Beyond clinical trials: real-world impact of immunotherapy on NSCLC in Jordan.

Background: This study aims to evaluate real-world (rw) outcomes of immunotherapy (IO) for advanced stage NSCLC at King Hussein Cancer Center (KHCC) in Jordan. Methods: Advanced stage NSCLC patients who received IO at KHCC between 2017 and 2022 were included. The data were retrospectively collected. PFS and OS were estimated for patients with ECOG performance status (ECOG PS) 0-1. Cox regression analyzed predictors of OS in first-line (1L) IO, regardless of performance status. Results: The total number of patients included was 244. Out of those, 160 (65%), 67 (28%), and 17 (7%) patients received IO as 1L, second-line (2L), or third-line or beyond (3L or beyond), respectively. The median age for all patients was 59 years. Male were 88%, and 77% were smokers. The median follow-up time was 12.5 months. The median PFS and OS for 1L IO were 7 [95% CI 5.8 - 10.3] and 11.8 [95% CI 8.8 - 14.4], months, respectively. In the first 3 months after starting 1L IO, 34/160 (21%) patients had died. For those who survived beyond 3 months after starting 1L IO, the median PFS and OS were 11.3 [95% CI 8.3 - 16.5] and 15.4 [95% CI 13.2 - 21] months, respectively. In the Cox regression model of 1L IO patients with any performance status, ECOG PS 2 was predictive of worse OS compared to ECOG PS 0-1 (p= 0.005). Conclusion: This real-world study of advanced-stage NSCLC patients treated with immunotherapy at KHCC reveals outcomes that fall short of those anticipated from clinical trials. The inclusion of Middle Eastern patients in lung cancer trials is essential to ensure adequate representation of various ethnicities in clinical research.

An Exploration of the Pillars of Leadership in Cancer Education.

Leadership plays a key role in cancer education (CE) and the success of its practices. Leaders in CE must effectively use their leadership skills to be able to communicate, collaborate, and educate their team members. There is a lack of formalized and standardized curriculums for institutions in developing leadership programs, including what themes to focus on in CE. In this article, the authors describe key pillars of leadership in CE that have presented themselves throughout their experience and within the literature. A search was conducted using the Ovid MEDLINE® database and articles were reviewed for eligibility. In this review, thirty articles were selected for their relevance to CE. With this literature search and the authors' reflections, four pillars of leadership in CE were identified: (1) leadership development, (2) collaboration, (3) diversity and equity, and (4) implementation. Within these themes, key areas of importance were discussed further, and barriers to CE leadership were identified. By reflecting upon pillars of leadership in CE, this article may be helpful for developing future leadership programs within CE. It is vital that initiatives continue to be held and barriers are addressed to increase leadership effectiveness within CE.

Health-related quality of life of pediatric brain tumor survivors after treatment in Jordan.

Background: The number of cancer survivors and survivorship are increasing. Health-related quality of life (HRQOL) has not been widely studied in low-and-middle-income countries (LMICs). The aim of this study is to explore HRQOL of childhood brain tumor survivors and its determinants in Jordan. Methods: Health-related quality of life information was collected from 80 patients treated at the King Hussein Cancer Center and their parents using the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scales questionnaire in Arabic. Multivariable linear OLS regression models were used to analyze correlates of HRQOL and compare differences between child- and parent-reported responses. Results: Health-related quality of life scores reported by survivors and by parents were positively correlated on all subscales and total PedsQL scores (r = 0.59, P = .001). Survivors reported better HRQOL in cognitive subscale (ß = 0.56, P = .03) and worse HRQOL in work subscale (ß = 0.43, P = .04), but no significant differences in the physical, emotional, and social subscales and total PedsQL scores. Significant predictors of HRQOL reported by parents and by children were different. Supratentorial tumor location was associated with a 10.97-unit lower physical HRQOL score, and recurrence of tumors predicted a 17.5-unit lower total HRQOL score, indicating worse quality of life. Male gender (ß = 14.9, P = .002) and diagnosis of hypopituitarism (ß = 16.1, P = .03) were associated with better HRQOL. Furthermore, patients that only had radiotherapy treatment had better emotional HRQOL (ß = 32.9, P = .006) compared to patients that had combined radiotherapy and chemotherapy. Conclusion: This study provides evidence on determinants of HRQOL of pediatric brain tumor patients in Jordan. Future studies need to capitalize on the findings of this study to institute a system for regular assessment of quality of life of pediatric cancer patients in Jordan and other countries with similar health care systems and sociocultural backgrounds.

