BERKELEY, CA (UroToday.com) - Most clinical stage I testicular seminoma patients who relapse on post-orchiectomy surveillance can be salvaged.[1, 2] The MRC TE19/EORTC 30982 study showed that a single dose of carboplatin chemotherapy is non-inferior to para-aortic radiotherapy for clinical stage I testicular seminoma. However, the toxicity of carboplatin chemotherapy beyond 10 years is not well-defined. Dutch registries revealed a 15% cumulative incidence of second malignant neoplasms 25 years after subdiaphragmatic radiotherapy for testicular seminoma; this was 2.6 times higher than the incidence rate among those treated with inguinal orchiectomy alone.
Subdiaphragmatic radiotherapy also results in a two-fold or greater risk of cardiovascular disease beyond 15 years.[6, 7, 8] Validated predictive factors are needed to improve the applicability of risk-adapted chemotherapy or radiotherapy for clinical stage I testicular seminoma.[9, 10, 11, 12] Consequently, post-orchiectomy surveillance has become the preferred approach for clinical stage I patients.[13, 14, 15, 16, 17, 18] Nevertheless, many clinical stage I patients in the United States continue to undergo para-aortic radiotherapy. As a result, the Principles of Radiotherapy for Pure Testicular Seminoma Subcommittee of the National Comprehensive Cancer Network (NCCN) Testicular Cancer Panel developed evidence-based radiotherapy guidelines for clinical stage IA-IIB patients with the caveat that post-orchiectomy surveillance has become the preferred approach for clinical stage I patients.
With regard to clinical stage IIA-IIB testicular seminoma patients, the NCCN Clinical Practice Guidelines in OncologyTM recommend radiotherapy; alternatively, chemotherapy may be given for selected clinical stage IIB patients. Clinical studies [21, 22, 23] and a nodal-mapping study support raising the inferior border of dog-leg radiotherapy fields from the obturator foramen to the top of the acetabulum. Computed tomography-based radiotherapy improves target delineation and kidney and bowel shielding.[20, 25, 26] Anteroposterior (AP) and posteroanterior (PA) radiotherapy fields remain the standard beam arrangement since they deliver relatively low doses to the kidneys, liver, and bowel. The mean dose (Dmean) and dose delivered to 50% of the volume (D50%) of the kidneys, liver, and bowel are lower with 2 as opposed to 7 fields. As a result, the risk of a second cancer arising in the kidneys, liver, or bowel may be lower with three-dimensional conformal radiation therapy than with intensity modulated radiation therapy.
- Agarwala AK, Perkins SM, Abonour R, et al. Salvage chemotherapy with high-dose carboplatin and etoposide with peripheral blood stem cell transplant in patients with relapsed pure seminoma. Am J Clin Oncol 2011;34:286-288.
- Choo R, Thomas G, Woo T, et al. Long-term outcome of postorchiectomy surveillance for Stage I testicular seminoma. Int J Radiat Oncol Biol Phys 2005;61:736-740.
- Oliver RT, Mead GM, Rustin GJ, et al. Randomized trial of carboplatin versus radiotherapy for stage I seminoma: mature results on relapse and contralateral testis cancer rates in MRC TE19/EORTC 30982 study (ISRCTN27163214). J Clin Oncol 2011;29:957-962.
- Pectasides D, Pectasides E, Constantinidou A, et al. Stage I testicular seminoma: management and controversies. Crit Rev Oncol Hematol 2009;71:22-28.
- van den Belt-Dusebout AW, de Wit R, Gietema JA, et al. Treatment-specific risks of second malignancies and cardiovascular disease in 5-year survivors of testicular cancer. J Clin Oncol 2007;25:4370-4378.
- Haugnes HS, Wethal T, Aass N, et al. Cardiovascular risk factors and morbidity in long-term survivors of testicular cancer: a 20-year follow-up study. J Clin Oncol 2010;28:4649-4657.
- Huddart RA, Norman A, Shahidi M, et al. Cardiovascular disease as a long-term complication of treatment for testicular cancer. J Clin Oncol 2003;21:1513-1523.
