Adjuvant radiotherapy in stage I seminoma: is there a role for further reduction of treatment volume?

SEOM-GG clinical guidelines for the management of germ-cell testicular cancer (2023)

Testicular germ cell tumors are the most common tumors in adolescent and young men. They are curable malignancies that should be treated with curative intent, minimizing acute and long-term side effects. Inguinal orchiectomy is the main diagnostic procedure, and is also curative for most localized tumors, while patients with unfavorable risk factors for recurrence, or those who are unable or unwilling to undergo close follow-up, may require adjuvant treatment. Patients with persistent markers after orchiectomy or advanced disease at diagnosis should be staged and classified according to the IGCCCG prognostic classification. BEP is the most recommended chemotherapy, but other schedules such as EP or VIP may be used to avoid bleomycin in some patients. Efforts should be made to avoid unnecessary delays and dose reductions wherever possible. Insufficient marker decline after each cycle is associated with poor prognosis. Management of residual masses after chemotherapy differs between patients with seminoma and non-seminoma tumors. Patients at high risk of relapse, those with refractory tumors, or those who relapse after chemotherapy should be managed by multidisciplinary teams in experienced centers. Salvage treatment for these patients includes conventional-dose chemotherapy (TIP) and/or high-dose chemotherapy, although the best regimen and strategy for each subgroup of patients is not yet well established. In late recurrences, early complete surgical resection should be performed when feasible. Given the high cure rate of TGCT, oncologists should work with patients to prevent and identify potential long-term side effects of the treatment. The above recommendations also apply to extragonadal retroperitoneal and mediastinal tumors.

ESMO Consensus Conference on testicular germ cell cancer: diagnosis, treatment and follow-up

The European Society for Medical Oncology (ESMO) consensus conference on testicular cancer was held on 3-5 November 2016 in Paris, France. The conference included a multidisciplinary panel of 36 leading experts in the diagnosis and treatment of testicular cancer (34 panel members attended the conference; an additional two panel members [CB and K-PD] participated in all preparatory work and subsequent manuscript development). The aim of the conference was to develop detailed recommendations on topics relating to testicular cancer that are not covered in detail in the current ESMO Clinical Practice Guidelines (CPGs) and where the available level of evidence is insufficient. The main topics identified for discussion related to: (1) diagnostic work-up and patient assessment; (2) stage I disease; (3) stage II-III disease; (4) post-chemotherapy surgery, salvage chemotherapy, salvage and desperation surgery and special topics; and (5) survivorship and follow-up schemes. The experts addressed questions relating to one of the five topics within five working groups. Relevant scientific literature was reviewed in advance. Recommendations were developed by the working groups and then presented to the entire panel. A consensus vote was obtained following whole-panel discussions, and the consensus recommendations were then further developed in post-meeting discussions in written form. This manuscript presents the results of the expert panel discussions, including the consensus recommendations and a summary of evidence supporting each recommendation. All participants approved the final manuscript.

[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.

Metastatic seminoma in the duodenum: diagnosis with endoscopy followed by successful treatment

Seminomas rarely metastasize to the gastrointestinal tract. In general, these lesions metastasize to the lungs or retroperitoneal lymph nodes. A 34-year-old Japanese man who had undergone orchiectomy for seminoma two years earlier experienced shortness of breath and tarry stools. The patient presented at our hospital and was diagnosed with metastatic seminoma to the third portion of the duodenum on double balloon endoscopy. He was effectively treated with chemotherapy and continues to progress well, with no episodes of recurrence.

Mapping patterns of nodal metastases in seminoma: rethinking radiotherapy fields

BACKGROUND AND PURPOSE

To analyze the location of metastatic lymph nodes in seminoma patients relative to vascular and bony anatomy and conventional radiation fields.

MATERIALS AND METHODS

Cross-sectional scans of 90 seminoma patients with infradiaphragmatic adenopathy were analyzed. The position of each node respective to vascular anatomy was transferred to a standardized template. Conventional radiation fields were overlaid on the template and locations of metastatic nodes were assessed.

RESULTS

One hundred and forty-five nodes were radiographically positive. Eighty-four percent, 9%, and 7% of nodes were located in the para-aortic, common iliac, and pelvic regions, respectively. Ninety-nine percent of nodes were within a 2.5 cm lateral and 2.1cm anterior expansion of the aorta inferior to T12/L1. No radiographically positive nodes were identified within the renal hilum or superior to L1 in left-sided seminomas. For right-sided seminomas, no radiographically positive nodes were superior to L2. Three percent of all radiographically positive nodes would have been located outside of conventional and modified fields.

