Short duration radiotherapy in stage I seminoma of the testis: preliminary results of a prospective study

[Role of radiotherapy in stage I testicular seminomas: about 25 cases]

Notre travail se proposait de rapporter les résultats d’une étude rétrospective, descriptive, portant sur 25 séminomes testiculaires de stade I et de préciser la place de la radiothérapie dans la prise en charge de cette entité. Entre janvier 2001 et décembre 2009, 25 patients atteints d'un séminome testiculaire de stade I ont été pris en charge au service de radiothérapie de l’institut national d’oncologie de Rabat. L’orchidectomie première a été réalisée par voie inguinale. Le bilan d’extension initial comportait un dosage de bHCG totale, d’alphafoetoprotéine, et une exploration des aires ganglionnaires sus- et sous-diaphragmatiques par une tomodensitométrie. L’irradiation adjuvante a été délivrée au moyen d’un accélérateur linéaire. L'âge médian est de 33 ans (18-52 ans). La tumeur testiculaire siégeait à droite chez 16 malades et à gauche chez les 9 autres. La radiothérapie était délivrée dans les aires ganglionnaires lomboaortiques pour 18 patients, lomboaortiques et iliaques homolatérales pour les 7 autres et ceci par deux faisceaux antéropostérieurs, délivrant une dose de 20 à 25 Gy en 10 à 14 fractions. La tolérance immédiate était excellente. La durée médiane de surveillance était de 73 mois. Vingt trois patients sont actuellement vivants, en situation de rémission complète. Un patient a rechuté au niveau pulmonaire 22 mois après la fin de sa radiothérapie. Un patient a été perdu de vue. Il n’a pas été observé de toxicité à long terme, en particulier gastro-intestinale. Aucune tumeur ou pathologie hématologique secondaire n’a été rapportée. La radiothérapie prophylactique reste le traitement adjuvant de référence des séminomes de stade I. La tolérance immédiate est satisfaisante et l’augmentation du risque de cancer secondaire est négligeable par rapport au bénéfice thérapeutique. Toutefois une surveillance armée ainsi qu’une chimiothérapie adjuvante avec un cycle de carboplatine sont aussi efficaces.

[Stage 1 testicular seminoma]

Testicular cancer is rare, representing only 1 % of malignant tumors, but the most common cancer in young men, 15 to 35 years. Adjuvant radiotherapy after orchidectomy in testicular seminoma stage I, reduces risk of relapse. It aims to eradicate micro-metastatic disease in lymph drainage territories. In the case of adjuvant radiotherapy, the relapse-free survival of 96 % with an overall survival of 98 % at 5 years. The irradiation volume is made up of lymph nodes paraaortic which it is possible to add the ipsilateral renal hilum to the testicular lesion. The current recommended dose is 20 Gy in 10 fractions and 2 weeks, usually delivered by two antero-posterior beams. The acute toxicities, mainly represented by nausea and diarrhea are usually quickly resolved to the end of irradiation. Regarding toxicities long-term, preservation of semen should be considered after surgery because of fear of infertility post-treatment. The risk of second cancer associated with exposure to ionizing radiation, albeit small, is especially important to consider these patients to significant life expectancy. Nevertheless, developments in radiotherapy techniques and lower doses and irradiated volumes can probably reduce this risk further.

Posttreatment surveillance after paraaortic radiotherapy for stage I seminoma: a systematic analysis

CONTEXT

The extent and duration of routine follow-up after paraaortic (PA) radiotherapy for stage I seminoma remain controversial in terms of efficacy, costs of technical investigations and long-term morbidity.

OBJECTIVE

To analyze the current literature assessing routine follow-up after PA radiotherapy for stage I seminoma.

EVIDENCE ACQUISITION

We identified all published reports on PA radiotherapy for stage I seminoma (1986-2005). We analyzed time patterns of recurrence, sites and methods of detection of relapse, and follow-up programs used.

