Stage II testicular seminoma: patterns of recurrence and outcome of treatment

OBJECTIVES: To review treatment outcome and patterns of failure for patients with stage II testicular seminoma and to identify prognostic factors for relapse. METHODS: From 1981 to 1999, 126 men with stage II seminoma were treated at Princess Margaret Hospital. Of these, 95 were treated with radiotherapy (RT) and 31 with chemotherapy (ChT). Patient and tumour characteristics were analyzed for prognostic significance for subsequent relapse. RESULTS: At median follow-up of 8.5 years, the 5- and 10-year overall survival were both 93%, the 5- and 10-year cause-specific survival were both 94% and the 5- and 10-year relapse-free rates were both 85%. Patients with stage IIA and IIB disease treated with RT and stage IIB treated with chemotherapy had 5-year relapse-free rates of 91.7%, 89.7% and 83.3%, respectively. Seventeen percent of patients treated with radiotherapy and 6% of those treated with chemotherapy have relapsed. Of the RT patients the commonest sites of relapse were left supraclavicular fossa, lung/mediastinum, bone, para-aortics and liver; nine patients had a solitary site of relapse. Two patients treated with chemotherapy had recurrence in the para-aortic and iliac nodes. For RT patients, larger primary tumour size was associated with a reduction in relapse rate. Age, rete testis invasion and lymphovascular invasion were found not to be of prognostic significance. CONCLUSIONS: In stage IIA/B seminoma, radiotherapy continues to provide excellent results, as the majority of patients will be cured with this treatment alone. Chemotherapy is the treatment of choice for stage IIC seminoma.     

A risk-adapted strategy of radiotherapy or cisplatin-based chemotherapy in stage II seminoma

ObjectivesIndications for radiotherapy and chemotherapy in stage II seminoma are currently debated.Materials and methodsSince1980, the policy at Institut Gustave Roussy was to treat patients with stage IIA-B disease with external radiotherapy and patients with stage IIB-C with cisplatin-based chemotherapy. In stage IIB disease, 3 cm was the usual tumor size threshold above which individual patients were considered for chemotherapy.ResultsDuring the period 1980–2001, 67 patients with stage II seminoma were treated: stage IIA (n = 5), stage IIB (n = 31), and stage IIC (n = 31). The median age was 40 years (range: 23–64). Among 37 patients who received radiotherapy, 5, 28, and 4 had a stage IIA, IIB, and IIC, respectively. Among 30 patients who received chemotherapy, 27 had a stage IIC. With a median follow-up of 9.4 years, 19 relapses (28%) occurred, including 11 and 8 cases treated with radiotherapy (30%) and chemotherapy (27%), respectively. The 5-year relapse-free survival was 71% (95% CI: 59–80). All but three relapses were salvaged with chemotherapy followed in selected cases by surgical resection of residual masses. Only 3 patients died of seminoma. The 5-year overall survival rate is 97% (95% CI: 89–99). Five patients subsequently developed a non-germ-cell second cancer, which occurred within the radiation field in 3 cases.ConclusionWith an overall survival rate of 97%, the overall outcome of patients with stage II seminoma managed according to this risk-adapted strategy is good. The possibility of extending the indications for chemotherapy to selected stage IIB seminoma patients needs to be further evaluated as potentially beneficial in terms of relapse risk.     