- Zagars GK, Ballo MT, Lee AK, et al. Mortality after cure of testicular seminoma. J Clin Oncol 2004;22:640-647.
- Aparicio J, Maroto P, Del Muro XG, et al. Risk-adapted treatment in clinical stage I testicular seminoma: the third spanish germ cell cancer group study. J Clin Oncol 2011;29:4677-4681.
- Chung P, Warde P. Stage I seminoma: adjuvant treatment is effective but is it necessary? J Natl Cancer Inst 2011;103:194-196.
- Chung PW, Daugaard G, Tyldesle S, et al. Prognostic factors for relapse in stage I seminoma managed with surveillance: A validation study. J Clin Oncol 2010;18:suppl; abstr 4535.
- Tandstad T, Smaaland R, Solberg A, et al. Management of seminomatous testicular cancer: a binational prospective population-based study from the Swedish Norwegian testicular cancer study group. J Clin Oncol 2011;29:719-725.
- Bosl GJ, Patil S. Carboplatin in clinical stage I seminoma: too much and too little at the same time. J Clin Oncol 2011;29:949-952.
- Krege S, Beyer J, Souchon R, et al. European consensus conference on diagnosis and treatment of germ cell cancer: a report of the second meeting of the European Germ Cell Cancer Consensus Group (EGCCCG): part II. Eur Urol 2008;53:497-513.
- Motzer RJ, Agarwal N, Beard C, et al. Testicular cancer. J Natl Compr Canc Netw 2012;10:502-535.
- Schmoll HJ, Jordan K, Huddart R, et al. Testicular seminoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010;21 Suppl 5:v140-146.
- Warde P, Gospodarowicz M. Evolving concepts in stage I seminoma. BJU Int 2009;104:1357-1361.
- Wood L, Kollmannsberger C, Jewett M, et al. Canadian consensus guidelines for the management of testicular germ cell cancer. Can Urol Assoc J 2010;4:e19-38.
- Arvold ND, Catalano PJ, Sweeney CJ, et al. Barriers to the implementation of surveillance for stage I testicular seminoma. Int J Radiat Oncol Biol Phys 2012;84:383-389.
- Wilder RB, Buyyounouski MK, Efstathiou JA, et al. Radiotherapy treatment planning for testicular seminoma. Int J Radiat Oncol Biol Phys 2012;83:e445-452.
- Bamberg M, Schmidberger H, Meisner C, et al. Radiotherapy for stages I and IIA/B testicular seminoma. Int J Cancer 1999;83:823-827.
- Classen J, Schmidberger H, Meisner C, et al. Radiotherapy for stages IIA/B testicular seminoma: final report of a prospective multicenter clinical trial. J Clin Oncol 2003;21:1101-1106.
- Schmidberger H, Bamberg M, Meisner C, et al. Radiotherapy in stage IIA and IIB testicular seminoma with reduced portals: a prospective multicenter study. Int J Radiat Oncol Biol Phys 1997;39:321-326.
- Paly J, Efstathiou JA, Hedgire SS, et al. Mapping patterns of nodal metastases in seminoma: Rethinking the para-aortic field. Int J Radiat Oncol Biol Phys 2011;81:S44 (abstr 88).
- Boujelbene N, Cosinschi A, Khanfir K, et al. Pure seminoma: a review and update. Radiat Oncol 2011;6:90.
- Martin JM, Joon DL, Ng N, et al. Towards individualised radiotherapy for Stage I seminoma. Radiother Oncol 2005;76:251-256.
- Zilli T, Boudreau C, Doucet R, et al. Bone marrow-sparing intensity-modulated radiation therapy for Stage I seminoma. Acta Oncol 2011;50:555-562.
- Hall EJ, Wuu CS. Radiation-induced second cancers: the impact of 3D-CRT and IMRT .Int J Radiat Oncol Biol Phys 2003;56:83-88.
Richard B. Wilder, MD, MS, MBA as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Radiation Oncology
Moffitt Cancer Center
12902 Magnolia Dr.
Tampa, FL 33612