Prognostic value of pretreatment circulating neutrophils, monocytes, and lymphocytes in oropharyngeal cancer stratified by human papillomavirus status.

BACKGROUND: The objective of this study was to investigate the prognostic value of the pretreatment circulating neutrophil count (CNC), circulating monocyte count (CMC), and circulating lymphocyte count (CLC) in human papillomavirus (HPV)-related (HPV+) and HPV-unrelated (HPV-) oropharyngeal cancer (OPC). METHODS: All p16-confirmed HPV+ and HPV- OPC cases treated with chemoradiotherapy from 2000 to 2010 were included. Overall survival (OS) and recurrence-free survival (RFS) were compared for high and low CNCs, CMCs, and CLCs (dichotomized by median values). A multivariate analysis (MVA) confirmed their prognostic value in HPV+ and HPV- tumors, respectively. RESULTS: Five hundred ten HPV+ OPC cases and 192 HPV- OPC cases were included. The HPV+ cohort had lower CNC and CMC values but a CLC similar to that of the HPV- patients (P < .01). The median follow-up was 4.8 years. In the HPV+ cohort, a high CNC or CMC correlated with reduced OS and RFS in comparison with a low CNC or CMC (P < .01 for all), but no difference was evident in OS (P = .30) or RFS (P = .10) with the CLC. MVA confirmed that a higher CNC or CMC independently predicted lower OS (hazard ratio [HR] for CNC, 1.14, P < .01; HR for CMC, 2.95, P < .01) and lower RFS (HR for CNC, 1.11, P < .01; HR for CMC, 3.39, P < .01), whereas a higher CLC was associated with higher RFS (HR, 0.66, P = .03) and marginally higher OS (HR, 0.80, P = .08). In the HPV- cohort, CNC, CMC, and CLC were not predictive of OS (P = .16, P = .86, and P = .14) or RFS (P = .61, P = .59, and P = .62). CONCLUSIONS: This relatively large cohort study demonstrates that a high CNC and a high CMC independently predict inferior OS and RFS, whereas a high CLC predicts better RFS and marginally better OS in HPV+ OPC patients. This association was not apparent in HPV- patients.

Inter-professional variability in the assignment and recording of acute toxicity grade using the RTOG system during prostate radiotherapy.

BACKGROUND AND PURPOSE: To compare the routine acute toxicity documentation practices of therapists and oncologists using the RTOG lower GI and GU scales. METHODS AND MATERIALS: Ninety consecutive prostate radiotherapy patients were identified. The weekly urinary and rectal acute toxicity grades routinely documented by therapists and oncologists were collected retrospectively from radiotherapy charts. These data were paired together, and compared between the professional groups. RESULTS: Only RTOG acute toxicity grades between 0 and 2 were recorded by either group. The overall rate of documentation was high (97% therapists/86% oncologists), but the rate of quantitative documentation was low from the oncologists (46%) who used a free-form text field for recording purposes. There was no significant difference in the incidence of maximum grade of acute toxicity reported by either professional group (p>0.1). There was good RTOG score concordance between the observer groups (kappa=0.756), with pair-wise absolute agreement in 76%. Pair-wise discrepancies between the observers were commonly attributable to differences in the time/date of assessment. CONCLUSIONS: Despite some methodological limitations, this study found that therapist-assessed RTOG acute toxicity grades demonstrated a good level of agreement with the grades assigned by their oncologist colleagues.

Automated Delineation of the Normal Urinary Bladder on Planning CT and Cone Beam CT.