Outcome of different post‐orchiectomy management for stage I seminoma: Japanese multi‐institutional study including 425 patients

Objectives: To clarify the contemporary clinical outcome of stage I seminoma and to provide information on treatment options to patients. Methods: A retrospective analysis of 425 patients who underwent orchiectomy for stage I seminoma between 1985 and 2006 at 25 hospitals in Japan. Relapse‐free survival rates were calculated using the Kaplan–Meier method and clinicopathological factors associated with relapse were examined by univariate and multivariate analyses using the Cox proportional hazards model. Results: A total of 30 out of 425 patients had relapsed. Relapse‐free survival rates at 10 years were 79, 94 and 94% in the surveillance, chemotherapy and radiotherapy groups, respectively. Post‐orchiectomy management and rete testis invasion were identified as independent predictive factors associated with relapse. Rete testis invasion remained to be an independent predictive factor, even if the cases with relapses in the contralateral testis were censored. Only one patient, who relapsed after adjuvant radiotherapy, died of the disease. Overall survival at 10 years was 100, 100 and 99% in the surveillance, chemotherapy and radiotherapy groups, respectively. More than half of the patients were lost to follow up within 5 years. Conclusions: The outcome of Japanese patients with stage I seminoma is similar to previously published Western reports. Surveillance policy is becoming a popular option in Japan, although the relapse rate in patients opting for surveillance policy is higher than those opting for adjuvant chemotherapy or radiotherapy. Rete testis invasion is an independent predictive factor associated with relapse regardless of the post‐orchiectomy management. Long‐term follow up is mandatory for detection of late relapse.     

Is surveillance for stage 1 germ cell tumours of the testis appropriate outside a specialist centre?

OBJECTIVE: To assess the results of treatment for stage 1 germ cell tumours of the testis, outside a specialist centre. PATIENTS AND METHODS: From May 1984 until March 1996, 123 patients with stage 1 disease were treated at our institution. Sixty patients with seminoma and 31 with teratoma were treated with orchidectomy only and surveillance; 32 patients with stage 1 seminoma elected for orchidectomy and adjuvant radiotherapy. The mean ages were 40, 31 and 35 years, and the median follow-up 52, 47 and 49 months, respectively. RESULTS: There were no disease- or treatment-related deaths. However, 18 (30%) patients with seminoma treated by orchidectomy only relapsed (median time 8 months, range 3-19); 14 of these responded to radiotherapy, three to radiotherapy and chemotherapy for second relapses outside the irradiated fields, and one to chemotherapy initially, for large-volume relapse. Fifteen (48%) patients with teratoma relapsed (median time 3 months, range 1-12); all responded to 4-6 courses of bleomycin/etoposide/cisplatin chemotherapy. One patient had a second relapse and is currently disease-free 3 years after surgical excision of a lung metastasis. CONCLUSION: These results show that stage 1 testis tumours can be managed successfully in a district general hospital. However, we are concerned about the high relapse rates and are now attempting to identify patients at greater risk of recurrence, to consider adjuvant therapy in this group.     

Management of Stage II testicular seminoma over a period of 40 years

ObjectivesTo review the treatment, toxicity, and outcomes in patients with Stage II seminoma after orchidectomy.Materials and methodsA retrospective chart review of all patients with Stage II seminoma referred for initial treatment, from 1965 to 2005, was performed. Treatment approaches, toxicity, and outcomes were analyzed.ResultsA total of 106 patients (83 with Stage IIA, 19 with Stage IIB, and 4 with Stage IIC) were seen between 1965 and 2005. Median age at diagnosis was 36 years (range: 19–71). Median follow-up was 21 years (range: 1.2–42). Eighty-nine patients were treated with adjuvant radiotherapy alone; 13 patients received a combined treatment modality with chemotherapy and radiotherapy after orchidectomy, 4 patients were treated with chemotherapy alone. Generally the treatment was well tolerated, with the main toxicity occurring in patients treated with extended-field radiotherapy. The 5-year disease-specific survival was 96% for the entire group. The 5-year relapse-free survivals for Stages IIA, IIB, and IIC disease were 94%, 72.5%, and 75%, respectively. Fifteen patients developed a relapse and were managed by chemotherapy; 5 of them achieved complete remission and remain free from further recurrence at last follow-up, while 10 died of the disease. Second malignancies were diagnosed in 4 (3.7%) patients during the follow-up.ConclusionsIn Stage IIA seminoma, radiotherapy continues to provide excellent results, as the majority of patients will be cured with this treatment alone. Radiotherapy or chemotherapy should be offered as an alternative to Stage IIB patients. Chemotherapy remains the treatment of choice for Stage IIC seminoma.     

