Late relapse of testicular seminoma in the posterior mediastinum

Patients with testicular seminoma are usually cured if they survive disease-free for 5 years after therapy. Late relapse can also occur but is rare. In particular, relapse of testicular seminoma in the form of a large mediastinal mass is extremely rare. We present here a 37-year-old man with a late relapse of a large testicular seminoma in the posterior mediastinum, encasing the descending thoracic aorta, and compressing the left atrium and left main bronchus on computed tomography (CT) and positron emission tomography (PET).     

Genome damage in testicular seminoma patients seven years after radiotherapy

Abstract

Purpose: Testicular seminoma cancer incidence has significantly increased over the last few decades, and although it is successfully treated by radiotherapy, long-term health risks are still unclear. The aim of the study was to show long-term genome damage in patients with seminoma after radiotherapy.

Materials and methods: Chromosome aberration (CA) and micronucleus (MN) assays seven years after radiotherapy with a total dose of 25 Gy were conducted in 10 testicular seminoma patients aged 23–49 years and results were compared with 10 healthy control subjects matched for age and smoking status.

Results: Although mean CA frequency did not deviate from control values, significantly increased frequencies of dicentrics, double minutes, and ring chromosomes were detected in seminoma patients. MN frequency in binuclear lymphocytes of patients was similar to controls (4.60/1000 vs. 5.82/1000, respectively). Significantly higher MN frequency was detected in mononuclear lymphocytes of patients than in controls (2.55/1000 vs. 0.73/1000, respectively). Average percentage of centromere-positive MN was 62.6% in seminoma patients.

Conclusion: This study shows the persistence of unstable CA in seminoma patients seven years after radiotherapy and the relevance of long-term follow up. MN frequency in mononuclear lymphocytes was shown to be relevant biomarker of long-term genome damage.     

The prognostic significance of anaplastic variants in patients with testicular seminoma subjected to exclusive radiotherapy

Three-hundred and sixty-six patients affected with seminoma testis (234 stage I, 85 stage II low, 47 advanced diseases) were treated between January 1968 and December 1985. Overall incidence of anaplastic lesions (43 patients) was 12%, progressively increasing with stage of the disease (9% stage I, 13% stage II low, 21% advanced disease). Only 343 patients submitted to exclusive curative/prophylactic radiotherapy were studied: 35 of them were anaplastic (22 stage I, 11 stage II low, 2 advanced disease). Radiation therapy was always performed regardless of the histologic subtype. Recurrences occurred in 14% of anaplastic tumors (5/35) and in 7.5% of classical seminomas (23/308). There was no statistically-significant difference between global and stage-by-stage failures. After literature review and complete analysis of the patterns of recurrence, the authors stress the lack of evidence suggesting a different radioresponsiveness of anaplastic versus classical seminomas; nonetheless, a more accurate staging is recommended for anaplastic variants, since they tend to appear in the advanced stages of the disease.     

The role of bipedal lymphangiography in testicular seminoma

Determining the extent of intra-abdominal spread of testicular seminoma by radiographic studies is an essential step in planning rational treatment following orchidectomy. CT scanning is generally accepted as being superior to lymphangiography in assessing the retroperitoneal space. We reviewed the relative contribution of these two procedures in a retrospective analysis of 73 consecutive patients with testicular seminoma managed at Westmead Hospital between January 1980 and September 1987. Abdominal CT scans and bipedal lymphangiography (LAG) were carried out in 72 and 51 patients respectively, 50 patients undergoing both procedures. We found concordance between the two techniques to be 88%. Upstaging occurred in 5 patients using CT (10%), 7 patients using LAG (14%), and in 8 patients (16%) when both tests were utilised. Four patients were upstaged by both techniques while the remaining 4 patients were upstaged using one technique alone. Serum beta-HCG was not a reliable screen for residual disease. Residual disease in the few patients with an elevated serum beta-HCG was easily detected by CT scanning. We conclude that there is a continuing role for LAG in assessing patients with clinical Stage I seminoma when the abdominal CT scan is equivocal or normal.     

'Watch policy' in patients with suspected stage I testicular seminoma: CT as a sole staging and surveillance technique

A study was undertaken to assess the role of computed tomography (CT) as the sole imaging technique for the staging and surveillance of patients with stage I testicular seminoma. Of the 15 patients studied, five (33%) relapsed. This relapse rate differs from other studies. The reasons for this are discussed.     