Adjusting the duration of androgen deprivation therapy (ADT) based on nadir PSA for high risk localized prostate cancer patients treated with definitive external beam radiation therapy and ADT.

BACKGROUND: A nadir Prostate-Specific Antigen (nPSA) of 0.06 ng/mL has been shown to be a strong independent predictor of biochemical recurrence-free survival (bRFS) in patients with intermediate or high-risk (HR) prostate cancer treated with definitive external beam radiation therapy (RT) and androgen deprivation therapy (ADT). We aimed to examine the association between the duration of ADT and bRFS in HR localized prostate cancer, based on nPSA. METHODS: Between 1998 and 2015, 204 patients with HR localized prostate cancer were identified. Of them, 157 patients (77.0%) reached the desired nPSA of < 0.06 ng/mL (favorable group), while 47 (23.0%) did not (unfavorable group). Duration of ADT varied among patients depending on physician preference, patient tolerance, and/or compliance. Survival outcomes were calculated using Kaplan-Meier methods and predictors of outcomes using multi-variable cox regression model. RESULTS: In the favorable group, ADT for at least 12 months lead to superior bRFS compared to ≤ 9 months of ADT (P = 0.036). However, no significant difference was seen when examining the value of receiving ADT beyond 12, 18, or 24 months, respectively. On univariate analysis for bRFS, the use of ADT for at least 12 months was significant (P = 0.012) as well as time to nadir PSA (tnPSA), (≤ 6 vs > 6 months); (P = 0.043). The presenting T stage was borderline significant (HR 3.074; 95% CI 0.972-9.719; P = 0.056), while PSA at presentation, Gleason Score and age were not. On multivariate analysis, the use of ADT for 12 months (P = 0.012) and tnPSA (P = 0.037) remained significant. In the unfavorable group, receiving ADT beyond 9 and 12 months was associated with improved bRFS (P = 0.044 and 0.019, respectively). However, beyond 18 months, there was no significant difference. CONCLUSION: In HR localized prostate cancer patients treated with definitive RT and ADT, the total duration of ADT may be adjusted according to treatment response using nPSA. In patients reaching a nPSA below 0.06 ng/mL, a total of 12 months of ADT may be sufficient, while in those not reaching a nPSA below 0.06 ng/mL, a total duration of 18 months is required.

Financial toxicity of cancer care in low- and middle-income countries: a systematic review and meta-analysis.

INTRODUCTION: The costs associated with cancer diagnosis, treatment and care present enormous financial toxicity. However, evidence of financial toxicity associated with cancer in low- and middle-income countries (LMICs) is scarce. AIM: To determine the prevalence, determinants and how financial toxicity has been measured among cancer patients in LMICs. METHODS: Four electronic databases were searched to identify studies of any design that reported financial toxicity among cancer patients in LMICs. Random-effects meta-analysis was used to derive the pooled prevalence of financial toxicity. Sub-group analyses were performed according to costs and determinants of financial toxicity. RESULTS: A total of 31 studies were included in this systematic review and meta-analysis. The pooled prevalence of objective financial toxicity was 56.96% (95% CI, 30.51, 106.32). In sub-group meta-analyses, the objective financial toxicity was higher among cancer patients with household size of more than four (1.17% [95% CI, 1.03, 1.32]; p = 0.02; I2 = 0%), multiple cycles of chemotherapy (1.94% [95% CI, 1.00, 3.75]; p = 0.05; I2 = 43%) and private health facilities (2.87% [95% CI, 1.89, 4.35]; p < 0.00001; I2 = 26%). Included studies hardly focused primarily on subjective measures of financial toxicity, such as material, behavioural and psychosocial. One study reported that 35.4% (n = 152 of 429) of cancer patients experienced high subjective financial toxicity. CONCLUSIONS: This study indicates that cancer diagnosis, treatment and care impose high financial toxicity on cancer patients in LMICs. Further rigorous research on cancer-related financial toxicity is needed.

Enhancing International Cancer Organization Collaborations: King Hussein Cancer Center and Princess Margaret Cancer Centre Model for Collaboration.