Commentary on “Patterns of care in the management of seminoma stage I: Results from a European survey.” Vossen CY,Horwich A,Daugaard G,Vossen CY,Horwich A,Daugaard G,van Poppel H,Osanto S,Department of Clinical Epidemiology,Leiden University Medical Centre,Leiden, the Netherlands : BJU Int 2012;110:524

Study Type - Therapy (practise pattern survey). Level of Evidence 3b. What's known on the subject? and What does the study add? The uncertainties about differences in relapse and rates of other late events such as second malignancy and cardiovascular events for the three post-orchidectomy strategies in seminoma stage I patients has led to debates about whether the three strategies are equally effective and safe. The differences in interpretation of the data as well as the debates are likely to result in differences in treatment after orchidectomy in seminoma stage I patient management. Current care patterns after orchidectomy are, however, unknown. We assessed patterns of care for seminoma stage I patients after orchidectomy by distributing a survey among doctors treating such patients across Europe. The 969 respondents showed large differences in care strategies between specialties and countries that indicate the need for research into long-term relapse rates and long-term adverse effects to standardize and optimize care for seminoma stage I patients.ObjectiveTo assess precise patterns of care after orchidectomy in Europe for stage I seminoma patients, we aimed to perform a survey among doctors in the various European countries.Patients and methodsWe distributed a survey in 2009 and 2010 among American Society of Clinical Oncology and European Association of Urology members.ResultsIn total, 969 questionnaires were included in the analysis. More than half of the 969 physicians (58%) currently offer only one post-surgical treatment: 18% only surveillance, 19% only radiotherapy and 21% only chemotherapy. Thirteen percent of the 969 physicians currently offer all three strategies, 25% offer surveillance and adjuvant radiotherapy or chemotherapy, and 5% offer either adjuvant radiotherapy or chemotherapy without surveillance. ? We found large differences in care patterns between specialties and countries. Even within countries, care after orchidectomy was not standardized. ? Before 2005, 73% of the physicians offered only one treatment and of those 51% gave adjuvant radiotherapy.ConclusionsLarge differences in pattern of care after orchidectomy for stage I seminoma patients exist between specialties and countries within Europe. ? More information on long-term relapse rates and long-term adverse effects of the three strategies is needed to standardize and optimize care after orchidectomy.     

Management of stage I testis cancer

OBJECTIVE: Over the last 5 years the management of stage I testis cancer has changed tremendously. This review focuses on the latest changes in diagnostics and treatment of clinical stage I non-seminomatous and seminomatous germ cell tumors. METHODS: A non-structured literature search (MEDLINE) was performed, including recently published papers (up to March 2006) on the subject. RESULTS: Organ-sparing surgery has become an accepted approach to treat malignant and nonmalignant tumours in a solitary testis. With certain precautions and adjuvant radiotherapy, this approach has proven to be as effective as orchidectomy. Prognostic factors strongly influence the decision for or against adjuvant treatment in seminoma and non-seminoma. With the help of a risk-adapted approach, about 50% of patients with clinical stage I testis cancer will favour close surveillance instead of immediate adjuvant treatment. Several well-conducted trials have helped to substantiate the management. Surgical staging by retroperitoneal lymph node dissection became an exception. Patients with non-seminoma with high risk for occult metastatic disease will favour adjuvant chemotherapy and in patients with seminoma radiotherapy with reduced dosage will be challenged by carboplatin monotherapy. CONCLUSION: With adequate diagnostics and treatment, 100% of patients with stage I testis cancer will survive. Future research will focus on quality control, adherence to guideline recommendations, and further reduction of treatment to diminish the risk of late sequalae for patients with adjuvant radiotherapy or chemotherapy.     

