A study of post-orchiectomy surveillance in stage I testicular seminoma

Safety of Minimizing Intensity of Follow-up on Active Surveillance for Clinical Stage I Testicular Germ Cell Tumors

Background

Objective

Design, setting, and participants

Outcome measurements and statistical analysis

Results and limitations

Conclusions

Patient summary

Postsurgical Policy in Stage I Testicular Seminoma: Cost and Benefit of Prophylactic Irradiation in a Long-term Experience

The definitive cure rate for clinical stage I testicular seminoma is very close to 100%, and prophylactic irradiation of the regional lymph nodes is associated with a low morbidity. Nevertheless, in recent years a “wait-and-see” policy has been proposed by some researchers. We analysed the cost/benefit ratio of radiotherapy (RT) by review of the case histories of 299 patients treated at the Department of Radiotherapy of the Istituto Nazionale per lo Studio e la Cura dei Tumori in Milan from January 1968 to December 1989. The 5-year overall survival was 99% (97.5% at 10 years), while the 10-year disease-free survival was 96%. The recurrence rate was 2.3%, but no patient relapsed in the irradiated areas. Acute toxicity was very moderate with only 4 (1.3%) serious radiation sequelae occurring 6 to 27 years after treatment. However, 9 second malignancies (3%) were observed. Lastly, we have calculated the costs for our National Health Service comparing surveillance policy and prophylactic irradiation.

Concentration of four heavy metals (cadmium, lead, mercury, and arsenic) in organs of two cyprinid fish (Cyprinus carpio and Capoeta sp.) from the Kor River (Iran)

Concentration of heavy metals in aquatic animals mainly occurs due to industrial contamination. In this study, the concentrations of four heavy metals (cadmium, lead, mercury, and arsenic) in organs of two cyprinid fish and in water collected from three sections of the Kor River, Iran were determined using the inductively coupled plasma method. Pathological and hormonal changes due to metal contamination were also measured. The concentrations of heavy metals in tissue of fish from the middle sampling zone were significantly higher (p < 0.05) than those from the other two sampling zones, whereas no significant differences (p > 0.05) were detected between the two sexes and species. High levels of metals were found in the ovaries and testes; estradiol in females and progesterone and testosterone in males from the middle study site were significantly (p < 0.05) lower than values from the other two sites. Pathological changes in blood cells, liver, and kidneys of fishes were significantly higher in highly polluted areas (middle sampling zone). These results show that industrial activities have polluted the river and that the maximum concentrations of Cd, Pb, and Hg were higher than the permissible levels for human consumption.

A comprehensive systematic review of testicular germ cell tumor surveillance

BACKGROUND

Testicular cancer is the most common malignancy in men aged 15-34, and its incidence has been increasing over the past half-century. Survival for stage I testis cancer approaches 100% regardless of management strategy which is often dictated by other factors such as perceived morbidity. Advances in treatment have attempted to decrease morbidity and surveillance is thought to achieve this goal.

METHODS

An English language literature search of MEDLINE from 1966 to December 2005 and CINAHL from 1982 to December 2005 was conducted using a broad search strategy. Comparative and descriptive original articles on outcomes of seminoma or NSGCT surveillance would be deemed eligible and review articles containing no original data were omitted. One hundred and thirty-eight articles were selected for formal review, during which a database was compiled that documented the first author, publication year, tumor histologic type, study purpose or topic(s), methodology, sample size, median follow-up, and relevant results.

RESULTS

Most evidence for the efficacy of surveillance is from descriptive series or non-experimental comparative studies. Relapse occurs in approximately 28% and 17% of surveillance patients in NSGCT and seminoma, respectively, and cause-specific survival is approximately 98% and 100%, respectively. Compliance with surveillance ranges from poor to adequate, however there is no evidence that compliance impacts clinical outcome. Cost analyses have yielded inconsistent results when comparing treatment modalities. There is scant literature on quality of life and psychosocial issues and results are inconsistent. Active surveillance appears to be appropriate and perhaps optimal first line management of clinical stage I seminoma and non-seminomatous germ cell tumors. Further quantitative and qualitative research is warranted to deepen understanding of these issues that may impact treatment decision-making.

Comparative proteomic analysis of neoplastic and non-neoplastic germ cell tissue

A comparative proteomic analysis of neoplastic versus non-neoplastic seminoma identified glutathione S-transferase M3 as a differentially expressed protein. This expression difference could also be observed at the mRNA level, implying neoplasm-associated alterations in transcriptional or post-transcriptional mechanisms.