PURPOSE: To quantify the volumetric effect of delineation variability when using manual versus semiautomated tools to contour the normal bladder on planning computed tomography (CT) and cone beam CT. METHODS: Following research ethics board approval, 10 prostate cancer patients were selected. For each patient, one pretreatment cone beam CT (CBCT) was randomly selected from the first treatment week and registered to the planning CT (planCT). Model-based auto adaptation was used to delineate the outer bladder (OB) surface for the planCT. That contour was then propagated and manually adapted onto the CBCT. A second observer delineated OB for the planCT and CBCT using typical manual methods. These delineation procedures were repeated four times on each image set, with observers blinded to the previous contours. Metrics of volumetric, geometric, and overlap concordance were used to compare the manual and automated OB contours. RESULTS: The mean pairwise difference between the manual and model-based planCT volumes was 4 cm3 (2%), and the model-based contours exhibited approximately half the observer variation of the manual ones (3 cm3, 2%). The mean of pairwise differences between the manual and propagated CBCT volumes was 13 cm3 (8%), but the propagated contours exhibited approximately half the observer related volume variation (11 cm3, 6%). Small CBCT bladder volumes displayed larger observer variation with manual methods (r2, -0.640). Variability between the automated contours was significantly smaller than for the corresponding manual observations (P = .004 and .002, respectively). Metrics of three-dimensional overlap concordance indicated excellent agreement within and between the delineation methods. Automated CBCT contours were significantly smoother than the manual ones (surface sphericity index, 1.29 vs. 1.35; P = .03). CONCLUSIONS: Volumetric, geometric, and overlap metrics all indicated that planCT and CBCT automated OB contours fell within the range of manually delineated contours. The CBCT propagated contours were significantly smoother and associated with smaller intraobserver variability, compared with manual contours. Importantly, the findings from this research suggest that contour propagation may be more robust than manual delineation, especially in the presence of poor image quality.

Planned versus 'delivered' bladder dose reconstructed using solid and hollow organ models during prostate cancer IMRT.

BACKGROUND AND PURPOSE: All studies to date have evaluated the dosimetric effect of bladder deformation using an organ model that includes the dose to the urine. This research reconstructed bladder dose using both hollow and solid organ models, to determine if dose/volume differences exist. MATERIALS AND METHODS: 35 prostate IMRT patients were selected, who had received 78Gy in 39 fractions and full bladder instructions. Biomechanical modelling and finite element analysis were used to reconstruct bladder dose (solid and hollow organ model) using every third CBCT throughout the treatment course. RESULTS: Reconstructed dose (ReconDose) was 11.3Gy greater than planned dose (planDose) with a hollow bladder model (p<0.001) and 12.3Gy greater with a solid bladder model (p<0.0001). Median reconstructed volumes within the 30Gy, 65Gy and 78Gy isodoses were 3-4 times larger with the solid organ model (p<0.0001). The difference between planning bladder volume and median treatment volume was associated with the difference between the planDose and reconDose below 78Gy (R(2)>0.61). CONCLUSIONS: Substantial differences exist between planned and reconstructed bladder dose, associated with the differences in bladder filling between planning and treatment. Dose reconstructed using a solid bladder model over-reports the volume of bladder within key isodose levels and overestimates the differences between planned and reconstructed dose. Dose reconstruction with a hollow organ model is recommended if the goal is to associate that dose with toxicity.

Outcomes after reirradiation for recurrent nasopharyngeal carcinoma: North American experience.

BACKGROUND: The purpose of this article was to report outcomes of reirradiation for locoregionally recurrent nasopharyngeal carcinoma (NPC). METHODS: A retrospective review was conducted of all patients with locoregionally recurrent NPC who received reirradiation between 2001 and 2012. Overall survival (OS), local control, regional control, distant control, and Radiation Therapy Oncology Group (RTOG) grades 3 to 4 late toxicity were examined. RESULTS: A total of 42 recurrent cases treated with intensity-modulated radiotherapy (IMRT; 27 patients) or non-IMRT (stereotactic radiotherapy [RT], 12 patients; 3D conformal RT, 3 patients) were identified. Median time from initial RT to recurrence was 4.6 years. Hyperfractionation with 1.1 to 1.4 Gy/fraction twice daily to a total of 40 to 60 Gy was used in 27 IMRT and 5 non-IMRT patients. The remaining 10 patients received conventional fractionation 1.8 to 2.0 Gy/fraction to 50 to 60 Gy. Median follow-up was 3.0 years. The 3-year OS, local control, regional control, distant control, and late toxicity rates were 49%, 46%, 71%, 79%, and 37%, respectively. CONCLUSION: Reirradiation for recurrent NPC, delivered mostly with hyperfractionated IMRT, can result in durable disease control with acceptable late toxicity. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1102-E1109, 2016.