Surveillance in stage I testicular seminoma

Treatment options in patients with stage I testicular seminoma include adjuvant radiotherapy (RT), surveillance, and adjuvant chemotherapy. RT was the treatment of choice for the past 50 years, but there has been increasing concern in the past decade regarding late complications. Surveillance, reserving treatment for patients who relapse, has been shown to be a safe and effective strategy. It allows >80% of patients to avoid any post-orchidectomy treatment and is the recommended approach for these patients. The possible role of adjuvant chemotherapy is currently being assessed in clinical trials and should not be used outside of a study setting.     

Modern radiotherapy results with bulky stages II and III seminoma

We treated 20 patients with stage II seminoma by primary radiotherapy from 1971 to 1982. Median patient age was 38 years (range 26 to 52 years) and median disease width in the transverse plane was 11 cm. (range 5 to 25 cm.). Four tumors were 5 to 9 cm., 9 were 10 to 14 cm. and 7 were 15 cm. or more wide. Tumor was palpable in 13 patients. Generous radiation ports (such as wide hockey stick or whole abdomen) often followed by a boost to the area of bulky disease were used as primary therapy in all patients. Median tumor dose was 37.5 Gy. (range 13.3 to 56.7 Gy.). Supradiaphragmatic prophylactic radiation was given to 16 patients (median dose 26 Gy., range 12 to 37.3 Gy.). Median followup was 56 months, and all patients currently are free of disease except for 1 who died without disease more than 10 years after completion of all therapy. Mediastinal failure occurred in 2 of 4 patients without and 1 of 16 with mediastinal prophylaxis. All 4 patients with relapse are currently free of disease after salvage therapy. Five patients 16 to 42 years old (median age 30 years) received primary radiation therapy for stage III disease. The median size of abdominal disease was 10 cm. (range 5 to 17 cm.). Of the 5 stage III cancer patients 3 had supradiaphragmatic disease demonstrated only in supraclavicular lymph nodes and all 3 were continuously free of disease 115 to 136 months after therapy. The remaining 2 stage III cancer patients had supradiaphragmatic disease by virtue of bulky mediastinal disease with or without supraclavicular involvement. Both patients had relapse in-field and distantly, and they died of disease despite salvage chemotherapy. A total of 30 fields with bulky disease (greater than 5 cm.) was treated either primarily or at relapse among the 25 stages II and III cancer patients. In-field relapse occurred in 3 of 21 patients receiving less than or equal to 36 Gy. and 0 of 9 who received greater than 36 Gy. These results justify radiation therapy as an acceptable initial primary treatment modality for typical bulky stage II seminoma. Disease greater than 5 cm. should receive greater than 36 Gy. Prophylactic radiation to the mediastinum is effective. However, patients who have mediastinal failure often can be salvaged with chemotherapy and/or radiation, and prophylactic mediastinal radiotherapy may be associated with poor tolerance to salvage chemotherapy and other significant late effects.(ABSTRACT TRUNCATED AT 400 WORDS)     

Surveillance in Stage I Seminoma Patients: A Long-Term Assessment

Background

Following orchidectomy patients with stage I seminoma of the testis may be managed by either surveillance or adjuvant treatment. In view of the very high cure rate, it is important to analyse long-term outcomes.

Objective

: To provide data to advise patients on treatment burden and risk of recurrence associated with surveillance.

Design, setting, and participants

We audited the case records of 164 stage I seminoma patients registered at the Royal Marsden Hospital who were managed with a surveillance policy between 1980 and 2004 and followed for 1–20 yr (median: 13.5 yr).

Measurements

All treatments and patterns of relapse were documented.

