Is there a Role for Radiotherapy in the Management of Testicular Non‐Seminomas?

Abstract

SUMMARY In recent years several new treatment options have become available in the management of Stage I and II nonseminomatous tumours of the testis as a result of more accurate staging of tumour extent and the development of curative chemotherapy. In addition some Australian centres now have surgeons on staff experienced in retroperitoneal node dissection which previously has not been a widely available option. There are few randomized comparisons of competing treatment options to determine precisely their relative therapeutic efficacy and morbidity and published results of some newer options, particularly orchi‐dectomy alone in C.S. I cases, are preliminary in nature. Despite these difficulties clinicians must select from the available options when individual patients are referred for assessment and further management following orchidectomy. It no longer seems acceptable to treat all C.S. I and II patients with post‐operative radiotherapy as a blanket policy. Some patients have a high probability of cure without adjuvant therapy while others are infrequently cured with radiotherapy alone. The routine use of retroperitoneal node dissection seems equally illogical and will result in virtually all cured patients being infertile. Administration of platinum‐containing chemotherapy following orchidectomy exposes these predominantly young men to substantial acute morbidity and psychological stress and a high risk of permanent infertility. In view of the efficacy of chemotherapy in salvaging patients who relapse its use as primary treatment in subgroups with a risk of relapse less than around 20% seems inappropriate. In groups with higher failure rates after surgery or radiotherapy it may be judged necessary especially in patients who may default from follow‐up. The current protocol of management for these tumours at our centre based upon the above considerations is outlined in Table 9. As further data accrues these recommendations may need to be altered. While the role of radiotherapy is considerably less than in the past it remains appropriate treatment for patients with limited retroperitoneal lymph node metastases (C.S. IIA; nodes less than 2 cms.) and provides a low rate of relapse for C.S. I patients where documented conversion of serum tumour marker levels from positive to negative after orchidectomy is not available as part of clinical staging.