Outcomes of intensity-modulated radiotherapy versus conventional radiotherapy for hypopharyngeal cancer.

BACKGROUND: The purpose of this study was to discuss if the adoption of intensity-modulated radiotherapy (IMRT) for hypopharyngeal squamous cell carcinoma (SCC) has improved the outcome. METHODS: We compared 3-dimensional (3D) radiotherapy (RT) and IMRT in all patients with hypopharyngeal SCC treated with curative intent RT or chemoradiation therapy (CRT) from January 1, 2000, to February 28, 2010. Locoregional control, overall survival (OS), distant relapse rate, larynx preservation rate, and enteral feeding tube duration were analyzed. RESULTS: Of 181 consecutive patients, 90 received 3D-RT and 91 received IMRT. At 3 years, the IMRT group had higher locoregional control compared with the 3D-RT group (75% vs 58%; p = .003), but similar OS (50% vs 52%; p = .99), distant relapse rate (23% vs 20%; p = .79), and larynx-preservation rate (90% vs 86%; p = .16). The 2-year enteral feeding tube dependency rate was similar in both groups (19% vs 18%; p = .12). CONCLUSION: Patients with hypopharyngeal SCC treated with IMRT showed a higher locoregional control compared with 3D-RT. However, distant-relapse rate and OS remain comparable between treatment techniques.

Appropriate radiation volume for stage IIA/B testicular seminoma.

PURPOSE: Prophylactic left supraclavicular fossa irradiation has been suggested to reduce relapse rates in patients treated for Stage IIA/B testicular seminoma. To address this issue, we reviewed patterns of failure and treatment outcome in patients treated with radiation therapy at our institution. METHODS AND MATERIALS: Between 1981 and 1999, 79 men with Stage II seminoma (IIA, 49; IIB, 30) were treated with radiation therapy (RT) to the para-aortic and ipsilateral (+/- contralateral) pelvic lymph nodes (dose: 25-35 Gy). RESULTS: With a median follow-up of 8.5 years, the 5-year relapse-free rate was 91% (standard error: 3%), and 2 patients have died of seminoma, giving a 5-year cause-specific survival of 97%. A total of 7 patients have relapsed with 2 isolated to the left supraclavicular fossa. Five of 7 patients have been successfully salvaged. CONCLUSIONS: Prophylactic left supraclavicular fossa irradiation might have prevented relapse in 2 of 79 patients in Stage IIA/B seminoma. However, 97% of patients would have received unnecessary left neck RT, so we continue to recommend, as standard treatment, infradiaphragmatic RT only.

Prospective evaluation of acute toxicity and quality of life after IMRT and concurrent chemotherapy for anal canal and perianal cancer.