Stage I seminoma of the testis: a bi-institutional retrospective analysis of patients treated with radiation therapy only

OBJECTIVE

To analyse relapse patterns, toxicity and second malignancy in patients with stage I pure germ cell testicular tumours, treated in 1970-1999.

PATIENTS AND METHODS

In all, 487 patients received irradiation after surgery to the infra- (407, 83.5%) or infra- and supra-diaphragmatic volumes (80, 16.5%). Treatment-related toxicity was classified according to previous criteria and fertility investigated in 246 men. Second malignancies were identified by retrospective analysis of clinical records or telephone interviews in men who no longer needed a long-term follow-up.

RESULTS

The 10-year overall survival was 97% (98% and 96%, respectively, for the aortic nodes only, or aortic and iliac nodes, i.e. the 'dog leg' field) and disease-free survival was 94%. Twenty-one patients relapsed (five with a true 'in-field' recurrence, nine progressed to the mediastinum, and seven had disseminated disease). Acute toxicity was mainly gastrointestinal, with 7.6% classified as grade II. In all, 73 men achieved paternity after irradiation; nine did not but had normal sperm. Second malignancies were diagnosed in 16 (3.3%) men.

CONCLUSION

Para-aortic irradiation may be used safely in patients with stage I seminoma and undisturbed testicular drainage, with equivalent results to the 'dog-leg' group; these unrandomized data confirm the lower toxicity and equivalent survival rates of this treatment.

Long-term experience with carboplatin monotherapy for clinical stage I seminoma: a retrospective single-center study

OBJECTIVES

To evaluate the long-term oncologic efficacy and morbidity of carboplatin monotherapy, which was introduced at our department 11 years ago for the treatment of Stage I seminoma. Radiotherapy is the standard treatment of patients with clinical Stage I seminoma. Carboplatin has been advocated as a treatment alternative to avoid the late side effects of radiotherapy and the high recurrence rate of surveillance strategies.

METHODS

From February 1990 until August 2001, 108 patients received two adjuvant cycles of single-agent carboplatin (400 mg/m2 body surface on days 1 and 22) 2 weeks after high inguinal orchiectomy. To assess for myelosuppression, complete blood counts were performed at least once a week until the nadir occurred after the second treatment cycle.

RESULTS

During a mean follow-up period of 59.8 months (range 6 to 134), 2 patients (1.85%) developed a recurrence (retroperitoneal tumor) within the first year. Both patients received cisplatin-based salvage chemotherapy. At last follow-up, all patients were alive without any evidence of disease. Carboplatin treatment was well tolerated by all patients and was associated with only mild gastrointestinal side effects. Leukopenia was noted in 32 patients (29.6%); 21 (19.4%) of these patients had World Health Organization (WHO) grade 1, 8 (7.4%) had grade 2, 3 (2.8%) had grade 3, and none had grade 4. No patient developed neutropenic fever. Thrombocytopenia was observed in 48 patients (44.4%); of these patients, 38 (35.2%) had WHO grade 1, 5 (4.6%) had grade 2, 2 (1.9%) had grade 3, and 3 (2.8%) had grade 4.

CONCLUSIONS

From an oncologic standpoint, two cycles of carboplatin monotherapy was highly effective and very well tolerated by all patients.

Long-term results of adjuvant irradiation or surveillance in stage I testicular seminoma

BACKGROUND

Excellent treatment results are obtained for stage I testicular seminoma treated with orchiectomy and prophylactic radiotherapy. In patients with stage I nonseminomatous testicular tumors, surveillance alone is successful, however, this treatment option for stage I testicular seminomas is controversial. There have been few reports of long-term follow-up of surveillance alone for patients with stage I testicular seminoma.

METHODS

To assess the appropriateness of th is treatment option, a retrospective survey of stage I testicular seminoma was undertaken. Twenty-seven patients who underwent prophylactic radiation therapy (RT group) and 41 patients followed only by surveillance (S group) after high orchiectomy were evaluated. Their follow-up consisted of frequent clinical examinations, abdominal CT scans, chest x-rays and serum tumor markers.

