Stage I seminoma: What should a practicing uro‐oncologist do in 2009?

Abstract

Testicular tumors are uncommon, but they continue to represent an important group of malignancies in young men. It is the most common solid malignancy in males between the ages of 20 and 35, and primary germ cell tumors are the most common histological type. In the United States in 2008, approximately 4800 cases of seminoma, approximately 4100 of which were stage I disease were projected after the completion of staging investigations.Remarkable progress has been made in the treatment of testicular seminoma over the past 25 years. Management options of stage I seminoma include radiotherapy, surveillance, or adjuvant chemotherapy. Standard management until recent years has been adjuvant retroperitoneal radiotherapy. Although providing excellent long term results, this approach has been associated with increased risk of gonadal toxicity, development of secondary malignancies and an increased risk of cardiovascular disease. The use of surveillance in management of patients with stage I seminoma is therefore becoming more frequent as it minimizes the burden of treatment and maintains the cure rate at virtually 100%. Adjuvant chemotherapy using Carboplatin has been investigated as an alternative management approach. However, the long term outcomes of patients managed with Carboplatin are not yet clear and this strategy should only be used in a study setting. It has been suggested that more patients with stage I seminoma will die of their treatment than of their cancer; therefore, the thrust of modern management should be to maintain 100% cure while minimizing the burden of treatment.

Outcome of different post‐orchiectomy management for stage I seminoma: Japanese multi‐institutional study including 425 patients

“…Recently, single‐agent carboplatin has been recognized as a potential option for the post‐orchiectomy management of stage I seminoma with encouraging short‐term results, 12,16,17 whereas long‐term results on cure rates and toxicities are yet to be clarified 18 . The surveillance policy was introduced in 1983 19 and has become an accepted option for the management of stage I seminoma, because subsequent prospective studies consistently showed that 80–85% of patients are cured by orchiectomy alone, and virtually all patients with relapse can be salvaged by subsequent chemotherapy, minimizing the burden of treatment 3,10 . The recent increase in choosing the surveillance policy in Japan might also be associated with our medical environment.…”

“…In this regard , we sought to elucidate contemporary outcomes for Japanese patients with stage I seminoma treated with surveillance, adjuvant chemotherapy or adjuvant radio- Outcome of stage I seminoma in Japan therapy. Although the median follow up duration in the present study is relatively short, the results of RFS or the relapse pattern after each type of the post-orchiectomy management are equivalent to those found in previous studies, 1,3,[9][10][11][12] showing that the behavior of localized testicular seminoma is not different between Japanese and Western populations. If we can predict the patients at high risk of relapse, adjuvant therapies, such as chemotherapy or radiotherapy, could be applied to these selected patients.…”

“…After orchiectomy, stage I seminoma patients can be managed by surveillance, adjuvant radiotherapy or adjuvant chemotherapy. Almost all patients can be salvaged, even after a relapse, mainly by chemotherapy; the overall cure rates approach 100%, regardless of the post‐orchiectomy management 2,3 …”

“…Almost all patients can be salvaged , even after a relapse, mainly by chemotherapy; the overall cure rates approach 100%, regardless of the postorchiectomy management. 2,3 Because the incidence of testicular germ cell tumors has been rising in Japan, 4,5 even though it is still lower than that in Western countries, we should pay more attention to this disease. However, little is known about post-orchiectomy management patterns and predictive factors associated with relapse in the Japanese population with stage I seminoma.…”

Radiotherapy for stage I seminoma of the testis

“…For the past 65 years, patients with stage I seminoma have been treated with adjuvant RT. [3] While we achieve 95-100% local control and survival rates this also brings along higher risks of early and late gonadal toxicities, secondary malignancy as well as highered risk of cardiovascular diseases. [4,5] As application of para-aortic field only (without pelvic field) [6,7] or delivering decreased RT doses at only about 20 Gy [8,9] aim to decrease specially the early toxicity; other modalities besides RT are in search to control the developing late risks.…”