PURPOSE: A prospective cohort study was conducted to evaluate toxicity, quality of life (QOL), and clinical outcomes in patients treated with intensity modulated radiation therapy (IMRT) and concurrent chemotherapy for anal and perianal cancer. METHODS AND MATERIALS: From June 2008 to November 2010, patients with anal or perianal cancer treated with IMRT were eligible. Radiation dose was 27 Gy in 15 fractions to 36 Gy in 20 fractions for elective targets and 45 Gy in 25 fractions to 63 Gy in 35 fractions for gross targets using standardized, institutional guidelines, with no planned treatment breaks. The chemotherapy regimen was 5-fluorouracil and mitomycin C. Toxicity was graded with the National Cancer Institute Common Terminology Criteria for Adverse Events, version 3. QOL was assessed with the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and CR29 questionnaires. Correlations between dosimetric parameters and both physician-graded toxicities and patient-reported outcomes were evaluated by polyserial correlation. RESULTS: Fifty-eight patients were enrolled. The median follow-up time was 34 months; the median age was 56 years; 52% of patients were female; and 19% were human immunodeficiency virus-positive. Stage I, II, III, and IV disease was found in 9%, 57%, 26%, and 9% of patients, respectively. Twenty-six patients (45%) required a treatment break because of acute toxicity, mainly dermatitis (23/26). Acute grade 3 + toxicities included skin 46%, hematologic 38%, gastrointestinal 9%, and genitourinary 0. The 2-year overall survival (OS), disease-free survival (DFS), colostomy-free survival (CFS), and cumulative locoregional failure (LRF) rates were 90%, 77%, 84%, and 16%, respectively. The global QOL/health status, skin, defecation, and pain scores were significantly worse at the end of treatment than at baseline, but they returned to baseline 3 months after treatment. Social functioning and appetite scores were significantly better at 12 months than at baseline. Multiple dose-volume parameters correlated moderately with diarrhea, skin, and hematologic toxicity scores. CONCLUSION: IMRT reduces acute grade 3 + hematologic and gastrointestinal toxicities compared with reports from non-IMRT series, without compromising locoregional control. The reported QOL scores most relevant to acute toxicities returned to baseline by 3 months after treatment.

Postoperative intensity-modulated radiotherapy following surgery for oral cavity squamous cell carcinoma: patterns of failure.

OBJECTIVES: To review outcomes and analyze the patterns of locoregional recurrence of oral cavity squamous cell carcinoma (OCSCC) treated with surgery and postoperative intensity-modulated radiation therapy (IMRT). MATERIALS AND METHODS: All patients with Stage I-IVB OCSCC treated with surgery and postoperative IMRT± concurrent chemotherapy between 2005 and 2010 were evaluated. Patient survival and tumor outcomes were prospectively recorded. Outcome measures were 2 year overall survival (OS), local control (LC), regional control (RC) and distant control (DC). Locoregional recurrences were spatially localized in relation to dosimetric plans. RESULTS: A total of 180 consecutive patients with median follow-up of 34 months were identified. Disease subsites were oral tongue (46%), floor of mouth (23%), alveolus and hard palate (12%), buccal (9%), retromolar trigone (5%), and lip (4%). The 2 year rates of OS, LC, RC, locoregional control (LRC), and DC were 65%, 87%, 83%, 78% and 83%, respectively. The 2-year estimated rates of LRC for larger subsites were: oral tongue (72%), floor of mouth (84%). Of the 180 patients, 38 (21%) had locoregional failure (LRF). Most LRFs were in-field (26, 68%) with 7 marginal and 5 out-of-field. Marginal/out-of-field failures occurred in the contralateral neck in N2b patients, at high level II/skull base, and in intentionally spared regions (near parotid) of pathologically involved necks. CONCLUSIONS: Nearly a third (12/38) of LR recurrences were marginal or out-of-field following postoperative IMRT for OCSCC. Postoperative IMRT following gross total surgical resection requires careful and comprehensive target volume delineation, and larger volumes may be needed than the primary RT setting.

Natural course of distant metastases following radiotherapy or chemoradiotherapy in HPV-related oropharyngeal cancer.