Collaborative partnerships, which link two health organizations with shared characteristics to achieve common goals and to improve healthcare quality, are becoming increasingly common in oncology. The purpose of this study is to review the collaboration between King Hussein Cancer Center (KHCC) and Princess Margaret Cancer Centre (PM). The context, input, process, and product (CIPP) model, a quasi-experimental form of program evaluation, has been applied to the KHCC-PM collaboration. This model is well suited to evaluate complex collaborations as it does not assume linear relationships. Data sources include stakeholders' judgements of the collaboration, assessment of achievements, and informal interviews with key participants involved in the program. KHCC and PM are recognized as high-caliber comprehensive cancer centers, with a common goal of delivering high-quality care to patients. Through personal relationships among faculty in the centers and the perceived opportunities for mutual benefit, KHCC and PM signed a memorandum of understanding in 2013 to enter into a formal partnership. This partnership has been an evolving process that started with collaboration on education and grew to include clinical care. Research is an area for potential future collaboration. Enabling factors in the collaboration include dedication of individuals involved, trusting relationships amongst faculty, and the reciprocal nature of the relationship. Challenges have been financial, competing interests, and the absence of a successful collaborative model to follow. The KHCC and PM collaboration has been successful. A strategic plan is being developed and followed to guide areas of expansion.

Novel coronavirus mitigation measures implemented by radiotherapy centres in low and middle-income countries: a systematic review.

BACKGROUND: The aim of the study was to identify strategies adopted by radiotherapy centres in low- and middle-income countries (LMICs) to mitigate the effects of COVID-19. Studies summarising COVID-19 mitigation strategies designed and implemented by radiotherapy centres in LMICs to avoid delays, deferrments and interruptions of radiotherapy services are lacking. MATERIALS AND METHODS: A systematic review was conducted and reported in accordance with the preferred reporting items for systematic review and meta-analysis guideline. Ovid Embase, Ovid MEDLINE and CINAHL were searched for peer-reviewed articles that reported measures adopted by radiotherapy centres in LMICs to reduce the risk of COVID-19. Information on different strategies were extracted from the included studies and textual narrative synthesis was conducted. RESULTS: Of 60 articles retrieved, eleven were included. Majority of the studies were conducted in China. Ten of the included studies employed a qualitative design. Four themes were identified: preparing and equipping staff; reinforcing infection prevention and control policies; strengthening coordination and communication; and maintaining physical distancing. Studies reported that radiotherapy centres had: formed COVID-19 response multidisciplinary team; maximised the use of telehealth; adjusted the layout of waiting areas; divided staff into teams; dedicated a room for isolating suspected cases; and adopted triage systems. CONCLUSIONS: Local adaptation of established global strategies coupled with timely development of guidelines, flexibility and innovation have allowed radiotherapy leaders to continue to deliver radiotherapy services to cancer patients in LMICs during the COVID-19 crisis. Robust data collection must be encouraged in LMICs to provide an evidence-based knowledge for use in the event of another pandemic.

The influence of 68Ga-prostate-specific membrane antigen PET/computed tomography on prostate cancer staging and planning of definitive radiation therapy.

OBJECTIVES: Prostate-specific membrane antigen (PSMA) PET/computed tomography (CT) is a novel imaging tool with an evolving role in the management of prostate cancer. This study aims to retrospectively evaluate the impact of 68Ga-PSMA PET/CT on prostate cancer staging and definitive radiation therapy planning. METHODS: Between April 2015 and June 2020, 366 men with prostate cancer were evaluated with 68Ga-PSMA PET/CT. Of these, 108 patients had PSMA PET/CT before radiation therapy. Radiation was given as primary treatment in 58 (54%) and as salvage radiation therapy for biochemical recurrence after primary surgery in 50 (46%) patients, respectively. Patient and disease characteristics were analyzed, and impact of PSMA PET/CT on disease staging and radiotherapy planning was evaluated in comparison to conventional imaging. RESULTS: Median age at presentation was 69 years, and median prostate-specific antigen was 18 ng/mL (3.6-400) for primary and 0.4 ng/mL (0.1-4.6) for salvage radiation, respectively. The combined change of disease stage rate was 36% (39/108) with 45% (26/58) in the subgroup of primary radiation and 26% (13/50) in the patients intended for salvage radiation. Upstaging was found in 24 (22%) and downstaging in 15 (14%) patients. Radiation planning was changed based on PSMA PET/CT in 34 (31%) patients, including 7 (6.4%) patients in which stereotactic body radiotherapy (SBRT) was added to oligometastatic sites. The radiation field was extended to include pelvic lymph node involvement in 21 patients. CONCLUSIONS: 68Ga-PSMA PET/CT changed the prostate cancer stage in around one-third of men. PSMA PET/CT significantly impacted radiation planning. Further prospective studies are still required.

