Changing Paradigms in the Adjuvant Treatment of Stage I Seminoma?

Abstract

Despite excellent long-term results, routine postoperative radiotherapy of the regional lymphatics has been questioned as standard treatment in the management of stage I seminoma. Alternative strategies focus on sparing acute and late treatment morbidity, including carcinogenesis, without comprising cure rates. Surveillance strategies have shown to be a viable alternative, avoiding therapy for 75–80% of all patients; the same high level of survival is achieved by the use of primary chemotherapy and/or radiotherapy for recurrence. However, in comparison with routine irradiation, there is prolonged psychological stress for the patients, danger of extensive relapse and lower cost-effectiveness due to the necessity of intensive follow-up procedures. In nonrandomized studies, elective chemotherapy with single-agent carboplatin was equally effective regarding tumor control in short-term analyses. The question whether or not this treatment has advantages over radiotherapy in terms of treatment toxicity and long-term outcome is not proven and must be clarified in ongoing randomized prospective trials. During the last decade, the total radiation dose was gradually reduced by lowering treatment doses to 25 Gy. In addition, target volumes were restricted to the paraaortic lymph nodes, thus avoiding radiation damage to the remaining testicle. Even at follow-up periods in excess of 5 years the incidence of pelvic lymph node relapses remains below 4%. To date, limited low-dose radiotherapy following orchiectomy has to be considered as the standard method of treatment outside clinical trials.