OBJECTIVES: To describe the natural course of distant metastases (DMs) following radiotherapy (RT) or chemoradiotherapy (CRT) in HPV(+) oropharyngeal carcinoma (OPC). METHODS: OPC treated with RT/CRT from 1/1/2000 to 5/31/2010 were reviewed. The natural course of DM were compared between HPV(+) and HPV(-) cohorts. RESULTS: Median follow-up was 3.9 years. The DM rate were similar (11% vs. 15% at 3-years, p=0.25) between the HPV(+) (n=457) vs. the HPV(-) (n=167) cases. While almost all (24/25) HPV(-) DM occurred within 2-years following RT (1 was at 2.1 years), 7/54 (13%) of HPV(+) DM were detected beyond 3 years (up to 5.3 years). Disseminating to >2 organs occurred in 18 (33%) HPV(+) vs. none in HPV(-). Post-DM survival rates were 11% vs. 4% at 2-years (p=0.02) for the HPV(+) vs. HPV(-) cases respectively. 5/6 HPV(+) with lung oligo-metastasis were still alive with stable disease beyond 2-years after salvage procedures for DM (chemotherapy: 3; surgical resection: 2; radiotherapy: 1). CONCLUSIONS: Although DM rates are similar, the natural course of HPV(+) DM differs from that of HPV(-) patients: it may occur after a longer interval, often with a "disseminating" phenotype, and a small number may have prolonged survival after salvage for DM.

Outcomes of HPV-related oropharyngeal cancer patients treated by radiotherapy alone using altered fractionation.

PURPOSE: To report outcome of HPV-related [HPV(+)] oropharyngeal cancer (OPC) managed predominantly by altered-fractionation radiotherapy-alone (RT-alone). METHODS: OPCs treated with RT-alone (n = 207) or chemoradiotherapy (CRT) (n = 151) from 2001 to 2008 were included. Overall survival (OS), local (LC), regional (RC) and distant (DC) control were compared for HPV(+) vs. HPV-unrelated [HPV(-)], by RT-alone vs. CRT, and by smoking pack-years (≤ 10 vs. >10). Multivariate analysis identified predictors. RESULTS: HPV(+) (n = 277) had better OS (81% vs. 44%), LC (93% vs. 76%), RC (94% vs. 79%) (all p < 0.01) but similar DC (89% vs. 86%, p = 0.87) vs. HPV(-) (n = 81). HPV(+) stage IV CRT (n = 125) had better OS (89% vs. 70%, p < 0.01), but similar LC (93% vs. 90%, p = 0.41), RC (94% vs. 90%, p = 0.31) and DC (90% vs. 83%, p = 0.22) vs. RT-alone (n = 96). Both HPV(+) RT-alone (n = 37) and CRT (n = 67) stage IV minimal smokers had favorable OS (86% vs. 88%, p = 0.45), LC (95% vs. 92%, p = 0.52), RC (97% vs. 93%, p = 0.22), and DC (92% vs. 86%, p = 0.37). RT-alone and heavy-smoking were independent predictors for lower OS but not CSS in multivariate analysis. CONCLUSIONS: Overall, HPV(+) RT-alone stage IV demonstrated lower survival but comparable disease control vs. CRT, but no difference was apparent among minimal smokers.

The effect of delineation method and observer variability on bladder dose-volume histograms for prostate intensity modulated radiotherapy.

PURPOSE: To quantify the effect of delineation method on bladder DVH, observer variability (OV) and contouring time for prostate IMRT plans. MATERIALS AND METHODS: Planning CT scans and IMRT plans of 30 prostate cancer patients were anonymized. For 20 patients, 1 observer delineated the bladder using 9 methods. The effect of delineation method on the DVH curve, discrete dose levels and delineation time was quantified. For the 10 remaining CTs, 6 observers delineated bladder wall using 4 methods. Observer-based volume variation and intraclass correlation coefficient (ICC) were used to describe the dosimetric effects of OV. RESULTS: Manual delineation of the bladder wall (BW_m) was significantly slower than any other method (mean: 20 min vs. ≤ 13 min) and the dosimetric effect of OV was significantly larger (V70 Gy ICC: 0.78 vs. 0.98). Only volumes created using a 2.5mm contraction from the outer surface, and a method providing a consistent wall volume, showed no notable dosimetric differences from BW_m in both absolute and relative volume. CONCLUSIONS: Automatic contractions from the outer surface provide quicker, more reproducible and reasonably accurate substitutes for BW_m. The widespread use of automatic contractions to create a bladder wall volume would assist in the consistent application of IMRT dose constraints and the interpretation of reported dose.