RESULTS

In the RT group, with a median follow-up period of 15 years, 1 patient (3.6%) had a recurrence in the lung at 4 months after orchiectomy and died, but the remaining 26 are alive with no evidence of disease (NED). In the S group, with a median follow-up period of 7.3 years, 5 (12.2%) relapsed in the retroperitoneal lymph nodes, but all are alive with NED following chemotherapy. The remaining 36 are all alive without recurrence (follow-up period, 38 to 132 months). Although the relapse rate in the S group was relatively higher than in the RT group, there was no significant difference between the 2 groups.

CONCLUSION

If a frequent follow-up protocol is administered and followed by the patient, surveillance alone may be a recommended management for stage I testicular seminoma.

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.

Pretreatment follicle-stimulating hormone: a prognostic serum marker of spermatogenesis status in patients treated for germ cell cancer

PURPOSE

We evaluate the use of pretreatment follicle-stimulating hormone (FSH) in patients with germ cell tumors as a prognostic serum marker of spermatogenesis after standard treatment. Additionally, Leydig cell function was investigated by estimation of luteinizing hormone (LH) and testosterone (T), and calculation of the T/LH ratio.

MATERIALS AND METHODS

Serum FSH, LH and T were determined radioimmunologically associated with semen analyses in 20 patients with seminoma (pathological stages IA to IIB) after unilateral orchiectomy before and up to 24 months after infradiaphragmatic radiotherapy. Additionally, hormone analyses were performed in 18 patients with nonseminomatous germ cell tumor (pathological stages IIA to C) before and up to 36 months after standard cisplatin based chemotherapy.

RESULTS

Seminoma patients undergoing radiotherapy were divided into 2 groups consisting of 12 patients with normal pretreatment serum FSH and 8 with elevated FSH reflecting spermatogenesis deficits even before treatment. Six months after irradiation a significant increase in FSH (p <0.01) associated with a decrease in sperm density was observed in both groups and 24 months after radiotherapy patients with initially normal FSH had significantly lower serum FSH (p <0.01) associated with higher sperm density than those with initially elevated FSH (p <0.01), indicating less impairment of Sertoli cell function. Comparable results were observed in chemotherapy treated germ cell tumor patients with initially normal (11) and elevated serum FSH (7), respectively, and 36 months after chemotherapy patients with initially normal FSH had significantly lower FSH concentrations than those with initially elevated FSH (p <0.01). Compensated impairment of Leydig cell function reflected by a subnormal T/LH ratio was evident before chemotherapy in 16.7% of patients increasing up to 41.2% 36 months after therapy. In contrast, 24 months after radiotherapy only 25% of seminoma patients showed a subnormal ratio reflecting less damage to the Leydig cells caused by irradiation.

CONCLUSIONS

Pretreatment FSH is a prognostic serum marker of spermatogenesis status of germ cell tumor patients receiving standard radiotherapy or chemotherapy. In contrast to seminoma patients after radiotherapy, impairment of Leydig cell function was evident in germ cell tumor patients after cisplatin based chemotherapy.

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).

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.

An analysis of surveillance for stage I combined teratoma--seminoma of the testis

We analysed 973 patients with stage I testicular tumours presenting between 1983 and 1994. The median ages at presentation for non-seminomatous germ cell tumour (teratoma) were 27 years, seminoma 36 years and combined tumour 33 years. These differences were statistically significant (Mann-Whitney P < 0.05), suggesting that combined tumours may have a separate natural history. We, therefore, analysed all stage I patients managed with surveillance (530 in total) post orchidectomy. The actuarial 5 year relapse-free survival and anatomical patterns of relapse were identical for non-seminomatous germ cell tumour (NSGCT) and combined tumour and both were statistically distinct from seminoma (P = 0.01, log-rank test, chi-square test P = 0.001). The association of seminoma within a histologically confirmed NSGCT has no influence on the clinical outcome.

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.

A novel anti-seminoma monoclonal antibody (M2A) labelled with technetium-99m: potential application for radioimmunoscintigraphy

OBJECTIVE

To study the potential usefulness of monoclonal antibody (mAb) M2A specific for seminoma to image tumour nodules in a preclinical nude mouse model.

MATERIALS AND METHODS

MAb M2A was labelled with technetium-99m (99mTc) following reduction and was administered intraperitoneally to nude mice bearing subcutaneous HEY cell xenografts against which the antibody was originally raised. Biodistribution and gamma scintigraphy studies were performed 24 h after administration of 99mTc-M2A.

