Stage I testicular seminoma: Management and controversies
Introduction
Testicular germ-cell tumours (TGCT) constitute the most common form of cancer in young men between the ages of 15 and 34 years. There has been a significant rise in their incidence over the last four decades [1], [2]. More than a half of patients are diagnosed with seminoma and approximately 70–80% of them have clinical stage I at presentation. Stage I is defined as tumour confined to the testis without evidence of metastasis on radiological imaging. Tumour markers (alpha-fetoprotein and human chorionic gonadotropin-beta) are normal or normalize after radical orchiectomy.
The management of clinical stage I seminoma has changed in recent years. For several decades post-orchiectomy irradiation of the para-aortic ± ipsilateral pelvic lymph nodes (dog-leg port) has been the standard treatment for this group of patients. With recurrence rates of 3–4% radiotherapy remained the established approach until the results of long-term follow-up studies confirmed its association with increased risk of cardiovascular toxicity and second malignancy. These concerns led to the exploration of other management options. In the last 20 years surveillance has been studied and accepted as a safe and effective alternative although relapse rates are as high as 15–20%. The role of adjuvant chemotherapy in the form of single-agent carboplatin (one or two cycles) has also been investigated. With relapse rates similar to those of radiotherapy and an acceptable acute toxicity profile, chemotherapy has been advocated by many clinicians over the other modalities.
Despite the availability of treatment options, the choice of the most appropriate method remains difficult in individual cases. This is largely due to the absence of formal comparisons between the different approaches. Efforts have been made to identify patients at high-risk of relapse and apply a risk-adapted model of therapy. To date, these models have not been validated. All three modalities of treatment offer high cure rates to this young population of patients and therefore toxicity issues, long-term morbidity and patients’ choice play a significant role in the decision-making process.
The present review briefly summarizes the current management options for clinical stage I seminoma but focuses on the latest advances in the post-surgical treatment approaches and highlights the controversies surrounding them.
Section snippets
Surgical treatment of the primary tumour
The initial standard treatment for seminoma is radical orchiectomy with ligation of the spermatic cord at the level of the internal inguinal ring (European Germ Cell Cancer Consensus EGCCCG II [3]). It does not only provide a histological diagnosis and staging of the primary tumour but it also achieves definitive local control. The related morbidity is minimal with haemorrhage being the most commonly occurring postoperative complication.
Organ-sparing orchiectomy [4], [5], [6] is an alternative
Postoperative management: radiotherapy, surveillance or chemotherapy
The postoperative management of clinical stage I seminoma has become the focus of attention for clinicians and researchers in this field, in recent years. The rationale and the implications of all three available therapeutic modalities (adjuvant radiotherapy, surveillance with administration of irradiation or chemotherapy in case of relapse, or adjuvant chemotherapy) are discussed here.
Conclusions
All three post-operative management options for clinical stage I seminoma offer highly curable rates and long-term survival. While maintaining these rates, it is of outmost importance to minimize the burden of therapy and treatment related toxicity. Advances in radiotherapy and chemotherapy have allowed the use of less toxic, effective regimens. Comprehensive Guidelines based on up to date clinical evidence provide clinicians and patients with useful recommendations. A multidisciplinary
Reviewers
Dr. Robert A. Huddart, Royal Marsden Hospital, Orchard House, Downs Road, Sutton SM2 5PT, United Kingdom.
Dr. Dirk H. Westermann, Department of Urology, University of Bern, Bern, Switzerland.
Conflict of interest
None.
Dimitrios Pectasides is a Medical Oncologist in the Second Department of Internal Medicine, Oncology Section of the University of Athens. He received his M.D. in 1975 at the Medical School of University of Athens, Greece, and then joined the University Hospital Laikon and Metaxas Memorial Cancer Hospital to complete residencies in the Departments of Medicine and Medical Oncology. He is a board certified member of European Society for Medical Oncology (ESMO). Dr. Pectasides is a member of
References (65)
- et al.
European Consensus Conference on Diagnosis and Treatment of Germ Cell Cancer: a Report of the Second Meeting of European Germ Cell Cancer Consensus Group (EGCCCG): Part II
Eur Urol
(2008) Organ preserving surgery of malignant germ cell tumors. NEEd
J Urol
(1995)- et al.
Organ sparing surgery for malignant germ cell tumor of the testis
J Urol
(2001) - et al.
Guidelines on testicular cancer
Eur Urol
(2005) - et al.
Risk of subsequent non-germ cell cancer after treatment of germ cell cancer in 2006 Norwegian male patients
Eur J Cancer
(1997) - et al.
Omission of the pelvic irradiation in stage I testicular seminoma: a study of postorchiectomy paraaortic radiotherapy
Int J Radiat Oncol Biol Phys
(1996) - et al.
Patterns of relapse following radiotherapy for stage I seminoma of the testis: implications for follow-up
Clin Oncol (R Coll Radiol)
(2001) - et al.
Radiotherapy for testicular seminoma stage I: treatment results and long-term post-irradiation morbidity in 365 patients
Int J Radiat Oncol Biol Phys
(1989) - et al.