Results and limitations

Twenty-two of 164 (13%) patients had relapsed at a median of 15.5 mo (range: 6–55 mo) from orchidectomy. Eighteen relapses appeared to be confined to the para-aortic nodes, but 6 of the 13 (46%) men treated with only para-aortic radiotherapy suffered a further relapse at another site. The disease-specific mortality was 1.3%. In the complete series of 164 patients, a total of 50 cycles of chemotherapy and 26 courses of radiotherapy was administered, representing an average of 0.46 “treatment units” per patient or an average of 3.45 treatment units per relapsing patient. The total number of treatment days was 390 d for radiotherapy and 133 d for chemotherapy, representing an average of 3.2 d per patient or 23.8 d per relapsing patient.This was a single-centre series extending back to the 1980s. Imaging and treatment protocols have advanced since then.

Conclusions

Surveillance postorchidectomy is a safe practice in the long term, and the majority of patients can avoid further treatment. There is the risk that those who do relapse face a higher burden of treatment than would be required if adjuvant treatment had been given.     

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.     

Stage IIA and IIB testicular seminoma treated post-orchiectomy with radiation therapy versus other approaches: a population-based analysis of 241 patients

Objectives

To evaluate post-orchiectomy utilization of radiation therapy (RT) versus other management approaches in stage IIA and IIB testicular seminoma patients.

Materials and Methods

Two hundred and forty-one patients with stage IIA and IIB testicular seminoma were identified between 1988 and 2003 using the Surveillance, Epidemiology, and End Results (SEER) database.

Results

Median follow-up was 10 years. Patients with stage IIA disease underwent RT more frequently than those with stage IIB disease (72% vs. 46%, respectively; P<0.001). There was no significant change in RT utilization for stage IIA or IIB disease between 1988 and 2003 (P = 0.89).

Conclusions

Between 1988 and 2003, stage IIA patients underwent RT more often than stage IIB patients in the United States. There was no significant change in RT utilization for stage IIA or IIB disease during this time period. Based on reports describing excellent progression-free survival with cisplatin-based chemotherapy, this approach has increased in popularity since 2003 and may eventually become the most popular treatment approach for both stage IIA and IIB testicular seminoma.     

Prognostic factors in seminomas with special respect to HCG: results of a prospective multicenter study. Seminoma Study Group

OBJECTIVE: In a prospective multicenter trial, it was our intention to elucidate clinical prognostic factors of seminomas with special reference to the importance of human chorionic gonadotropin (HCG) elevations in histologically pure seminomas. METHODS: Together with 96 participating urological departments in Germany, Austria, and Switzerland, we recruited 803 seminoma patients between 1986 and 1991. Out of 726 evaluable cases, 378 had elevated, while 348 had normal HCG values in the cubital vein. Histology was reviewed by two reference pathologists. HCG levels were determined in local laboratories and in a study laboratory. Standard therapy was defined as radiotherapy in stages I (30 Gy) and IIA/B (36 Gy) to the paraaortal and the ispilateral (stage I) and bilateral (stage IIA/B) iliac lymph nodes; higher stages received polychemotherapy and surgery in case of residual tumor masses. Statistics included chi-square tests, linear Cox regression, and log-rank test. RESULTS: The HCG elevation is associated with a larger tumor mass (primary tumor and/or metastases). HCG-positive and HCG-negative seminomas had no different prognostic outcome after standard therapy. The overall relapse rate of 6% and the survival rate of 98% after 36 months (median) indicate an excellent prognosis. The calculation of the relative risk of developing a relapse discovered only stage of the disease and elevation of the lactate dehydrogenase concentration and its prolonged marker decay as independent prognostic factors for seminomas. A more detailed analysis of the prognostic significance of the stage revealed that the high relapse rate in stage IIB seminomas after radiotherapy (24%) is responsible for this result. CONCLUSIONS: We conclude that HCG-positive seminomas do not represent a special entity. Provided standard therapy is applied, HCG has no influence on the prognosis. Patients with stage IIB disease should be treated with chemotherapy because of the demonstrated higher relapse rate outside the retroperitoneum.     

