Management preferences following radical inguinal orchidectomy for Stage I testicular seminoma in Australasia

A survey to evaluate the preferred patterns of management of Stage I seminoma was conducted during March 2001. The questionnaire was distributed by the Royal Australian and New Zealand College of Radiologists to all qualified radiation oncologists, 74 out of 170 responded. All performed a staging CT scan of the abdomen and pelvis. Thoracic imaging consisted of either chest X‐ray (29%) or chest CT (38%) while 33% performed both. Fifty‐four percent of radiation oncologists discussed surveillance with their patients but estimated that 5% or less would choose this option. The most commonly prescribed dose was 25 Gy in 15 or 20 fractions (79%). Sixty‐five percent of respondents treated the para‐aortic (PA) nodes alone. Forty‐two of 48 clinicians treating the PA field reported a change in practice after publication of the Medical Research Council study in 1999. Of these, 40 and 23% perform CT scans of the pelvis annually and every 6 months. Thirty‐one percent did no follow‐up CT scan. Compared to a similar survey from North America, we are more likely to use PA fields and less likely to discuss surveillance. As in the USA, and in contrast to Canada, few patients choose surveillance. There is no consensus regarding the frequency of follow‐up scans in either North America or Australasia.     

Management of stage I testicular seminoma

Adjuvant treatment options for stage I seminoma include surveillance, radiation, and hemotherapy. Despite excellent results for both adjuvant chemotherapy and radiotherapy, many concerns have been raised in regards to the potential long-term toxicities of these treatments. To minimize the burden of treatment, there has been a shift away from adjuvant treatments for stage I testicular seminomas toward surveillance protocols for seminoma survivors. This article reviews the evidence for all adjuvant treatment options for stage I testicular seminomas with a particular focus on surveillance.     

Treatment-related ureteral cancer following stage II testicular seminoma

We report two cases of left ureteral carcinoma that may have been related to prior radiotherapy and anticancer chemotherapy for stage II testicular seminoma. Both patients had undergone radiotherapy (60 Gy) and cisplatin-based chemotherapy, one 17 years before the present presentation and the other 24 years earlier. They underwent retroperitoneoscopy-assisted left nephroureterectomy under a diagnosis of left upper ureteral cancer, established by means of ureteroscopy and brush biopsy. The urologic and radiologic outcomes have been satisfactory after more than 2 years of follow-up. Recently, some investigators have reported that testicular cancer survivors are at significantly increased risk of solid tumors for at least 35 years after treatment. Young patients may have a high risk of cancer when they reach an advanced age.     

Surveillance after orchidectomy for patients with clinical stage I nonseminomatous testis tumors.

PURPOSE: This study was designed to determine the proportion of patients with clinical stage I nonseminomatous germ cell tumors of the testis (NSGCTT) managed with surveillance after orchidectomy who have more advanced disease and, therefore, require further treatment, the time to progression, the sites of progression, and the efficacy of treatment delayed until progression was recognized. PATIENTS AND METHODS: One hundred five patients were observed prospectively without further treatment after orchidectomy and full clinical staging. Treatment was given immediately upon detection of marker-positive, clinical, or radiologic evidence of disease. RESULTS: Thirty-seven patients (35.2%) have required further therapy for disease progression, occurring from 2 to 21 months after diagnosis. Thirty-six patients have been successfully treated. Overall, 104 patients (99%) remain alive and free of disease at 12 to 121 months after orchidectomy. Progression occurred in the retroperitoneum in 25 of 37 patients who developed further disease on surveillance. The presence of vascular invasion in the primary tumor was predictive of an increased risk of progression. CONCLUSION: Surveillance is a valid alternative to immediate retroperitoneal lymph node dissection in patients with clinical stage I NSGCTT but should be recommended only under the close supervision of physicians experienced in the diagnosis and treatment of testicular cancer.     

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, 2 and 5 and 2 and 5 and 2 and 5 and 相似文献   

Alternatives to the radiotherapy of stage I testicular seminoma

Adjuvant irradiation is currently the most frequently used standard treatment for the clinical stage I seminoma (CSI) following orchiectomy. There is a potential carcinogenic risk with irradiation that prompted a search for alternative adjuvant treatment approach. The cure in CSI seminoma patients can be achieved with surveillance or chemotherapy. Surveillance takes into account the fact that 80% of patients do not need any adjuvant treatment after orchiectomy and are overtreated by adjuvant irradiation. Recently, one cycle of adjuvant carboplatin has been proven in a prospective randomized trial. Taken together, all three treatment options are acceptable standard strategies for the management of patients with CSI. Finally, the experience with surveillance strategy allowed an in-depth meta analysis of factors predictive for relapse discrimining the patients who are in need of post orchiectomy adjuvant treatment from those who safety can be followed by the surveillance strategy. However, this risk adapted approach is still under prospective evaluation.     

