Surveillance following orchidectomy for stage I testicular seminoma

Abstract

Summary An analysis of the primary tumour histopathology was performed on 103 patients managed by orchidectomy and surveillance for stage I seminoma. Patients have been followed for 14-141 months (median 62 months) after orchidectomy. Seventeen patients relapsed, the probability of remaining relapse free at 5 years being 82% (95% confidence intervals, 74%-88%). No patients died of progressive germ cell tumours. The only significant histological factor predicting relapse was the presence of lymphatic and vascular invasion. Four of 42 patients with neither lymphatic or vascular invasion recurred, nine of 53 patients with either lymphatic or vascular invasion recurred and three of eight cases with both lymphatic and vascular invasion recurred (P = 0.05-trend). Though initial recurrence was usually of moderate volume and confined to para-aortic nodes, eight patients were treated with chemotherapy either because of the extent of their initial relapse (four cases), or because of subsequent relapse (four cases). In view of the difficulties of identifying patients at risk and of detecting early relapse, surveillance for stage I seminoma should remain a research protocol.The conventional management of stage I seminoma of the testis is by adjuvant retroperitoneal node irradiation. This policy is highly successful, recurrence occuring in less than 5% of patients (Hamilton et al., 1986;Zagars, 1991). Surveillance following orchidectomy was introduced as an alternative with the rationale that a substantial proportion of patients with stage I seminoma would not need further treatment and could thus avoid the side-effects of radiotherapy. This supposition was based partly on a series of retroperitoneal lymph node dissection in stage I seminoma, which revealed microscopic nodal involvement in only 8% of patients (Maier et al., 1968), and partly on the success of a surveillance policy in stage I non-seminomatous tumours of the testis (Freedman et al., 1987;Horwich & Peckham, 1988;Cullen, 1991). Preliminary results of surveillance for stage I seminomas have been reported (Thomas et al., 1989;Duchesne et al., 1990) and it has become apparent that the policy presents some clinical difficulties, such as for example, the relatively indolent natural history of seminoma leading to a requirement for prolonged surveillance. A second problem is the lack of a sensitive serum marker for seminoma (in contrast to non-seminoma) making it difficult to monitor patients sufficiently closely to detect small volume relapse.In (median 36 years). They have been followed for a median of 5 years and 2 months from orchidectomy (range 14 months to 141 months).Initial staging investigations prior to registering the patient for surveillance always included thorough physical examination, assay of serum concentrations of the beta sub-unit of human chorionic gonadotrophin (HCG) and alpha-fetoprotein (AFP), CT scan of thorax abdomen and pelvis, lymphogram and chest X-ray. The histopathology had always been reviewed in the Department of Histopathology of The Ro...

Radiotherapy for stages I and IIA/B testicular seminoma

“…The overall survival in surveillance studies is not different from survival after post-operative irradiation of the para-aortic and iliac nodes (Horwich et al, 1992). In a meta-analysis, only tumor size and invasion of rete testis were predictive for relapse under surveillance (von der Maase et al, 1998).…”

“…Despite the high cure rates achieved with postoperative radiotherapy, efforts were made to introduce a ''wait-andsee'' policy (Horwich et al, 1992) that would potentially reduce the major side effects of radiotherapy, such as a possible impairment of fertility through scattered irradiation to the contralateral testis (Jacobsen et a1., 1997), gastro-intestinal morbidity (Aas et al, 1992) and the development of secondary radiation-induced neoplasms (Travis et al, 1997). Carboplatinum chemotherapy has been proposed as another alternative to adjuvant radiotherapy in stage I seminoma, and toxicity of treatment is reported to be low (Krege et al, 1997).…”

Para-aortic irradiation for stage I testicular seminoma: results of a prospective study in 675 patients. A trial of the German testicular cancer study group (GTCSG)

“…Several study groups could demonstrate that the DSS of the patients managed by surveillance is not compromised as compared to radiotherapy. The rate of relapse is in the range of 14 -19%, and the DSS approaches 100% (Horwich et al, 1992;Maase et al, 1993;Oliver et al, 1994;Warde et al, 1997). In a pooled analysis of the three largest surveillance protocols, the tumour size (44 cm) and tumour invasion of the rete testis were identified as independent prognostic factors for relapse (Warde et al, 2002).…”

Canadian consensus guidelines for the management of testicular germ cell cancer

“…[13][14][15][16][17][18][19][20] The data in these series are now mature and relapse rates have consistently been reported to be about 15% in unselected patients with stage I disease. The predominant site of relapse in all studies was in the paraaortic lymph nodes; 41 of 49 (82%) of relapses in the Danish Testicular Cancer Study Group (DATECA) study and 57 of 64 (85%) in the Princess Margaret Hospital (PMH) series.…”