EVIDENCE SYNTHESIS

We identified 11 publications reporting outcome in 2,280 patients. Median time to recurrence in 80 relapsing patients was 15.5 months. Less than 10% of recurrences were diagnosed beyond the third year of follow-up. Isolated locoregional or distant recurrence was observed in 52 and 20 patients, respectively, without significant difference in median time to relapse. 19 out of 43 recurrences with reported method of detection of relapse were diagnosed by routine technical investigations. There was no significant difference in time to relapse between those patients followed with low volume as compared to high-volume imaging protocols.

CONCLUSIONS

Our data suggest that technical investigations in posttreatment surveillance should be restricted to the first 3 years of follow-up. Furthermore, surveillance programs with a high volume of imaging apparently do not lead to earlier detection or less advanced stage at the time of relapse as compared to protocols with low volume imaging.

Long-term results of para-aortic irradiation for patients with Stage I seminoma of the testis

PURPOSE

Adjuvant postoperative para-aortic lymph nodal irradiation is an acceptable alternative to para-aortic and ipsilateral pelvic irradiation postorchiectomy for patients with Stage I seminoma of the testis. In this article, we report the long-term results of our prospective evaluation of para-aortic irradiation only for such patients.

METHODS AND MATERIALS

Between March 1991 and September 2000, 71 patients with Stage I seminoma were treated with adjuvant irradiation to the para-aortic region only after radical inguinal orchiectomy. Radiotherapy was delivered using parallel-opposed fields extending from T11 to L5. A total dose of 25 Gy in 15 fractions was prescribed to midpoint. Follow-up was performed every 3 months for the first year, every 4 months for the second and third years, every 6 months for the fourth and fifth years, and annually thereafter. Chest X-ray, tumor markers, and computed tomography scan of the pelvis were performed routinely as part of the follow-up investigation.

RESULTS

At a median follow-up of 75 months, 68 of 71 patients are alive and free of relapse. Only 1 patient (1.4%) experienced failure in the ipsilateral inguinal nodal region. Two patients (2.8%) died of unrelated causes. The actuarial 10-year relapse free survival is 98.5% and the actuarial 10-year overall survival is 92%. No late toxicity has been encountered.

CONCLUSION

Patients with Stage I seminoma of the testis may be safely treated with para-aortic radiotherapy only. Risk of pelvic failure is very low and treatment toxicity minimal.

Germ cell tumours of the testis

Cancer of the testis is a relatively rare disease, accounting for about 1% of all cancers in men. Cryptorchidism is the only confirmed risk factor for testicular germ cell tumour. The majority of GCT are clinically detectable at initial presentation. Any nodular, hard, or fixed area discovered in the testis, must be considered neoplastic until proved otherwise. The appropriate surgical procedure to make the diagnosis is a radical orchidectomy through an inguinal incision. Many GCT produce tumoural markers (AFP, HCG, LDH), who are useful in the diagnosis and staging of disease; to monitor the therapeutic response and to detect tumour recurrence. In 1997 a prognostic factor-based classification for the metastatic germ cell tumours was developed by the IGCCCG: good, intermediate and poor prognosis, with 5-year survival of 91, 79 and 48%, respectively. GCT of the testis is a highly table, often curable, cancer. Germ cell testicular cancers are divided into seminoma and non-seminoma types for treatment planning because seminomatous testicular cancers are more sensitive to radiotherapy. Seminoma (all stages combined) has a cure rate of greater than 90%. For patients with low-stage disease, the cure approaches 100%. For patients with non-seminoma tumours, the cure rate is >95% in stages I and II; it is approximately 70% with standard chemotherapy and resection of residual disease, if necessary, in stages III and IV. Minimum guidelines for clinical, biochemical, and radiological follow-up have been reported by ESMO in 2001.

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.

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).

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.

Low-dose radiotherapy for stage I seminoma: early results

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