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

Stage I seminoma: treatment outcome at King Hussein Cancer Center in Jordan

BACKGROUND

The aim of this report is to address treatment outcomes of patients with early-stage seminoma in a single institution with special reference to patients with history of surgical violation of the scrotum.

METHODS

Seventy four patients with pure seminoma were treated at King Hussein Cancer Center (Amman, Jordan) between 2003 and 2010. All patients underwent orchiectomy. All but 3 patients received adjuvant radiotherapy. Patients who underwent surgical violation of the scrotum prior to referral were managed by further excision or irradiation of the scrotal scar. The follow-up ranged from 1 to 200 months (mean, 33 months).

RESULTS

At the time of follow-up; all but one patient remain alive. The 3-year relapse-free survival for the entire cohort was 95.9%. Three patients developed relapse, all of whom received adjuvant irradiation following inguinal orchiectomy and initially harbored tumors larger than 4 cm upon pathological examination. Median time to relapse was 14 months (range, 8-25 months). None were associated with elevated tumor markers prior to detection of relapse. All but one patient were successfully salvaged by chemotherapy.

CONCLUSIONS

Our results confirm the excellent prognosis of patients with early-stage seminoma treated by orchiectomy and adjuvant radiotherapy in a developing country. Although all patients who developed relapse demonstrated adverse pathological findings upon initial assessment, no consistent predictor of relapse was found. Scrotal scar re-excision or irradiation in patients with prior history of surgical violation of the scrotum are effective measures in preventing local failure.

Incidence of second malignancies after external beam radiotherapy for clinical stage I testicular seminoma

OBJECTIVES

• To determine the use of adjuvant external beam radiotherapy (EBRT) for patients with clinical stage I testicular seminoma in the USA. • To quantify the risk of specific second primary malignancies (SPMs) associated with radiation exposure in these patients.

PATIENTS AND METHODS

• We used the Surveillance, Epidemiology and End Results database to identify patients diagnosed with clinical stage I testicular seminoma between 1973 and 2000. • We evaluated the use of EBRT in these patients. • We calculated standardized incidence ratios of specific SPMs in these patients. • We stratified the incidence of SPMs based on age at seminoma diagnosis and time to SPM from initial seminoma diagnosis.

RESULTS

• Adjuvant EBRT use declined from the first decade of the study period to the last decade of the study period (80.6% vs 70.2%). • Overall, there was a 19% increase in SPMs in patients exposed to EBRT (observed/expected, O/E, 1.51; 95% CI, 1.08-1.31) compared to the general population. • Specifically, significantly increased risks were observed for thyroid cancer (O/E, 2.32; 95% CI, 1.16-4.16), pancreatic cancer (O/E, 2.38; 95% CI, 1.43-3.72), non-bladder urothelial malignancies (O/E, 4.27; 95% CI, 1.57-9.29), bladder cancer (O/E, 1.47; 95% CI, 1.01-2.28), all haematological malignancies (O/E, 1.44; 95% CI, 1.08-1.89) and non-Hodgkin's lymphoma (O/E, 1.77; 95% CI, 1.22-2.48). • Patients had a persistently elevated risk of SPMs 15 years from the time of initial clinical stage I testicular seminoma diagnosis (O/E, 1.29; 95% CI, 1.10-1.49).

CONCLUSIONS

• We confirmed the increased risk of SPMs after EBRT for seminoma, and we identified the specific types of SPMs that develop. • The risk of EBRT-associated SPM persists for years after the initial seminoma diagnosis, and patients should be informed about these long-term risks.

Management of stage I seminomatous testicular cancer: a systematic review

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

Controversies in the management of early-stage germ cell tumors

The optimal management of clinical stage I testicular germ cell tumors remains controversial despite a cure rate of 99%. Alternatives for stage I nonseminomas include close surveillance, retroperitoneal lymph node dissection, and chemotherapy. For pure seminomas, the options are surveillance, chemotherapy, and radiation. Understanding the pros and cons of each approach may help in choosing a management plan.