History and Current State of Radiation Oncology Services and Practice in Jordan.

Radiation therapy (RT) for patients with cancer in Jordan began with a small individual effort and has now grown to be one of the most prominent treatment centers in the Middle East. Currently, there are 4 different centers that provide RT not only for the people of Jordan but also for citizens of other neighboring Arab countries. Because Jordan is a developing country, it still faces problems with the insufficient number of RT machines available and their supporting staff (physicists and technologists among others). In this article, we shed light on the history and current status of radiation oncology in Jordan and discuss the challenges we face.

Successful Development of a Competency-Based Residency Training Program in Radiation Oncology: Our 15-Year Experience from Within a Developing Country.

One of the main challenges of delivering high quality of care to cancer patients in developing countries is the lack of well-trained radiation oncologists. This is a direct cause for the lack of residency programs coupled with lack of resources. This article describes and details establishments of a successful and sustainable radiation-oncology residency program in our country. The program has been in operation for 14 years and has trained and graduated radiation oncologists who are now working in various countries. The curriculum of the 4-year residency program, fashioned according to American College of Radiologists (ACR) recommendations, includes site-specific clinical rotations and didactic lectures in clinical oncology, radiobiology, medical physics, statistics, and epidemiology. It also includes a component of advanced clinical experience in the form of 3-month externship at one of collaborating centers outside the country. Evaluation of the residents is conducted annually via written exams and 360° feedback. Residents also sit for the formal certification exam in radiation oncology from the national Medical Council. The exam consists of 2 written exams and one oral. As a form of benchmarking residents' knowledge, they are required to sit for the ACR examinations held annually and conducted in Amman in tandem. The program has successfully trained and graduated 28 residents, who now work as consultant radiation oncologists locally and abroad. Each resident has gone through a structured training that includes exposure to a Western-style patient-management culture, enhancing the breadth and width of their clinical experience. The residency program, initiated in a developing country, underwent many challenges, yet it overcome all obstacles and resulted in a successful training of competent radiation oncologists serving the region.

Enhancing value of quality assurance rounds in improving radiotherapy management: a retrospective analysis from King Hussein Cancer Center in Jordan.

PURPOSE: The quality assurance (QA) chart rounds are multidisciplinary meetings to review radiation therapy (RT) treatment plans. This study focus on describing the changes in RT management based on QA round reviews in a single institution. MATERIALS AND METHODS: After 9 full years of implementation, a retrospective review of all patients whose charts passed through departmental QA chart rounds from 2007 to 2015. The reviewed cases were presented for RT plan review; subcategorized based on decision in QA rounds into: approved, minor modifications or major modifications. Major modification defined as any substantial change which required patient re-simulation or re-planning prior to commencement of RT. Minor modification included treatment plan changes which didn't necessarily require RT re-planning. RESULTS: Overall 7,149 RT treatment plans for different anatomical sites were reviewed at QA rounds. From these treatment plans, 6,654 (93%) were approved, 144 (2%) required minor modifications, while 351 (5%) required major modifications. Major modification included changes in: selected RT dose (96/351, 27%), target volume definition (127/351, 36%), organs-at-risk contouring (10/351, 3%), dose volume objectives/constraints criteria (90/351, 26%), and intent of treatment (28/351, 8%). The RT plans which required major modification according to the tumor subtype were as follows: head and neck (104/904, 12%), thoracic (12/199, 6%), gastrointestinal (33/687,5%), skin (5/106, 5%), genitourinary (16/359, 4%), breast (104/2387, 4%), central nervous system (36/846, 4%), sarcoma (11/277, 4%), pediatric (7/251, 3%), lymphoma (10/423, 2%), gynecological tumors (2/359, 1%), and others (11/351, 3%). CONCLUSION: Multi-disciplinary standardized QA chart rounds provide a comprehensive and an influential method on RT plans and/ or treatment decisions.

Variables altering the impact of respiratory gated CT simulation on planning target volume in radiotherapy for lung cancer.

