 11 Stage IIB, 5 Stage III, and 4 Stage IV patients. Of these 60 patients, 56 underwent laparotomy with or without cryptorchiectomy (37 radical orchiectomy, 7 partial orchiectomy, and 12 biopsy of the primary or cervical node), and 4 cervical node biopsy only. All patients were further treated with radiotherapy, chemotherapy, or a combination of both. Patients with Stage I and II disease received radiotherapy, whereas patients with Stage III and IV were treated with chemotherapy.

RESULTS

The overall and disease-free survivals at 5 and 10 years were 92% and 87%, and 88% and 84%, respectively. The 5- and 10-year survivals were 100% for Stage I, 94% and 87% for Stage II, and 56% and 42% for Stage III/IV, respectively (p < 0.05). Volume of irradiation, i.e., whole abdominal-pelvic radiotherapy (10 patients), versus hockey-stick encompassing paraaortic, ipsilateral iliac nodes and the primary tumor or tumor bed (17) did not influence outcome in Stage I patients. Five patients relapsed within 2-12 years after treatment, and four of these patients were successfully salvaged. Four patients developed a second malignant tumor and died.

CONCLUSION

Stage I and II PCS can be adequately controlled by radiotherapy regardless of the surgical procedure. Whole abdominal-pelvic irradiation for Stage I and IIA disease is not required, and fields can be limited to the paraaortic, ipsilateral iliac nodes and primary tumor or tumor bed. We recommend platinum-based chemotherapy for Stage IIB-IV PCS.

Management of seminoma of the testis: recommendations based on treatment results

BACKGROUND

The results of management of seminoma of the testis at the Department of Radiation Oncology St Vincent's Hospital, Sydney were evaluated retrospectively to: (i) establish that outcomes were in keeping with published results from centres in Australia and overseas; (ii) assess the impact of chemotherapy on management; and (iii) to determine 'best practice' management protocols based on our results and a review of the relevant literature.

METHODS

(i) Assessment of treatment results for stage I and II seminoma of the testis treated by post-orchidectomy radiotherapy and/or chemotherapy at St Vincent's Hospital between 1979 and 1993; (ii) literature review of published data from Australian and overseas centres on the management of seminoma of the testis, and in particular the use of surveillance or chemotherapy either alone, at time of relapse or combined with radiotherapy; and (iii) development of recommendations for use as management protocols in our department.

RESULTS

Our data and a review of the literature suggest that post-orchidectomy radiotherapy with chemotherapy for relapse in stage I and IIA disease results in long-term cure rates approaching 100%. Treatment with chemotherapy either routinely or selectively or using a surveillance policy is unlikely to show any improvement in outcome and may be less cost-effective and/or produce increased morbidity and the risk of secondary leukaemia. For stage IIB disease (5-10 cm) the use of initial combination chemotherapy with or without subsequent radiotherapy did not appear to give better outcomes than initial radical radiotherapy alone, reserving chemotherapy or further radiotherapy for relapse. For bulkier stage IIB disease (> 10 cm), the use of initial chemotherapy plus consolidation radiotherapy appeared to be an appropriate treatment.

CONCLUSIONS

Management protocols for seminoma of the testis at St Vincent's Hospital, Sydney Department of Radiation Oncology currently are (i) stage I, IIA and IIB (5-10 cm): post-orchidectomy radiotherapy alone with chemotherapy or further radiotherapy for relapse; and (ii) stage IIB (> 10 cm) disease: initial chemotherapy post-orchidectomy followed by radiotherapy to sites of initial disease involvement.

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.

Omission of the pelvic irradiation in stage I testicular seminoma: a study of postorchiectomy paraaortic radiotherapy

PURPOSE

To review the survival, cure rate, and pattern of relapse or progression of patients with histologically confirmed Stage I testicular seminoma who underwent orchiectomy and radiation therapy to paraaortic lymphatics only. The pelvic ipsilateral lymph nodes were not irradiated.

METHODS AND MATERIALS

Between 1978 and 1992, 150 patients with Stages I or II testicular seminoma received treatment at the Department of Radiation Oncology of the University of Wuerzburg. The distribution by stage was Stage I, 117 patients of which 93 were pT1 N0 M0 and 24 were pT2 N0 M0. Four patients were staged as Stage II (pT3 N0 M0), and in 29 patients the T Stage was not specified. Eighty-six patients from the 117 Stage I (pT1-pT2, N0 M0 according to the TNM classification) seminoma received postorchiectomy irradiation, and are analyzed for outcome in this article. The distribution of the Stage I patients by pT Stage was 71 pT1 and 15 pT2 patients. All these 86 patients had their paraaortic nodes (the biological target volume extending from top of L1 to the bottom of L5) irradiated with four field technique. Tumor dose was specified at normalization point along the central axis. The median tumor dose was 30 Gy given in 1.8-2.0 Gy fractions. Elective irradiation to the ipsilateral hemipelvis (iliac nodes) was totally abandoned.