Exploration of treatment options for the management of stage I testicular seminoma

Seminoma is the epitome of a highly treatable neoplastic malignancy. Approximately 80% of patients presenting with seminomatous germ cell tumors are diagnosed with stage I disease. Men with clinical stage I seminomas have an excellent chance of achieving a cure irrespective of the treatment option selected. With such high disease-specific survival rates, attention has turned to reducing treatment-related morbidity. Adjuvant radiotherapy to the para-aortic retroperitoneal lymph nodes in conjunction with orchidectomy has been the standard treatment since the mid-1990s. There is some evidence, however, suggesting potential deleterious long-term sequelae from radiation treatment. Adjuvant chemotherapy has gained support as an acceptable adjuvant treatment strategy for stage I seminoma. While long-term studies are limited, short-term data regarding the therapeutic efficacy of single-agent carboplatin are promising. Finally, surveillance following orchidectomy is an attractive option for motivated patients interested in avoiding immediate adjuvant therapy. It may be the optimal choice for compliant men who are able to handle the mental burden of not receiving active treatment.     

Transient neurological adverse effects following low dose radiation therapy for early stage testicular seminoma.

BACKGROUND AND PURPOSE: The aim of this study was to estimate the rate of neurological adverse effects following radiotherapy for testicular seminoma and to disclose possible dose-related effects. PATIENTS AND METHODS: All seminoma patients (n=346) treated 1980-2001 at our department with radiotherapy as the only treatment modality following orchiectomy constitute the study group (median follow-up 10 years). Since 1980, clinical data including possible side effects have systematically been recorded in these patients. These records were used to identify men with possible neurological adverse effects. Univariate logistic regression was used to estimate dose-related effects. RESULTS: Overall, 11 men (3.2%) with neurological symptoms probably related to radiotherapy were identified. Seven men treated with 25.2-36 Gray presented with sensory symptoms about 2 months following radiotherapy. These symptoms resolved in all but one after 1-3 months. The remaining four men (dose 36-40 Gray) had motor impairment which lasted at least one year, but none had persistent pareses at long-term follow-up. There was a statistically significant (p=0.02) increase in rate of motor symptoms with higher dose. CONCLUSIONS: Although motor impairment is unlikely to occur at current standard doses for seminomas, physicians should be ware of the sensory symptoms these men may exhibit.     

Exploration of treatment options for the management of stage I testicular seminoma

Seminoma is the epitome of a highly treatable neoplastic malignancy. Approximately 80% of patients presenting with seminomatous germ cell tumors are diagnosed with stage I disease. Men with clinical stage I seminomas have an excellent chance of achieving a cure irrespective of the treatment option selected. With such high disease-specific survival rates, attention has turned to reducing treatment-related morbidity. Adjuvant radiotherapy to the para-aortic retroperitoneal lymph nodes in conjunction with orchidectomy has been the standard treatment since the mid-1990s. There is some evidence, however, suggesting potential deleterious long-term sequelae from radiation treatment. Adjuvant chemotherapy has gained support as an acceptable adjuvant treatment strategy for stage I seminoma. While long-term studies are limited, short-term data regarding the therapeutic efficacy of single-agent carboplatin are promising. Finally, surveillance following orchidectomy is an attractive option for motivated patients interested in avoiding immediate adjuvant therapy. It may be the optimal choice for compliant men who are able to handle the mental burden of not receiving active treatment.     

Results of radiotherapy for stage II testicular seminoma

Of 53 patients with Stage II seminoma treated with radiotherapy between 1970 and 1984, 9 (17%) relapsed, 5 (9%) died of testicular cancer and 1 (2%) died of intercurrent disease. Relapse rates for IIA, IIB and IIC were 11, 18 and 28% respectively. Supradiaphragmatic irradiation was not advantageous; of 22 patients receiving infradiaphragmatic irradiation, 3 (14%) relapsed, compared with 6/31 (19%) of those who had supra- and infradiaphragmatic irradiation. Despite the radioresponsiveness of seminoma, 50% of IIC patients had residual masses 4 months after radiotherapy and 20% at one year, however, this finding did not predict eventual outcome. Serum human chorionic gonadotrophin (HCG) levels were raised prior to radiotherapy in 3/26 (11.5%) Stage IIA and IIB patients and 3/10 (30%) IIC patients. However, this did not influence the outcome of radiotherapy since only 0/6 patients with raised HCG levels relapsed compared with 7/30 (23%) of those with normal levels. Analysis of the pattern of relapse together with the fact that 2/6 patients who had the extent of tumour defined at laparotomy and/or who had total abdominal irradiation relapsed, suggests that further refinement of radiotherapy is unlikely to improve the results of treatment for IIC patients and that chemotherapy should be considered the treatment of choice.     

Management options for stage I seminoma

Stage I seminoma is the most common clinical scenario among patients with testicular cancer. Following orchiectomy, various treatment alternatives (adjuvant radiotherapy, surveillance, chemotherapy) can be offered that yield similar efficacy results and definitive cure is the rule. However, there is no consensus on the optimal management choice and considerable debate has been raised in recent years. The pros and the cons associated with each therapy, as well as their long-term outcomes are discussed in this review. Overall burden of treatment needed, therapy-related morbidity, economic costs, quality of life issues and patient preferences should all be considered. Refinement in the knowledge of predictive factors for relapse and mounting experience with both surveillance and adjuvant chemotherapy have led to consideration of risk-adapted treatment strategies as an alternative to standard radiotherapy. Although this model needs to be improved and validated, active close surveillance for low-risk patients and adjuvant therapy for those uncompliant or at higher risk of relapse seem to be acceptable options for patients with stage I seminoma.     