CONCLUSIONS

Infradiaphragmatic nodal metastases from a contemporary cohort of seminoma patients localized to a smaller area than is targeted by conventional radiation fields. Modified treatment fields based on vascular, rather than bony, anatomy are smaller and may allow for a significant decrease in normal tissue irradiation and toxicity.

[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.

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

PURPOSE

The aim of this study was to review retrospectively the results of low-dose radiotherapy for Stage I seminoma using four different fractionation schedules and target volume definitions.

METHODS AND MATERIALS

A total of 191 patients underwent irradiation for histologically proven Stage I seminoma after undergoing an inguinal orchiectomy. Fractionation schedules were used one after another as follows: Total dose 30 Gy (dose/fraction 1.5 Gy, 16 patients), total dose 25.5 Gy (dose/fraction 1.5 Gy, 62 patients), total dose 20 Gy (dose/fraction 2 Gy, 69 patients), total dose 26 Gy (dose/fraction 2 Gy, 29 patients). The remaining 12 patients were excluded from this study. In the same period the target volume was gradually reduced. In 1983 the paraaortic, pelvic and inguinal regions were irradiated; later the target volume was reduced to the paraaortic region exclusively.

RESULTS

Overall survival and event-free survival were identical in all groups ranging from 95% to 100% /5 years. Three patients experienced a lymph node metastasis during follow-up, 3 patients a distant metastasis to the lung and the bones. Mild acute side effects were noted in 8% to 15% of the patients, and very mild long-term side effects in 1% to 5% of patients. Multivariate analysis showed no prognostic significance of total dose, dose per fraction, or target volume. In univariate analysis, a higher frequency of acute side effects to the skin and the bowel was related to a higher total dose, and an elevated frequency of nausea was related to a higher daily dose per fraction.

CONCLUSION

Using lower doses and limiting the target volume to the paraaortic region exclusively did not result in a worse prognosis in our patient series.

The management strategies for stage I seminoma

About 80% of men with seminomatous testicular germ-cell cancer are diagnosed with stage I disease. For many years, the standard treatment for this patient group has been radiation to para-aortic and iliacal lymph nodes at the same side as the orchiectomy. However, iliac radiotherapy is unnecessary in patients without prior inguinal or scrotal surgery. Furthermore, in recent years, other treatment modalities for this patient group have evolved. The use of single-agent carboplatin has shown promising results, similar to the effects obtained by radiotherapy. In addition, surveillance after primary orchiectomy with no additional treatment is found to be a safe follow-up for many of these patients. On the basis of new knowledge about primary tumour risk factors, it is now possible to identify patients at a particular high risk of relapse (rete testis invasion, primary tumour size > 4 cm, or both). This will be a helpful tool to identify patients who can be safely included into a surveillance strategy, and those who could have adjuvant treatment. The final decision about treatment will depend on risk factors, capacity of the healthcare service to carry out frequent follow-up examinations and the patient's own preferences. In this paper, we will discuss advantages and disadvantages of the various treatment options in the management of stage I seminoma.

Towards individualised radiotherapy for Stage I seminoma

BACKGROUND AND PURPOSE

Adjuvant radiotherapy is currently standard treatment of Stage I seminoma (SOS). The use of computerised tomogram (CT) planning is compared with traditional planning for greater treatment individualisation.

MATERIAL AND METHODS

Two plans were generated for each of 10 patients: one using traditional rectangular para-aortic fields, and one using conformal fields. The primary target volume compared was the dosimetric coverage of the inferior vena cava and aorta.

RESULTS

The dosimetric analysis of traditional plans showed that they provided reasonable dosimetric coverage of the CTV. However, if 1cm is used for uncertainty based on nodal coverage then the periphery of the PTV could be significantly under-dosed. The CT based plan delivered improved dosimetry to the vessel PTV compared with the traditional field (CT D 95=24.7 Gy, traditional D 95=23.6 Gy, P=0.002). CT-based plans were significantly wider than traditional plans (CT=11.8 cm, traditional=9 cm, P=0.002). The CT plan tended to irradiate relatively small volumes of the kidneys to higher doses.

CONCLUSIONS

Traditional para-aortic fields may deliver suboptimal dosimetry to an anatomically defined PTV. Our CT-based fields tend to be wider than traditional fields, and provide improved dosimetry to vessels based target volumes. Given that traditional fields are often delivering significantly less than the prescribed dose to the target volume, and that marginal relapses cause a high proportion of treatment failure, there is a suggestion that CT-based plans may avoid under-dosage and geographical miss sometimes seen with traditional plans.