RESULTS

The 10-year disease-free survival and overall survival were 95.3 and 100%. No recurrence in the irradiated field was noted. Four patients (4.7%) experienced relapse of disease outside the treated volume. The most common site of solitary failure was the ipsilateral hemipelvis (one iliacal and one inguinal). One patient developed metastatic disease to the lung. One patient developed a mediastinal recurrence with superior vena cava syndrome and was successfully salvaged by mediastinal irradiation and chemotherapy.

CONCLUSIONS

Recommendation for the future management of Stage I seminoma include: reduced biological target volume to the paraaortal lymph nodes (from lumbar vertebra L1 to L5). Complete elimination of irradiation to the pelvic nodes is warranted. Radiation dose should not exceed 30 Gy.

Spermatocytic seminoma: a clinicopathological review of ten patients

Spermatocytic seminoma is an uncommon variety of testicular neoplasm, differing from its classical counterpart at both clinical and pathological levels and having a low propensity to metastasize. This is a retrospective review of ten patients with pathologically confirmed and reviewed disease who were seen at the Royal Marsden Hospital. All patients presented as Stage I. Five were treated with radiotherapy and five have undergone surveillance. The median age was 56.5 years. The median follow-up is 8 years and no patient has relapsed. Two have died of intercurrent disease. Our series supports others of a similar size in the literature with respect to both the rarity and the good prognosis of spermatocytic seminoma. With only one case of relapse confirmed in the literature, this is a subgroup of patients in whom radiotherapy can safely be omitted.

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.

Radiotherapy for stages I and II testicular seminoma: results and morbidity in 238 patients

We have undertaken a retrospective analysis of 238 patients with Stages I and II seminoma of the testis treated with radiotherapy in Edinburgh between 1974 and 1989. There were five deaths from seminoma. Cause-specific survival for the whole group at 2 and 5 years was 99.2% and 98.1%, respectively. Cause-specific survival at 2 and 5 years by stage (Royal Marsden staging classification) was: Stage I, 99.5% and 98.7% and Stage II, 98.1% and 96.1%. Fourteen (5.9%) patients relapsed (one after treatment for his second testicular seminoma). Eight were given successful salvage treatment, five died of seminoma and one died of intercurrent disease. 13 (5.5%) patients developed World Health Organisation (WHO) grade 3 gastrointestinal or haematological toxicity and two developed grade 4 gastrointestinal toxicity as a result of abdominal radiotherapy. 22 patients (9.2%) developed problems ascribed to late morbidity of abdominal radiotherapy including 18 with peptic ulcer disease. Contralateral testicular tumours occurred in seven (2.9%) patients and five (2.1%) patients developed malignancies at other sites.

Cisplatin, vincristine and ifosphamide combination chemotherapy of metastatic seminoma: results of EORTC trial 30874. EORTC GU Group

The aims of the trial were to establish the response rate and determine the toxicity of combination chemotherapy with ifosphamide, vincristine and cisplatin (HOP regimen) in advanced metastatic seminoma and to study the role of post-chemotherapy consolidation treatment. Patients with bulky metastatic non-alpha-fetoprotein-producing seminomas were eligible for this phase II study [serum human chorionic gonadotropin < 200 U l-1 (< 40 ng l-1)] if they presented with abdominal masses > or = 10 cm or had extra-gonadal seminoma or had relapsed after previous radiotherapy. The HOP regimen consisted of four 3-weekly cycles of the following drug combination: ifosphamide (days 1-5, 1.2 mg m-2 day-1), vincristine (day 1, 2 mg) and cisplatin (days 1-5, 20 mg m-2 day-1). Residual masses persisting 6 months after chemotherapy could be considered for consolidation surgery or radiotherapy. Maximal response to the HOP chemotherapy (evaluated at any time) was based on the WHO criteria. The median observation time was 2.5 years (range 1.8-5.5 years). Thirteen institutions treated 42 eligible patients within the study (testicular cancer stage > or = IID, 25; extragonadal, 5; relapse after previous radiotherapy, 12). Two patients were not evaluable for response owing to premature treatment discontinuation. Maximal response was as follows: complete remission (CR), 26 (65%); partial remission (PR) 11 (28%); no change (NC), 2 (5%); progressive disease (PD), 1 (3%). Four patients have died, three from their malignancy (two without previous irradiation and one with prior radiotherapy). The fourth patient died of treatment-related toxicity. The 3 year survival for all 42 eligible patients was 90%. Dose reduction and treatment postponement were necessary in 25 and 14 patients respectively. Ten patients experienced granulocytic fever. Previously irradiated patients tolerated chemotherapy as well as non-irradiated patients. Immediately after HOP chemotherapy a mass persisted in 16 of 17 patients with retroperitoneal masses of > or = 100 mm at presentation. Three of these residual lesions were resected within the following 6 months showing complete necrosis. Four lesions dissolved spontaneously during the first year of follow-up. Nine lesions persisted for > or = 1 year (one after consolidation radiotherapy) without leading to relapse. Four of seven patients with mediastinal lesions achieved CR and three a PR after HOP chemotherapy. The HOP chemotherapy regimen is highly effective in patients with advanced metastatic seminoma or those relapsing after previous radiotherapy, but is associated with a high risk of toxicity, in particular myelotoxicity.