RESULTS

Biodistribution studies showed specific targeting of 99mTc-M2A to HEY tumours in comparison with control mAb 99mTc-6E8 and 99mTc-2G3 which do not bind to HEY cells. Subcutaneous HEY cell tumours (0.5-1.0 g) were successfully imaged using gamma-scintigraphy following administration of 99mTc-M2A.

CONCLUSION

The results of this study indicate the potential usefulness of 99mTc-M2A as a clinical reagent for imaging seminoma metastases.

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)

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.

Mortality and cancer incidence following radiotherapy for seminoma of the testis

From the records of the Thames Cancer Registry, 859 patients were identified, who were treated with radiotherapy for seminoma of the testis between 1961 and 1985. Second cancer incidence and mortality and also causes of non-cancer deaths in the study population were examined. Fifty-one (6%) patients died of testicular cancer, 42 within 5 years of diagnosis. There were 42 second cancers (other than second testicular cancers), and 20 deaths from second cancer (expected, 22.1--non-significant). The only subtype of cancer with a notable excess was leukaemia (4 incident cases observed; 0.64 expected; relative risk 6.2, 95% C.I., 2.7-14.8, 95% C.I., 2.7-14.7). The overall death rate from causes other than testicular cancer was not elevated (82 observed, 82.06 expected). There was some suggestion of an increase in the risk of mortality with time; for 10 or more years after treatment the relative risk was 1.31 (95% C.I., 0.95-1.81). There was no evidence of excess non-cancer deaths (62 observed, 60 expected). We conclude that there is no definite evidence from this investigation of increased risk of mortality secondary to radiotherapy; however, the excess incidence of leukaemia may be treatment-related and the cohort will be followed further.

Radiation therapy for stage I and IIA testicular seminoma

PURPOSE

To review the survival, cure rate, treatment morbidity, and late sequelae of histologically confirmed seminoma patients who underwent orchiectomy and radiation therapy at the Radiation Oncology Center, Mallinckrodt Institute of Radiology, from 1964 to 1988.

METHODS AND MATERIALS

There were 128 patients, with a median patient age of 37 years (range, 17-79 years). Follow-up ranged from 1-24 years, with a median of 6.7 years. There were 95 patients with Stage I and 33 with Stage IIA disease. All patients were treated with orchiectomy followed by iliac and paraaortic irradiation (median tumor dose: 2500 cGy for Stage I and 3400 cGy for Stage IIA patients). Twenty-five of 33 patients with Stage IIA disease received prophylactic mediastinal and left supraclavicular irradiation (median dose, 2700 cGy).

RESULTS

For patients with Stage I disease, 5-year disease-free survival, overall survival, and survival corrected for intercurrent disease were 97%, 100%, and 100%, respectively. For patients with Stage IIA disease, the 5-year disease-free survival, overall survival, and survival corrected for intercurrent disease were 93%, 89%, and 97%, respectively. Four patients (3%) had recurrences; all were outside the radiation treatment field. Three of four were successfully salvaged with chemotherapy and rendered disease-free; the other patient refused treatment. There were no mediastinal recurrences whether prophylactic mediastinal irradiation was administered or not. Bowel obstruction and necrosis developed in one patient who received 3363 cGy midplane dose to the pelvic and paraaortic areas as well as additional intraperitoneal colloidal 198Au (150 mCi) for a ruptured seminoma from an undescended testis.

CONCLUSION

In summary, radical orchiectomy and irradiation of the iliac and paraaortic lymphatics is the treatment of choice for patients with Stage I and IIA testicular seminoma.

Stage I testicular tumours: the Tata Memorial Hospital experience

One hundred and fifty-six patients with stage I testicular germ cell tumours--81 seminomas and 75 nonseminomatous tumours--were treated at the Tata Memorial Hospital, Bombay over a 5 year period. Among the seminomas, 71 were treated with post-orchidectomy prophylactic radiation therapy to the retroperitoneum and/or mediastinum, while 10 patients refused radiation therapy and were put on surveillance. The disease-free and total survival in seminomas were 92.6% and 100%, respectively. Among the patients with nonseminomatous tumours, 58 had normal levels of serum biomarkers while 17 had raised biomarkers. In the normal marker group, 20 patients underwent retroperitoneal lymph node dissection (RPLND) with a nodal positivity of 30%, while the other 38 patients refused surgery and were either placed on unplanned surveillance (33 patients) or chemotherapy (5 patients). In this group, the patients undergoing RPLND had a survival rate of 100% as compared to 93.9% in those with surveillance. The overall disease-free and total survival rates in patients with normal markers were 86.2% and 96.6%, respectively. In the raised marker group, 6 patients underwent RPLND with a survival rate of 100% and 11 patients received chemotherapy with a survival of 90%, with the overall survival for patients with raised markers being 94.1%. The overall disease-free and total survival rates for all patients with stage I nonseminomatous tumours were 88% and 96%, respectively.