Guidelines for the diagnosis and therapy of testicular cancer and new developments

The guidelines of testicular cancer were elaborated and agreed upon interdisciplinarily. Standard therapy of stage I seminoma is infradiaphragmatic radiotherapy. Possible alternatives are adjuvant carboplatin therapy (still in test procedure) and, in case of lacking risk factors, the watch-and-wait strategy. If small metastases of lymph nodes exist, radiotherapy requires a higher dose and a larger beam field. Standard therapy in clinical stage IIC-III is cisplatin-based multidrug chemotherapy. In regard to nonseminomatous germ cell tumor there are no universal recommendations: retroperitoneal lymphadenectomy (RLA) with protection of ejaculation function, watch-and-wait strategy as well as adjuvant chemotherapy have the same cure rate but differ in relapse rate and morbidity. Knowing the crucial risk factors - depending on the expected relapse rate - it will be possible to recommend adjuvant chemotherapy or wait-and-see strategy in the future. In case of lymph nodes up to 5 cm, three different therapeutic strategies are possible. They reach the same cure rate, but are associated with different morbidity: primary nerve-sparing RLA plus adjuvant chemotherapy, primary nerve-sparing RLA without adjuvant chemotherapy, and primary chemotherapy. Advanced stages are related to three different groups in reference to their prognosis. At present, they are still treated with three or four cycles of PEB. In current protocols, patients with 'poor prognosis' receive high-dose therapy afterwards. These results have to be taken in consideration when updating the guidelines. The present guidelines also give notes for the therapy of TIN, residual tumor resection (RTR), management of CNS metastases, and therapy of recurrences. Copyright Copyright 1999 S. Karger AG, Basel     

No adjuvant chemotherapy in selected patients with pathologic stage II nonseminomatous germ cell tumors of the testis

In a previous report on patients with resected stage II nonseminomatous germinal cell testis tumors the findings of retroperitoneal metastases larger than 5 cm., macroscopic extranodal spread and tumor invasion into retroperitoneal veins (pathologic stage IIC) almost invariably were associated with relapse and poor survival in the absence of adjuvant chemotherapy, while postoperative cisplatin, vinblastine and bleomycin therapy was effective in preventing relapses in all cases. From February 1980 to January 1982, 40 consecutive patients underwent retroperitoneal lymphadenectomy for stage II disease. Only patients with pathologically assessed stage IIC cancer received 4 cycles of adjuvant cisplatin, vinblastine and bleomycin, while those with pathologic stages IIA and IIB disease, with or without microscopic extracapsular extension of the tumor, received no further therapy and were followed carefully at monthly intervals. After a median followup of 26 months or more relapses were noted in none of the 14 treated patients compared to 9 of 26 untreated patients (35 per cent). Of the latter 9 patients 8 (89 per cent) had continuous complete remission after salvage therapy and 39 of 40 patients (97.5 per cent) currently are free of disease. No difference was observed in the relapse rate and survival between patients with stages IIA and IIB disease. We conclude that patients with pathologic stages IIA and IIB disease can be treated safely only at the time of relapse, while the usefulness of adjuvant chemotherapy has been confirmed in those with stage IIC cancer.     