Post-orchidectomy radiation therapy alone for patients with early stage non-seminomatous germ cell tumours of the testis

The aim of this study was to review the patterns of disease relapse and survival outcomes for patients treated post-orchidectomy with radiotherapy for early stage (I and IIA) non-seminomatous germ cell tumors of the testis (NSGCT). The clinical records were reviewed of 117 men consecutively treated at the Queensland Radium Institute from 1960-90 (inclusive) for stage I or IIA NSGCT. A total of 108 patients received radiotherapy to the para-aortic nodes and ipsilateral hemipelvis following orchidectomy; nine patients received radiotherapy to the para-aortic nodes and whole pelvis. Twenty-two of 99 (22.2%) stage I and eight of 18 (44.4%) stage IIA patients relapsed following definitive radiotherapy. The 5 year overall and recurrence-free survivals were 84 and 75%, respectively. Factors associated with a significantly worse outcome included: (i) patients with stage IIA disease; (ii) the presence of undifferentiated elements in the operative specimen; (iii) a primary tumor < 5 cm size; and (iv) treatment given prior to 1979. Given the unsatisfactory recurrence rate following radiation therapy alone and the availability of cisplatin-based chemotherapy regimens, it is recommended that radiation therapy alone for patients with early stage NSGCT be abandoned in favour of other management strategies.

Post-orchidectomy radiation therapy for patients with stage I seminoma of the testis

The outcome of radiotherapy in patients with stage I testicular seminoma was evaluated. During the period 1960-89 (inclusive) 270 patients with stage I seminoma of the testis received radiotherapy to the para-aortic nodes and ipsilateral hemipelvis following radical orchidectomy. Two hundred and fifty seven patients (95.2%) received a minimum tumour dose of 30Gy in 20 daily fractions using 4-6 MV photons. The 5 year overall and recurrence-free survival rates were 97 and 95%, respectively. Only eight of the 270 patients relapsed and three were cured with 'salvage' therapies. Of the 11 patients who died, four deaths (36%) were the result of uncontrolled testicular cancer, six (55%) intercurrent illness and one (9%) the result of attempted salvage. Patients staged and treated prior to 1979 had a significantly worse disease-free survival compared to patients treated during and after 1979. As side effects were negligible, it was concluded that radiotherapy for stage I seminoma provides excellent cure rates. The difficulties arranging a 'surveillance' programme in so large a State as Queensland are discussed.

Pilot studies of 2 and 1 course carboplatin as adjuvant for stage I seminoma: should it be tested in a randomized trial against radiotherapy?

PURPOSE

Underpinned by increased confidence in cure of metastatic seminoma by chemotherapy during the past 12 years, three management strategies for Stage I seminoma have been evaluated by six collaborating centers within the Anglian Germ Cell Tumor Group. This paper evaluates the efficacy of surveillance, prophylactic radiotherapy and adjuvant chemotherapy, and discusses these differing management approaches.

METHODS AND MATERIALS

Patients were recruited into the study between 1982 and 1992. There was no randomization between treatment groups. Seventy-nine patients received prophylactic radiotherapy (median follow-up = 51 months), 67 patients had surveillance alone (median follow-up = 61 months) and 78 patients were treated with adjuvant single agent platinum (median follow-up = 44 months). Fifty-three of these patients received two courses of platinum (median follow-up = 51 months) and 25 patients received one course (median follow-up = 29 months, range 22-72 months).

RESULTS

There were 18 (27%) recurrences on surveillance, five (6%) after radiotherapy, one (1%) after two courses of adjuvant single agent platinum and none after one course of carboplatin. There was one death from testis cancer after radiotherapy and none after adjuvant chemotherapy treatments. Two patients died with drug resistant disease after relapse on surveillance. There was one death from a myocardial infarction after prophylactic radiotherapy and one death from suicide in the surveillance group. A retrospective quality of life questionnaire reviewing the incidence of early and late toxicity revealed no major differences though they suggest that those treated with one course adjuvant carboplatin had somewhat less sickness and an earlier return to work.

CONCLUSION

Single agent carboplatin appears well tolerated and is an effective adjuvant treatment for Stage I seminoma. A multicenter randomized trial of the different treatment modalities is required to further evaluate its use.