Treatment of stage I testis seminoma by radiotherapy: long-term results--a 30-year experience

PURPOSE

From 1956 to 1986, we have retrospectively studied 184 patients with a Stage I testis seminoma treated by orchidectomy and radiotherapy at the Institut Gustave Roussy.

METHODS AND MATERIALS

The 184 patients received adjuvant radiotherapy to the para-aortic and ipsilateral iliac nodes. Of the 184 patients, 133 received additional mediastinal and supraclavicular irradiation, 47 received supraclavicular without mediastinum irradiation, 98 patients received additional radiotherapy given to inguino-scrotal area. The mean dose of irradiation is 21 Gy which is the lowest dose published. The actuarial survival rate is, respectively, 96%, 93%, 83% and 77% at 5, 10, 15, and 20 years.

RESULTS

Four patients relapsed, and four died of progressive disease. Four patients presented cardiovascular disease, all of them had mediastinal irradiation, two were heavy smokers. Seventeen second malignancies were observed, six tumors in the contralateral testis. The actuarial risk of developing a second malignancy is 10% at 10 years, 21% at 20 years. The cure rate and relapse rate in our patients is the same as that obtained by higher dosage of irradiation.

CONCLUSION

We conclude that low dose of prophylactic irradiation in lumbo aortic and ipsilateral iliac lymph nodes is active and safe in the treatment of Stage I testis seminoma.

Results of a policy of surveillance in stage I testicular seminoma

PURPOSE

To determine what proportion of patients with Stage I testicular seminoma will be cured with orchidectomy alone.

METHODS AND MATERIALS

From August 1984 to December 1991 148 patients with Stage I testicular seminoma were entered on a prospective study of surveillance following orchidectomy. The eligibility criteria included a normal chest X ray, lymphogram, computed tomography (CT) of the abdomen and pelvis, and normal post-orchidectomy tumor markers (AFP and BHCG). Patients were followed with a clinical assessment (markers, chest X ray and CT abdomen and pelvis) at 4 to 6 monthly intervals.

RESULTS

With a median follow-up of 47 months (range 7-87 months), the actuarial relapse-free rate was 81% at 5 years. Twenty-three patients have relapsed with a median time to relapse of 15 months (range 2-61 months). Four patients (17%) relapsed at 4 or more years from diagnosis. Twenty-one of the 23 relapses occurred in the paraaortic lymph nodes, one patient relapsed in the mediastinum and ipsilateral inguinal nodes and one patient had an isolated ipsilateral inguinal node relapse. Nineteen patients were treated for relapse with external beam radiation therapy of which three developed a second relapse and were salvaged with chemotherapy. Four patients were treated for first relapse with chemotherapy and one developed a second relapse and died of disease. Age at diagnosis was the only prognostic factor for relapse, with patients age < or = 34 having an actuarial relapse-free rate at 5 years of 70% in contrast to a 91% relapse-free rate in those > 34 years of age.

CONCLUSIONS

We recommend that surveillance in Stage I testicular seminoma should only be performed in a study setting until further data regarding the risk of late relapse and the efficacy of salvage chemotherapy is available.

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.

Skip metastases from testicular seminoma

A unique case of metastatic testicular seminoma which did not initially involve the retroperitoneal lymph nodes is presented. Modern treatment, with cis-platinum based chemotherapy and involved-field irradiation, resulted in cure.

Surveillance following orchidectomy for stage I seminoma of the testis

From 1985 to 1988, 261 unselected patients entered a nationwide Danish study of surveillance only for testicular seminoma stage I. The median follow-up time after orchidectomy was 48 months, range 6-67 months. 49 patients relapsed (19%). Sites of relapse were paraaortic lymph nodes in 41 patients, pelvic lymph nodes in 5, inguinal lymph nodes in 2 and lung metastases in 1 patient. The median time to relapse was 14 months, range 2-37 months. The 4-year relapse-free survival was 80%. 37 of the relapsing patients (76%) had radiotherapy as relapse treatment. Of these patients, 4 (11%) had a second relapse and received chemotherapy. 1 died of disseminated seminoma. Of the relapsing patients, 12 (24%) had chemotherapy as relapse treatment because of bulky (11 patients) or disseminated disease (1 patient). None of these patients have had a second relapse. However, 2 patients died of infection due to chemotherapy-induced neutropenia. Thus, there have been three seminoma-related deaths (1.1%). The testicular tumour size had an independent prognostic significance. The 4-year relapse-free survivals were 94, 82 and 64% for tumours < 3, 3 to < 6 and > or = 6 cm, respectively. Patients with tumours > or = 6 cm will now be given prophylactic radiation treatment, whereas we will continue to use surveillance only after orchidectomy for patients with tumours < 6 cm.