Seminoma of the testis: results of treatment and patterns of failure after radiation therapy
Int J Radiat Oncol Biol Phys
(1982) Testicular seminoma-analysis of radiation therapy for stage II disease
J Urol
(1983)
Seminoma of the testis: a 22-year experience with radiation therapy
Int J Radiat Oncol Biol Phys
Testicular seminoma: analysis of treatment results and failures
Int J Radiat Oncol Biol Phys
Radiotherapy for stage I seminoma testis: results of treatment and complications
Radiother Oncol
Stage I testicular seminoma: rationale for postorchiectomy radiation therapy
Int J Radiat Oncol Biol Phys
Radiation therapy of seminoma: 17-year experience at the Joint Center for Radiation Therapy
Radiother Oncol
Orchidectomy followed by radiotherapy in 176 stage I and II testicular seminoma patients: benefits of a 10-year follow-up study
Radiother Oncol
Radiation therapy for stage I and IIA testicular seminoma
Int J Radiat Oncol Biol Phys
Surveillance following orchidectomy for stage I seminoma of the testis
Eur J Cancer
Prognostic factors for relapse in stage I testicular seminoma treated with surveillance
J Urol
Pilot studies of 2 and 1 course carboplatin as adjuvant for stage I seminoma: should it be tested in a randomized trial against radiotherapy?
Int J Radiat Oncol Biol Phys
Adjuvant treatment of clinical stage I seminoma: is a single course of carboplatin sufficient?
Urology
Longterm experience with carboplatin monotherapy for clinical stage I seminoma: a retrospective single-center study
Urology
Multicenter study evaluating a dual policy of postorchiectomy surveillance and selective adjuvant single-agent carboplatin for patients with clinical stage I seminoma
Ann Oncol
MRC TE19 collaborators and the EORTC 30982 collaborators. Radiotherapy versus single-dose carboplatin in adjuvant treatment of stage I seminoma: a randomised trial
Lancet
The long-term risks of adjuvant carboplatin treatment for stage I seminoma of the testis
Ann Oncol
Stage I seminoma of the testis: is post-orchidectomy surveillance a safe alternative to routine postoperative radiotherapy?
Clin Oncol (R Coll Radiol)
Surveillance is an appropriate management strategy in patients with stage I seminoma
Int J Radiat Oncol Biol Phys
Long-term outcome of postorchiectomy surveillance for Stage I testicular seminoma
Int J Radiat Oncol Biol Phys
Cancer statistics, 2006
CA Cancer J Clin
Stage I seminoma of the testis: a bi-institutional retrospective analysis of patients treated with radiation therapy only
BJU Int
Cited by (14)
Testicular seminoma metastasis to duodenum. Misdiagnosed as primary duodenal tumor
2016, International Journal of Surgery Case ReportsCitation Excerpt :In this case, patient was discovered to have testicular seminoma. Statistically, more than half of the patients with testicular cancers are seminomas [7]. Less than 5% of seminomas manifest themselves with symptomatology derived from metastatic disease [4].
What's new in the treatment of seminomas?
2011, Cancer/RadiotherapieAdjuvant radiotherapy for Stage i seminoma: A Single-institutional experience
2019, Journal of Cancer Research and TherapeuticsRadiotherapy in testicular germ cell tumours - A literature review
2017, Wspolczesna Onkologia
Dimitrios Pectasides is a Medical Oncologist in the Second Department of Internal Medicine, Oncology Section of the University of Athens. He received his M.D. in 1975 at the Medical School of University of Athens, Greece, and then joined the University Hospital Laikon and Metaxas Memorial Cancer Hospital to complete residencies in the Departments of Medicine and Medical Oncology. He is a board certified member of European Society for Medical Oncology (ESMO). Dr. Pectasides is a member of several scientific societies and he is actively involved in the teaching and research of Oncology fellows and students. He is Associate Professor of Medicine and Director of the Medical Oncology Department at Oncology Section, Attikon University Hospital of University of Athens. Dr. Pectasides has published over 150 peer reviewed articles in such journals as the New England Journal of Medicine, Journal of Clinical Oncology, Annals of Oncology, European Urology and Cancer Treatment Reviews.
Eirini Pectasides is a Postdoctoral Research Associate at the Yale Cancer Center. She received her M.D. in 2006 at the Medical School of the University of Athens, Greece, and then joined Attikon University Hospital as a postdoctoral research fellow, conducting clinical research in oncology. Dr. Pectasides has co-authored several scientific publications and has presented her work in many international oncology meetings. She is currently working at the Yale Cancer Center, conducting translational research in head and neck squamous cell carcinoma.
Anastasia Constantinidou is a specialist registrar in Medical Oncology at the Royal Marsden Hospital London UK. Following her M.D. in Athens she became a member of the Royal College of Physicians (UK) in 2005 and she received a Specialist Accreditation in Internal Medicine in 2006. She is a member of several scientific societies including the Royal Society of Medicine and the American Society of Clinical Oncology. She is actively involved in the teaching of medical and oncology students and fellows. Her most recent clinical research focuses on the role of Positron Emission Tomography in the diagnosis and management of early stage melanoma and advanced breast cancer.
Gerasimos Aravantinos is a Medical Oncologist in the Medical Oncology Department of Ag. Anargiri Hospital, Greece. His main fields of interest are Gynecologic, Genitourinary Cancers, Breast Cancer, Gastrointestinal Cancers and Supportive Oncology. He is full member, currently Vice President (2005 to date) and former General Secretary (1999–2005), of the Hellenic (Greek) Society of Medical Oncology (HESMO). He is a member of several national and international Oncologic societies, board certified member of European Society of Medical Oncology (ESMO) and full member of American Society of Clinical Oncologist (ASCO). He has a M.D. degree and has obtained Ph.D. from the University of Athens. For the past 20 years he has been involved in clinical research nationally and internationally. He has delivered lectures at many local and international meetings and congresses and has published more than 100 peer reviewed articles.