Retrospective study of palliative radiotherapy in newly diagnosed head and neck carcinoma.

PURPOSE: To examine the patterns of care, outcomes, and prognostic factors for patients with head-and-neck cancer (HNC) treated with palliative radiotherapy (RT). METHODS AND MATERIALS: An institutional HNC anthology and electronic patient records were used to identify patients with previously untreated HNC of mucosal or salivary gland origin who underwent palliative RT at our institution between July 2003 and June 2008. Overall survival was determined from the start date of RT to either the date of death or the date of last follow-up for living patients. The data were censored if the subject was either lost to follow-up or had not been seen for follow-up at our institution for ≥4 months. RESULTS: We identified 148 eligible patients. The median age was 72 years (range, 19-94). Of the 148 patients, 12 had Stage II-III, 39 Stage IVA, 36 Stage IVB, and 54 Stage IVC; for 7 patients, the stage was unknown. Oropharyngeal primary cancer (40) was the most common primary site. The Eastern Cooperative Oncology Group performance status was 0 in 15, 1 in 69, 2 in 40, 3 in 19, and 4 in 5 patients. The Adult Co-morbidity Evaluation-27 scale was 0 in 33, 1 in 47, 2 in 44, and 3 in 21. The median radiation dose was 50 Gy (range, 2-70), the median fraction number was 20 (range, 1-40), and the median total treatment time (including breaks) was 29 days (range, 1-80). At analysis, 108 patients (73%) had died, 20 (13.5%) were alive, and 20 (13.5%) had been censored. The median follow-up was 4.8 months, and the median survival time was 5.2 months. Information on the treatment response was available for 103 patients (70%). On multivariate analysis, the radiation dose was an independent predictor of both overall survival (hazard ratio 0.97, 95% confidence interval 0.96-0.99, p <.01) and treatment response (odds ratio 1.05, 95% confidence interval 1.01-1.08, p <.01). CONCLUSION: For patients considered unsuitable for curative RT, the radiation dose might be an independent predictive factor for both overall survival and treatment response. Additional research is required to more effectively select those patients who might benefit from more aggressive treatment.

Stakeholder Insights into Autonomous Setup Correction by Radiation Therapists during High-Dose Prostate Radiotherapy.

Although online setup correction is beneficial during high-dose radiotherapy, little is known about the attitudes and concerns of stakeholders directly involved in this process. Therefore, the purpose of this research was to explore radiation oncologists' and therapists' insights on changes in workload, procedures, and professional practice resulting from involvement in therapist-autonomous online setup correction for patients receiving radiotherapy for prostate cancer. This was a single-center study with a qualitative design. All 10 radiation oncologists and 20 therapists involved in the online-autonomous process for prostate radiotherapy were approached for participation. Two specifically designed questionnaires were developed (one for therapists and one for oncologists) using a standard interview-to-pilot process. These were distributed to the participants both by hand and by e-mail. Content analysis methods and descriptive statistics were used to summarize the qualitative responses. Twenty-eight responses to the questionnaire were received. According to the results, the online-autonomous process was considered efficient when left solely in the hands of therapists (27 of 28 responses). Participant confidence with the process was influenced by communication (8/8), education (23/28), and documentation (20/20). Stakeholder perceptions indicated that the process was implemented exclusively to improve patient outcomes (28/28). The respondents experienced no professional resentment or resistance to change (20/20). The assumption of responsibility for online setup correction improved the therapists' perceptions of their role and themselves as professionals. Despite limited generalizability, this study confirms that within a well-established process, radiation oncologists are willing to cede responsibility for autonomous image approval and setup correction to therapists. Despite increases in professional accountability, radiation therapists are prepared to accept that responsibility for the benefit of their patients.

Lack of influence of intravenous contrast on head and neck IMRT dose distributions.