Single inguinal node metastasis of stage I testicular seminoma shown by scrotal scintigraphy, 6 months following radical orchiectomy

Lymphatic drainage of the testes is known to follow a predictable pathway that usually involves the retroperitoneal, paraaortic, paracaval and interaortocaval nodal chains. Herein we report the case of a 41 years old man with a stage I testicular seminoma, with an unexpected inguinal lymph node metastasis. During his routine follow-up visit, 6 months after radical orchiectomy, a spherical mass in the right inguinal region was palpated. Thoraco-abdominal CT did not reveal any evidence of retroperitoneal enlarged lymph nodes or distant metastases, but showed a 2cm right inguinal mass. Scrotal scintigraphy with technetium-99m pertechnetate was performed in order to evaluate the local vascularity of the right inguinal area. The angiographic phase (0-1min) and the blood pool images at 15, 30, 45 and 60min revealed high uptake in the right inguinal region, suggesting a hyperemic mass suspicious for tumor recurrence. The excised mass was found to be an enlarged lymph node infiltrated with seminoma. The patient received adjuvant radiotherapy to which he showed a complete response and has been disease free at 2 years follow-up. In conclusion, in the case presented scrotal scintigraphy showed a hyperemic mass at the right inguinal region that proved to be the sentinel node of a stage I testicular seminoma and was treated accordingly.     

The impact of treatment errors on post-operative radiotherapy for testicular tumours

Twenty-four patients receiving post-operative radiotherapy for testicular tumours have been studied to assess the impact of treatment errors. Regular treatment verification radiographs were performed and compared with simulator planning radiographs. It was demonstrated that lymph nodes in the area most at risk, i.e., para-aortic nodes at L1 to L3 on the ipsilateral side, were inadequately irradiated on 10% of treatments, and that at least one lymph node miss was recorded in 12 of the 24 patients. These results are considered to be a minimum estimate. Mostly para-aortic fields 8.0 cm wide were used, but it was shown that the number of lymph-node misses could have been substantially reduced by using fields 9.0 cm wide, whilst the consequent increase in irradiated kidney volume was considered acceptable.     

Treatment of subdiaphragmatic lymph node metastases of primary testicular seminoma (stage II)

From January 1968 through December 1985, 123 patients with subdiaphragmatic lymph node metastases from testicular seminoma were observed. Eighty-five patients presented with metastases not bigger than 5 cm (stage II low), and they were all treated with radiotherapy (target dose: 35-45 Gy). Out of 38 patients with advanced retroperitoneal disease (because of metastases bigger than 5 cm: stage II, bulky), 18 were treated with radiotherapy, 14 with chemotherapy, and 6 with combined radiotherapy and chemotherapy; moreover, 14 out of 38 patients underwent surgical treatment (whole/partial lymph node resection). Actuarial relapse-free survival rate has proven higher for "low" patients than for "bulky" ones, both at 5 years (85.4% versus 75.8%) and at 10 years (83.5% versus 75.8%). On the contrary, overall survival has been higher for "low" patients at short-term follow-up only (90.4% vs 83.9% at 5 years), while long-term follow-up (10 years) has proven the same in both groups. Relapses (22 cases) occurred within 2 years in 75% of cases, and within 3 years in 90%. Overall incidence of lymph node recurrence has been 10.6%, higher in "bulky" patients (13.3% if treated with radiotherapy alone and 21.4% if treated with chemotherapy and/or surgery). Distant metastases occurred in 8.1% of cases. Long-term salvage treatment by chemotherapy was performed on 1/13 failures in stage II "low" patients and in 3/9 failures in stage II "bulky" patients. Four patients underwent effective salvage therapy in the "low" group, 3 by radiotherapy and 1 by surgery. The authors stress how curative radiotherapy appears to be the best treatment for retroperitoneal lymph node metastases less than 5 cm diameter, while chemotherapy is still to be demonstrated to yield better results than radiotherapy as first treatment for patients with advanced abdominal disease.     

Role of radiotherapy in the treatment of seminoma of the testis

From 1965 through 1988, 113 patients affected with testicular seminoma were treated at the Dept. of Radiotherapy, University "La Sapienza", Rome, Italy. Mean age of the patients was 38 years; in 70 cases tumor developed in the right testis and in 43 in the left one. In 9 patients underlying cryptorchidism was observed. All cases underwent radical orchiectomy. Histology diagnosed anaplastic seminoma in 5 cases and pure seminoma in all the other patients. Structures were involved in 7 cases. Eighty-four patients were in stage I, 20 in stage IIA, 4 in IIB, 4 in IIIA, and 1 in stage IIIB. All patients staged as I and IIA were treated with exclusive radiotherapy on paraaortic lymph nodes and inguinal and iliac lymph nodes of the involved sites (total doses: 28-35 Gy in stage I and 34-40 Gy in stage IIA). Before 1970 these patients underwent prophylactic irradiation of mediastinum and of left supraclavicular lymph nodes (total dose: 25-28 Gy). Patients in stage IIB were administered subdiaphragmatic lymph nodes irradiation with inverted-Y field (total dose: 36-45 Gy). Two cases were irradiated also on mediastinum and left supraclavicular lymph nodes, and 2 received two cycles of polychemotherapy (PVB) before irradiation. Patients in stage IIIA underwent sub-/supra-diaphragmatic irradiation (total dose: 40-45 Gy, and 40-42 Gy). The case in stage IIIB underwent palliation chemotherapy and local irradiation. All cases in stages I, IIA and IIB obtained complete remission. Three cases of the 4 in stage IIIA obtained complete remission (75%), while 1 (25%) progressed and died 8 months after diagnosis; the only case in stage IIIB progressed and died after 7 months of follow-up. Two cases in stage I recurred (2.4%), 1 in the mediastinum and 1 in the left supraclavicular lymph nodes. Both were cured with salvage radiation therapy. Toxicity related to treatment was low. Two cases in stage I developed secondary malignant neoplasms, at 4 and 34 months of follow-up, respectively.     