BACKGROUND: Respiratory gated CT simulation (4D-simulation) has been evolved to estimate the internal body motion. This study aimed to evaluate the impact of tumor volume and location on the planning target volume (PTV) for primary lung tumor when 4D simulation is used. METHODS: Patients who underwent CT simulation for primary lung cancer radiotherapy between 2012 and 2016 using a 3D- (free breathing) and 4D- (respiratory gated) technique were reviewed. For each patient, gross tumor volume (GTV) was contoured in a free breathing scan (3D-GTV), and 4D-simulation scans (4D-GTV). Margins were added to account for the clinical target volume (CTV) and internal target motion (ITV) in 3D and 4D simulation scans. Additional margins were added to account for planned target volume (PTV). Univariate and multivariate analyses were performed to test the impact of the volume of the GTV and location of the tumor (relative to the bronchial tree and lung lobes) on PTV changes by more than 10% between the 3D and 4D scans. RESULTS: A total of 10 patients were identified. 3D-PTV was significantly larger than the 4D-PTV; median volumes were 182.79 vs. 158.21 cc, p = 0.0068). On multivariate analysis, neither the volume of the GTV (p = 0.5027) nor the location of the tumor (peripheral, p = 0.5027 or lower location, p = 0.5802) had an impact on PTV differences between 3D-simulation and 4D-simluation. CONCLUSION: The use of 4D-simulation reduces the PTV for the primary tumor in lung cancer cases. Further studies with larger samples are required to confirm the benefit of 4D-simulation in decreasing PTV in lung cancer.

[68Ga]PSMA PET/CT Improves Initial Staging and Management Plan of Patients with High-Risk Prostate Cancer.

PURPOSE: In this retrospective study, we compared the diagnostic value of 68Gallium prostate-specific membrane antigen positron emission tomography computed tomography ([68Ga]PSMA PET/CT) in primary staging of patients with high-risk prostate cancer (PCa), in comparison to CT, magnetic resonance imaging (MRI), and bone scans, and we explored its overall impact on patients' management plan. PROCEDURES: Patients with pathological confirmation of PCa with high-risk disease were included in this study. Information on patient demographics, clinical and histopathological findings with Gleason score and initial prostate specific antigen PSA levels, and radiological findings for CT, MRI, bone scan, and [68Ga]PSMA PET/CT were retrieved. We stratified the concordance and discordance of each imaging modality on per-patient and per-lesion-site bases. RESULTS: Twenty-one patients with high-risk disease were included in this study. [68Ga]PSMA PET/CT revealed a significantly higher concordance rate (90 %) compared to the concordance rates of bone scan (75 %), MRI (73 %), and CT (60 %). [68Ga]PSMA PET/CT had a similar accuracy to MRI in detecting prostate lesions but a higher accuracy for suspicious pelvic lymph nodes (95.2 % vs. 80 %). It also superseded CT scan in detecting suspicious pelvic lymph nodes (95.2 % vs. 75 %) and extra-pelvic lymph nodes (100 % vs. 75 %), as well as bone lesions via bone scan (100 % vs. 62.5 %). [68Ga]PSMA PET/CT changed the management in 11 patients (52 %). CONCLUSIONS: [68Ga]PSMA PET/CT is an invaluable imaging modality in the assessment of primary high-risk PCa with great potential for the detection of lymph node spread and bone metastases that would impact the management plan.

Nadir PSA is a strong predictor of treatment outcome in intermediate and high risk localized prostate cancer patients treated by definitive external beam radiotherapy and androgen deprivation.

BACKGROUND: The aim of this study is to investigate the effect of tumor characteristics and parameters of treatment response in predicting biochemical disease-free survival (BFS) for patients with intermediate or high risk prostate cancer treated by combined definitive external beam radiation therapy (EBRT) and androgen deprivation therapy (ADT). METHODS: Between June 1995 and January 2015, 375 patients with localized prostate cancer and a National Comprehensive Cancer Network (NCCN) intermediate or high risk categories were treated by definitive EBRT and ADT. Median duration of androgen blockade was 10 months (range: 3-36 months); Median radiation dose was 72 Gy (Range: 70-78 Gy). Median follow-up time was 5.8 years (range: 0.8-16.39 years). The main study endpoint was biochemical disease free survival (BFS). RESULTS: Forty seven patients (12.5%) developed biochemical recurrence (BCR) during the observation period. Monovariate analysis identified baseline PSA (bPSA) (p = 0.024), T-stage (p = 0.001), Gleason's score (GS) (p = 0.042), radiation dose (p = 0.045), PSA pre-radiation therapy (p = 0.048), and nadir PSA (nPSA), (p < 0.001) as significant variables affecting BCR. The receiver operating characteristic (ROC) curve identified a nPSA of 0.06 ng/ml as optimal cut-off value significantly predicting the patients' risk of BCR (p < 0.001). Multivariate cox regression analysis revealed T-stage, GS, and nPSA as independent variable affecting BFS, while bPSA, age, and radiation dose were not. CONCLUSION: Nadir PSA at 0.06 is a strong independent predictor of BFS in patients with intermediate or high risk prostate cancer treated by definitive EBRT and ADT.