Stadienspezifische Therapie testikulärer Keimzelltumoren

Testicular germ cell tumours (GCT) represent the most common solid neoplasm of young men aged 20–40 years with an increasing incidence in Western countries during the last 50 years. It is mandatory for all physicians involved in the primary care of testis cancer patients to adhere to the guidelines of stage-specific treatment in order not to impair the high cure rate of about 90% and to prevent long-term toxicities due to inadequate therapy. Risk-adapted therapeutic options in stage I seminoma include active surveillance, retroperitoneal radiation therapy (RT) with 20 Gy or carboplatinum monotherapy depending on the presence of the risk factors tumour size > 4 cm and rete testis invasion. Retroperitoneal RT represents the standard therapeutic approach in stage IIA seminoma, whereas RT and PEB chemotherapy are alternative treatment options in stage IIB tumours. Primary chemotherapy with 3–4 cycles PEB according to the IGCCCG criteria is the treatment of choice in metastatic seminomas ≥ stage IIC. In clinical stage I NSGCT active surveillance is the treatment of choice in low-risk patients, and primary chemotherapy with 1–2 cycles PEB is the preferred treatment for high-risk patients. Treatment of metastatic GCT is performed with 3–4 cycles PEB chemotherapy and postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in cases of residual disease according to the IGCCCG risk classification. PC-RPLND is best performed in experienced centres due to the complex nature of surgery and the necessity for adjunctive surgery in 25% of the patients. PC-RPLND, primary treatment of patients with intermediate and poor prognosis and salvage therapy should be performed in tertiary referral centres only.     

Adjuvant chemotherapy in non-seminomatous testis cancer: "mini-VAB" regimen: long-term followup

Since 40 to 50 per cent (range 20 to 80 per cent) of patients with stage II non-seminomatous germ cell tumors of the testis suffer relapse after orchiectomy and retroperitoneal lymph node dissection, relatively non-toxic adjuvant chemotherapy (consisting of vinblastine, actinomycin D, bleomycin and chlorambucil) was given to 62 patients after lymphadenectomy. Of these patients 82 per cent remained free of disease with a 4-year median followup and 18 per cent had relapse. Retrospective analysis reveals that no patient (0 of 33) with stage IIA and 38 per cent (11 of 29) with stage IIB disease had relapse. Patients with histologic evidence of extranodal extension of disease (N3 category) had the highest relapse rate (62 per cent). Based on our experience we recommend that patients with resected stage IIB disease, particularly those with extranodal extension of tumor, receive aggressive adjuvant chemotherapy.     

Adjuvant chemotherapy of metastatic stage II nonseminomatous testis tumor.

In a prospective randomized trial, 225 patients with stage IIB nonseminomatous testis tumor after radical retroperitoneal lymph node dissection received 2 versus 4 courses (arms 1 and 2, respectively) of adjuvant chemotherapy with cis-platinum, vinblastine and bleomycin. With a median followup of 43 months, a total of 7 relapses occurred; 6 in arm 1 and 1 in arm 2. Three patients died: 2 during adjuvant chemotherapy and 1 of progressive disease. The difference in relapse rates between arms 1 and 2 is not statistically significant. Patient compliance differed: chemotherapy was administered according to protocol in 83% and 50% of the cases in arms 1 and 2, respectively. Most frequent side effects observed were nausea, vomiting and alopecia. No significant differences regarding these or other side effects were obtained. Patients with stage IIB nonseminomatous testis tumor after retroperitoneal lymph node dissection are treated sufficiently with 2 courses of adjuvant cis-platinum-containing chemotherapy.     

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.     

Spermatocytic seminoma: a review

OBJECTIVE: Spermatocytic seminoma is a rare testicular tumour that has an extremely low rate of metastasis. We present a review of the management of this malignancy at our institution. METHOD AND MATERIALS: Between 1981 and 1999, 771 patients were treated at our institution for testicular seminoma. Of these, 13 had spermatocytic seminoma; one was excluded as he had treatment elsewhere. All patients were initially diagnosed at other hospitals and subsequently referred for management and had their pathology reviewed locally prior to any treatment. RESULTS: All patients had stage I disease, 5 patients received radiotherapy to the para-aortic and pelvic nodes, the other 7 were followed on a surveillance program. The median age was 62 years. With a median follow-up of 8.5 years no relapses were observed. Some patients exhibited adverse histological features associated with increased risk of relapse in seminoma including rete testis invasion and large primary tumour size. CONCLUSIONS: Spermatocytic seminoma may occur in younger patients and may not be restricted to the older population as commonly reported. Surveillance following orchidectomy is the preferred management option.