Ⅰ期睾丸精原细胞瘤术后三维适形放疗与常规放疗的剂量学对比分析

目的 比较睾丸精原细胞瘤术后行三维适形放疗（3D CRT）与传统放疗照射靶区及周围正常组织的剂量学差异。方法 对12例确诊的Ⅰ期睾丸精原细胞瘤患者经腹股沟高位睾丸切除术后行术后放疗。利用治疗计划系统（TPS） 为每例患者设计3D-CRT计划和虚拟常规计划（VCP）。应用剂量体积直方图（DVH）比较两种治疗计划的靶区适形度指数（CI）、不均匀性指数（HI）和正常组织受量。结果 3D-CRT计划的CI及HI均优于VCP计划,CI值分别为0.88±0.06和0.82±0.05,HI值分别为0.15±0.03和0.29±0.11（P＜0.05）。3D-CRT计划的照射体积（IV）显著低于VCP计划,分别为（5268.20±1018.60）cm³和（5970.24±1471.49）cm³（P＜0.05）。3D-CRT计划的小肠平均剂量以及V15低于VCP计划（P＜0.05）,睾丸的平均剂量低于VCP计划（P＜0.05）。结论 常规照射野是根据患者的骨性标志确定下来,未必适应于每个患者,3D-CRT更加个体化。此外3D-CRT在靶区覆盖率、剂量适形度及剂量均匀性方面均优于虚拟常规计划,同时降低了小肠低剂量照射体积和睾丸的散射剂量,这些剂量学方面的优势能否转换成临床受益还需要进一步临床验证。     

Clinical stage I seminoma

Stage I seminoma is highly curable. There are different treatment options for this disease: radiotherapy, surveillance and chemotherapy. In recent years, adjuvant chemotherapy in particular has been extensively evaluated. This paper offers suggestions about the advantages and disadvantages of the different strategies, which will be discussed considering prognostic factors; future perspectives will also be evaluated. Through a review of the literature and their clinical experience, the authors outline the importance of prognostic factors in the management of patients suffering from seminomas. Although no treatment modalities have demonstrated survival advantages over others, acute and late side effects, acceptability and quality of life are the main elements of comparison between them. Our findings support the hypothesis that the final decision about the treatment of these tumors depends essentially on three different aspects: risk factors, the patient's own preferences, and single-center expertise. These aspects should play a fundamental role in the final decision-making.     

Evidence-based guidelines for following stage 1 seminoma

BACKGROUND: The authors developed evidence-based guidelines for a follow-up schedule after orchiectomy for stage 1 seminoma. Required investigations, frequency of assessment, overall duration of follow-up, and management strategies were identified. METHODS: A systematic review of the literature was performed of prospective studies in stage 1 seminoma. Studies published after 1980 were considered eligible for inclusion. Data extracted included relapse-free rates, number of patients at risk, and relapse locations. Five strategies were identified: Surveillance, Extended-Field Radiotherapy, Para-aortic Radiotherapy, and either 1 or 2 cycles of Carboplatin Chemotherapy. For each strategy, Kaplan-Meier relapse-free estimates were used to calculate weighted-mean cumulative hazards of relapse over time. These were used to calculate semiannual weighted-mean relapse hazards. RESULTS: Seventeen prospective studies with a total of 5561 patients were identified. Actuarial data on relapse was available in 5013 (90.1%) patients, and 92.9% of all relapses had location data reported. Annual hazard rates for relapse were determined. CONCLUSIONS: Evidence-based recommendations for follow-up frequency based on risk of relapse were formulated. The authors suggested 3 times per year when the risk is >5%, 2 times per year when the risk is 1% to 5%, and annually until the risk is <0.3%. Investigations should reflect location(s) at risk of relapse and include computed tomography of the abdomen and pelvis for surveillance and adjuvant carboplatin, whereas for para-aortic radiotherapy, pelvic computed tomography alone is required. These recommendations offer the possibility of maximal patient convenience and optimal healthcare resource allocation without compromising disease control.     

Post-orchiectomy management in stage I testicular seminoma: Elective irradiation or surveillance?

Fifty-six patients with stage I testicular seminoma were treated at this institute between January 1982 and December 1988. Post-orchiectomy elective radiotherapy to ipsilateral iliac-inguinal and para-aortic lymph nodes was delivered in 54 cases. An overall 3 year survival rate of 96% was observed in this series. Four patients (7%) relapsed (one junctional recurrence in iliac node region, two mediastinal/hilar nodes and one skeletal metastasis). Salvage chemotherapy proved successful in two out of three cases with nodal relapse. No dose limiting acute or late radiation related complications were noticed. No definite correlation was found between the patients who relapsed and various known adverse prognostic factors. We recommend elective irradiation of the draining lymph nodes in stage I seminoma, particularly at centres where surveillance is not feasible.     

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.