Orchidectomy followed by radiotherapy in 176 stage I and II testicular seminoma patients: benefits of a 10-year follow-up study

Results are presented for 176 patients with stage I and II primary testicular seminoma treated at the Dr. Daniel den Hoed Cancer Center (DDHCC) between 1975 and 1985. The median follow-up time was 7 years and 4 months. One-hundred and seventy-four (99%) of these patients were treated primarily with radiotherapy after extensive staging. According to the Royal Marsden Staging Classification, 132 patients (75%) were stage I, 8 (5%) were stage IIA, 21 (12%) were stage IIB, 9 (5%) were stage IIC and for 6 stage II patients a further subdivision was not possible. At 5 years the actuarial relapse-free survival and the actuarial survival were 95 and 99%, respectively, for stage I, and 77 and 91% for stage II. Prophylactic irradiation of the mediastinum has not been performed for stage II patients. Five stage II patients relapsed in the mediastinum. Four out of these five relapses were cured with chemotherapy, and in one case, in combination with radiotherapy, at the time of relapse. These results indicated that prophylactic irradiation of the mediastinum appeared to be unnecessary for stage II patients. Tumour markers were not useful in the discovery of metastases. Five years after treatment no relapses were seen. Therefore, it is proposed that a maximum follow-up of 5 years is sufficient to measure disease-free survival.

Surveillance following orchidectomy for stage I testicular seminoma

An analysis of the primary tumour histopathology was performed on 103 patients managed by orchidectomy and surveillance for stage I seminoma. Patients have been followed for 14-141 months (median 62 months) after orchidectomy. Seventeen patients relapsed, the probability of remaining relapse free at 5 years being 82% (95% confidence intervals, 74%-88%). No patients died of progressive germ cell tumours. The only significant histological factor predicting relapse was the presence of lymphatic and vascular invasion. Four of 42 patients with neither lymphatic or vascular invasion recurred, nine of 53 patients with either lymphatic or vascular invasion recurred and three of eight cases with both lymphatic and vascular invasion recurred (P = 0.05-trend). Though initial recurrence was usually of moderate volume and confined to para-aortic nodes, eight patients were treated with chemotherapy either because of the extent of their initial relapse (four cases), or because of subsequent relapse (four cases). In view of the difficulties of identifying patients at risk and of detecting early relapse, surveillance for stage I seminoma should remain a research protocol.

Spermatic Cord β-Human Chorionic Gonadotropin Levels in Seminoma and their Clinical Implications

Current opinions differ as to the biological significance and treatment of pure seminoma associated with the serological establishment of beta-human chorionic gonadotropin. Between December 1987 and April 1990, 147 patients with malignant testicular tumors were treated. Of these patients 47 (32%) had a pure seminoma. In 35 of the 47 patients we measured the tumor markers beta-human chorionic gonadotropins and alpha-fetoprotein in the cubital vein blood and testicular vein blood. There were elevated beta-human chorionic gonadotropin levels in the cubital veins of 26% of the patients, in agreement with the literature. However, elevated levels were found in the testicular veins of 80% of the patients, which reflects the high sensitivity of marker identification in testicular vein blood. Apparently, most seminomas produce beta-human chorionic gonadotropin even if it is not detectable in the cubital vein. We believe that the presence of this marker in patients with pure seminoma is not an indication of greater tumor aggressiveness but of tumor mass.

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.

Stage I seminoma of the testis. Adjuvant radiotherapy or surveillance?