Radiotherapy of testicular seminoma. Stages I and II A, B

From June 1977 through June 1987, 46 patients (36 evaluable) affected by stage I and II non-bulky testicular seminoma were treated with postoperative telecobaltotherapy (TCT). In stage I seminomas, radiotherapy was extended to the omolateral iliac and the para-aortic areas (total dose: 30 Gy over 4 weeks). In stage II seminomas, the subdiaphragmatic lymph nodes were irradiated with 40-45 Gy over 5-6 weeks; after an interval of one month the subdiaphragmatic lymph nodes were irradiated again with a total dose of 25 Gy over 3.5 weeks. Minimal follow-up lasted two years and maximum ten years (average: 5.5). Two (5.5%) recurrences occurred, but salvage radiotherapy and salvage chemotherapy respectively allowed a complete permanent remission. One patient died from a different neoplasia with no evidence of testicular involvement. The 5-year actuarial survival is 96.6 +/- 3.4. In 20% of the patients the side effects were nausea and/or vomiting, easily controlled. No late complications were observed.     

The usefulness of gallium-67 citrate scanning in testicular seminoma

An analysis of 77 consecutive patients with a histologic diagnosis of seminoma testis, assessed and treated at the Cross Cancer Institute between 1977 and 1982, is presented. Ga-67 citrate was first used in the assessment of patients with malignant testicular tumors in 1973. Following three years of study that supported the observation of the gallium-avid nature of seminoma, gallium scans became routine in the initial staging assessment and were used also when recurrence was suspected. From 1977 through 1982, 72 patients with biopsy-proven seminoma testis were assessed initially for extent of disease by Ga-67 scanning. Comparison with intravenous pyelography and bipedal lymphography was possible for accuracy of tumor assessment. The scan sensitivity was 83%, and the specificity was 95%. During the same period, gallium was studied in nonseminomatous testicular tumors but the results were disappointing and its use was discontinued. The gallium-avid nature of seminoma testis may be useful in determining the extent of disease.     

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.     

Postoperative radiotherapy in the treatment of adenocarcinoma of the endometrium in pathological stage I

We report on 49 patients with pathologic stage I endometrial adenocarcinoma who underwent postoperative whole-pelvis irradiation (RT) (45-50 Gy in 5-6 weeks) from November 1981 to December 1988. RT was performed when one or more of the following unfavorable prognostic factors were discovered: myometrial infiltration greater than 1/3 (42 cases, or 85.7%), poorly-differentiated tumor (10, or 20.4%), tubaric angles involvement (4; or 8.2%), pelvic nodal metastases (1, or 2.0%). Five-year actuarial disease-free survival was 91.4%. After an average follow-up of 58 months, we observed recurrent disease in 4 patients (8.2%) (3 cases with distant metastases, 6.1%; 1 case with vaginal relapse, 2.0%). All recurrences were observed within 18 months from treatment and occurred only in patients with both myometrial infiltration greater than 1/3 and poorly or moderately differentiated tumor. The patient with vaginal relapse had a complete response after endocavitary curietherapy, but died later on from lung metastases. None of the treated patients experienced severe complications related to the treatment. Our results are comparable with those of the most recent literature, and confirm the good tolerance and efficacy of postoperative RT to prevent loco-regional relapses in early stage endometrial cancer with unfavorable prognostic factors.     

Feasibility of sentinel node lymphoscintigraphy in stage I testicular cancer

The aim of this study was to investigate the feasibility of lymphoscintigraphy for sentinel node identification in testicular cancer. Five patients with clinical stage I testicular cancer were prospectively included. A single dose of technetium-99m nanocolloid (mean dose 99 MBq, volume 0.2 ml) was injected into the funiculus in the first patient and into the testicular parenchyma in the following four patients. Dynamic lymphoscintigraphy was performed over 10 min, followed by early and late static images after 15 min and 2 to 24 h, respectively. Lymphoscintigraphy was followed by laparoscopic sentinel node biopsy on the same day in the last two patients using patent blue dye and an endoscopic gamma probe. The funicular administration route showed five hot spots in the right inguinal region after 2 h. Intratesticular administration resulted in sentinel node visualisation in three of the four patients. Dynamic images showed afferent lymphatic vessels to one sentinel node in the left para-aortic region in two patients and two sentinel nodes in the left para-aortic region in another patient. Sentinel nodes were intraoperatively identified in one of two patients who underwent laparoscopic exploration. It is concluded that lymphoscintigraphy for sentinel node identification is feasible in stage I testicular cancer using intratesticular radiocolloid administration.