BERKELEY, CA (UroToday.com) - According to the American Joint Commission on Cancer staging system, testicular seminoma patients with persistently elevated serum lactate dehydrogenase and/or beta subunit of human chorionic gonadotropin levels after radical inguinal orchiectomy but without regional lymph node or distant metastases are classified as having stage IS disease. Post-orchiectomy surveillance is not recommended for stage IS disease as it is for stage IA/IB disease.
Phase III studies of stage I testicular seminoma have typically excluded patients with stage IS disease.[3, 4, 5] Due to the rarity of stage IS disease, the optimal post-orchiectomy treatment approach is unclear. Consequently, Ahmed and Wilderstudied 323 stage IS testicular seminoma patients in the Surveillance, Epidemiology, and End Results (SEER) database between 1998 and 2005. Median follow-up was 7.2 years. Their article is the first one specifically addressing stage IS disease. Similar to two analyses of the SEER database wherein stage IA, IB, and IS testicular seminoma patients were combined,[6, 7] adjuvant radiotherapy was associated with an improvement in overall survival. Most second malignancies occur more than 15 years after radiotherapy.[6, 8, 9] Consequently, longer follow-up is necessary to determine if the overall survival benefit associated with modern radiotherapy, which involves doses of just 20 Gy in 10 fractions and fields encompassing only the para-aortic lymph nodes, persists.
Ahmed and Wilder (2) observed a steady decrease in utilization of post-orchiectomy radiotherapy for stage IS disease in the United States from 100% in 1998 to 58% in 2005 (p=0.01). This may be due to the increasing popularity of one cycle of carboplatin chemotherapy with an area under the curve (AUC) x 7. For example, the Swedish and Norwegian Testicular Cancer Project protocol was amended in 2004 to allow for carboplatin chemotherapy as a treatment option in stage I testicular seminoma patients. Carboplatin chemotherapy may be a less toxic alternative to radiotherapy, realizing that the toxicity beyond 10 years is not well-defined. Chemotherapy may also reduce the risk of contralateral testis cancer, particularly in those with an elevated follicle-stimulating hormone level.
In summary, although proponents of radiotherapy argue that it remains the preferred approach for stage IS testicular seminoma, chemotherapy continues to grow in popularity. Additional studies will help to clarify the role of carboplatin chemotherapy in stage IS disease.
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- Ahmed KA, Wilder RB. Outcomes and treatment patterns as a function of time in stage IS testicular seminoma: A population-based analysis. Cancer Epidemiol 2014;38:124-128.
- Fossa SD, Horwich A, Russell JM, et al. Optimal planning target volume for stage I testicular seminoma: A Medical Research Council randomized trial. Medical Research Council Testicular Tumor Working Group. J Clin Oncol 1999;17:1146.
- Jones WG, Fossa SD, Mead GM, et al. Randomized trial of 30 versus 20 Gy in the adjuvant treatment of stage I Testicular Seminoma: a report on Medical Research Council Trial TE18, European Organisation for the Research and Treatment of Cancer Trial 30942 (ISRCTN18525328). J Clin Oncol 2005;23:1200-1208.
- 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.
- Beard CJ, Travis LB, Chen MH, et al. Outcomes in stage I testicular seminoma: A population-based study of 9193 patients. Cancer 2013;119:2771-2777.
- Jones G, Arthurs B, Kaya H, et al. Overall survival analysis of adjuvant radiation versus observation in stage I testicular seminoma: a surveillance, epidemiology, and end results (SEER) analysis. Am J Clin Oncol 2013;36:500-504.
- Hallemeier CL, Choo R, Davis BJ, et al. Excellent long-term disease control with modern radiotherapy techniques for stage I testicular seminoma-The Mayo Clinic experience. Urol Oncol 2013.
- Zagars GK, Ballo MT, Lee AK, et al. Mortality after cure of testicular seminoma. J Clin Oncol 2004;22:640-647.
- Wilder RB, Buyyounouski MK, Efstathiou JA, et al. Radiotherapy treatment planning for testicular seminoma. Int J Radiat Oncol Biol Phys 2012;83:e445-452.
- 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.
- Oldenburg J, Fossa SD, Nuver J, et al. Testicular seminoma and non-seminoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013;24 Suppl 6:125-132.
Richard B. Wilder, MD 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, Tampa, FL USA