Lately the role of radiotherapy in stage I seminoma of the testis has been questioned by some authors who reported on a "surveillance" strategy for these patients. Since 1980, 124 patients with seminoma of the testis have been referred to this institution; 97 of 116 patients analysed presented with stage I disease and 10 of these had elevated levels of beta HCG. A total of 64 patients were given radiotherapy after orchiectomy and 33 entered a surveillance protocol. After a median follow-up of 48 months, 3 patients in the surveillance group relapsed after 5, 13 and 49 months and 2 of the irradiated patients did so after 25 and 33 months. Elevation of beta HCG was not significant because none of these patients showed progression. A low rate of progression and excellent survival are associated with standard treatment (orchiectomy and radiotherapy) and good results have been achieved with chemotherapy in cases of relapse. A surveillance policy is not recommended in stage I seminoma because of its slower growth compared with non-seminomatous germ cell tumours (NSGCT), the absence of a specific tumour marker, the 10% risk of occult metastases and the 3-fold higher progression rate compared with irradiated patients. We suggest the use of a reduced dosage and radiation field.

Treatment results and acute and late toxicity of radiation therapy for testicular seminoma

From 1977 to 1988, 215 patients with a diagnosis of testicular seminoma were referred to the University Hospital, Hamburg, West Germany, for radiation therapy (RT). In 15 patients a careful review of the histologic condition showed signs of embryonal cell carcinoma. Three patients refused completion of therapy. No patient was lost to follow-up. On this basis, a retrospective review of 197 patients was carried out. One hundred thirty-three patients were classified as Stage I (67%), 39 as Stage II (20%), 8 as Stage III (4%), and 17 as Stage IV (9%). One hundred eighty patients had classic seminoma and 17 had anaplastic seminoma. All patients underwent high inguinal orchiectomy before treatment. Seven patients with Stages III and IV received chemotherapy before RT. Patients with Stages I and II were treated with 40-Gy photons to paraaortic and parailiac fields. Ten patients with Stage III and IV seminoma received 30-Gy photons to mediastinal and supraclavicular fields as well. Sixty patients received additional inguinal RT. The overall 5-year survival rate (corrected for intercurrent death, except for treatment toxicity) was 100% for Stage I, 100% for Stage II, 87% for Stage III, and 87% for Stage IV. The mean follow-up time was 6.3 years (range, 0.6 to 11.9 years). An evaluation of all patients showed no difference according to histologic condition or prior chemotherapy. Mediastinal and supraclavicular irradiation showed no improvement in treatment results. Acute toxicity consisted of mild to moderate emesis, increased bowel frequency, erythema, and, in four cases leucopenia and thrombopenia (all World Health Organization [WHO] Grades I to II). However, one patient died of a pulmonary fibrosis 1 month after mediastinal irradiation and 2 months after polychemotherapy, and a gastroduodenal ulcer developed in another patient 1.5 months after paraaortic RT and prior polychemotherapy. Overall, the data suggest that to avoid overtreatment and consecutive treatment morbidity reduced doses of 30 Gy and a restrictive treatment planning adapted to the individual risk are sufficient for RT for testicular seminoma. An alternative to postoperative RT in Stage I (and possibly Stage II) seminoma could be no RT, but close follow-up instead.

Is placental alkaline phosphatase (PLAP) a useful marker for seminoma?

The usefulness of placental alkaline phosphatase (PLAP) as a tumour marker was assessed in 1578 serum samples from 236 patients with seminoma. Smoking habits were known for all but 7 patients (22 samples). Smoking was associated with significantly higher mean levels of PLAP in disease-free patients (28.8 [S.E. 2.1] U/l vs. 15.9 [1.3] U/l in non-smokers). Mean PLAP levels were higher in patients with active disease (78.6 [23.5] U/l in non-smokers and 47.2 [18.5] U/l in smokers). The median values showed a similar trend. However, there was considerable overlap between the various groups and differences between mean and median values indicated that PLAP values were distributed asymmetrically. The predictive value of PLAP as a tumour marker was consequently much less than superficial inspection of these values might suggest. In 97 patients on surveillance, only 2 out of 11 patients who relapsed had elevated PLAP at the time of clinically detectable relapse. With the upper limit of normal PLAP quoted by our laboratory (35 U/l), specificity and sensitivity were, respectively, 88% and 45% (all patients) and 96% and 47% (non-smokers). The sensitivity and specificity of PLAP were assessed in more detail for a series of threshold values (normal vs. abnormal) with a graphical method. Only in non-smokers did PLAP seem useful and even in this group the positive predictive value of an "abnormal" test may be low; less than 50% in clinically relevant circumstances. Serum PLAP assay cannot usefully stand alone as a marker for seminoma and its routine estimation contributes little to follow-up.