Advanced Tracheal Adenoid Cystic Carcinoma with Thyroid Invasion Mimicking Thyroid Cancer Treated with Definitive Radiation: Case Report and Review of the Literature.

A 54-year-old female patient, a breast cancer survivor and a case of unresectable adenoid cystic carcinoma of the trachea, with thyroid invasion, presented with suprasternal neck swelling mimicking thyroid primary. A literature search was undertaken to highlight this rare presentation. There have been few reports in the literature describing tracheal adenoid cystic carcinoma involving the thyroid.

Choroidal Metastasis as an Unusual Initial Presentation of Transitional Cell Carcinoma of the Kidney.

Metastases of transitional cell carcinoma (TCC) of the renal pelvis to the eye is a very rare event, as only one previous case has been described in the literature. We present a patient with choroidal metastasis secondary to TCC of the renal pelvis, with a review of the relevant literature. A 61-year-old male presented with sudden-onset loss of vision of the left eye. Upon evaluation and assessment, the patient was found to have unilateral choroidal metastasis secondary to TCC of the renal pelvis. He is currently on palliative chemotherapy with carboplatin and gemcitabine. External beam radiation therapy is a common mode of treatment and will be considered accordingly.

Unusual presentation of non-small cell lung cancer with clival metastases: Case report.

A 37-year-old female with unusual presentation of metastatic non-small cell lung cancer (NSCLC), as she presented with symptoms related to clival bone metastases. This case highlights the unpredictable presentations and the variety of metastatic sites of which metastatic NSCLC could be presented.

Choroidal metastasis secondary to prostatic adenocarcinoma: case report and review of literature.

Choroidal metastasis from prostate adenocarcinoma is exceedingly rare. Furthermore, data addressing the optimal therapeutic strategy is limited. A 62-year-old male patient with metastatic prostate cancer was found to have a choroidal metastasis after complaining of decreased vision in his left eye. Following treatment with external beam radiotherapy, complete response in the choroidal metastasis was demonstrated. A literature search was undertaken to highlight the therapeutic options for this rare presentation. Choroidal metastasis secondary to adenocarcinoma of the prostate is exceedingly rare, as only eight cases have been reported so far. External beam radiotherapy is an effective therapeutic modality.

Stage I seminoma: treatment outcome at King Hussein Cancer Center in Jordan.

BACKGROUND: The aim of this report is to address treatment outcomes of patients with early-stage seminoma in a single institution with special reference to patients with history of surgical violation of the scrotum. METHODS: Seventy four patients with pure seminoma were treated at King Hussein Cancer Center (Amman, Jordan) between 2003 and 2010. All patients underwent orchiectomy. All but 3 patients received adjuvant radiotherapy. Patients who underwent surgical violation of the scrotum prior to referral were managed by further excision or irradiation of the scrotal scar. The follow-up ranged from 1 to 200 months (mean, 33 months). RESULTS: At the time of follow-up; all but one patient remain alive. The 3-year relapse-free survival for the entire cohort was 95.9%. Three patients developed relapse, all of whom received adjuvant irradiation following inguinal orchiectomy and initially harbored tumors larger than 4 cm upon pathological examination. Median time to relapse was 14 months (range, 8-25 months). None were associated with elevated tumor markers prior to detection of relapse. All but one patient were successfully salvaged by chemotherapy. CONCLUSIONS: Our results confirm the excellent prognosis of patients with early-stage seminoma treated by orchiectomy and adjuvant radiotherapy in a developing country. Although all patients who developed relapse demonstrated adverse pathological findings upon initial assessment, no consistent predictor of relapse was found. Scrotal scar re-excision or irradiation in patients with prior history of surgical violation of the scrotum are effective measures in preventing local failure.