PURPOSE: Intravenous (i.v.) contrast at the time of CT-Simulation facilitates radiotherapy contouring, but may introduce a discrepancy between planned and delivered dose due to density variation in blood vessels. Here, the effect of physiologic and non-physiologic extremes of i.v. contrast densities on intensity modulated radiotherapy (IMRT) plans for patients with head and neck cancer was investigated. METHODS AND MATERIALS: This planning study was conducted using i.v. contrast CT scans of ten patients with squamous cell cancer of the head and neck treated with IMRT. The target volumes and normal tissues, including the blood vessels of the head and neck, were contoured and IMRT plans were created according to RTOG Protocol 0022. The density within the blood vessels was then virtually altered to mimic non-contrast and extreme (bone and air) densities. The dose was then recalculated using the same IMRT plan. Plans obtained with and without density overrides were then compared. RESULTS: The change in planning target volume (PTV) coverage for plans with and without i.v. contrast was minimal. The volume of the PTVs covered by the 93% and 100% isodoses changed on average by 0.57%. The minimum dose to PTVs varied by a maximum of 0.17 Gy. The maximum point dose to critical organs changed by a maximum of 0.12 Gy (brainstem). Non-physiologic extremes of density within blood vessels also resulted in minimal changes in tumor or normal tissue dosimetry. CONCLUSION: The use of i.v. contrast at time of CT-simulation does not significantly affect dose calculation in head and neck IMRT plans.

Spermatocytic seminoma: a review.

OBJECTIVE: Spermatocytic seminoma is a rare testicular tumour that has an extremely low rate of metastasis. We present a review of the management of this malignancy at our institution. METHOD AND MATERIALS: Between 1981 and 1999, 771 patients were treated at our institution for testicular seminoma. Of these, 13 had spermatocytic seminoma; one was excluded as he had treatment elsewhere. All patients were initially diagnosed at other hospitals and subsequently referred for management and had their pathology reviewed locally prior to any treatment. RESULTS: All patients had stage I disease, 5 patients received radiotherapy to the para-aortic and pelvic nodes, the other 7 were followed on a surveillance program. The median age was 62 years. With a median follow-up of 8.5 years no relapses were observed. Some patients exhibited adverse histological features associated with increased risk of relapse in seminoma including rete testis invasion and large primary tumour size. CONCLUSIONS: Spermatocytic seminoma may occur in younger patients and may not be restricted to the older population as commonly reported. Surveillance following orchidectomy is the preferred management option.

Stage II testicular seminoma: patterns of recurrence and outcome of treatment.

OBJECTIVES: To review treatment outcome and patterns of failure for patients with stage II testicular seminoma and to identify prognostic factors for relapse. METHODS: From 1981 to 1999, 126 men with stage II seminoma were treated at Princess Margaret Hospital. Of these, 95 were treated with radiotherapy (RT) and 31 with chemotherapy (ChT). Patient and tumour characteristics were analyzed for prognostic significance for subsequent relapse. RESULTS: At median follow-up of 8.5 years, the 5- and 10-year overall survival were both 93%, the 5- and 10-year cause-specific survival were both 94% and the 5- and 10-year relapse-free rates were both 85%. Patients with stage IIA and IIB disease treated with RT and stage IIB treated with chemotherapy had 5-year relapse-free rates of 91.7%, 89.7% and 83.3%, respectively. Seventeen percent of patients treated with radiotherapy and 6% of those treated with chemotherapy have relapsed. Of the RT patients the commonest sites of relapse were left supraclavicular fossa, lung/mediastinum, bone, para-aortics and liver; nine patients had a solitary site of relapse. Two patients treated with chemotherapy had recurrence in the para-aortic and iliac nodes. For RT patients, larger primary tumour size was associated with a reduction in relapse rate. Age, rete testis invasion and lymphovascular invasion were found not to be of prognostic significance. CONCLUSIONS: In stage IIA/B seminoma, radiotherapy continues to provide excellent results, as the majority of patients will be cured with this treatment alone. Chemotherapy is the treatment of choice for stage IIC seminoma.