Contemporary Role of Radiation Therapy in Testicular Cancer.

Testicular cancer is a rare but curable male malignancy. Seminoma represents the majority of germ cell tumors and is considered radiation sensitive. Radiation treatment plays a role in adjuvant therapy after orchiectomy of stage I, IIA, and IIB seminomas. Radiation dose de-escalation has been effective in preventing tumor recurrences while also limiting acute and long-term toxicities. However, long-term risks, including the prevailing concern of secondary malignancy risk, between adjuvant radiation and chemotherapy play a role in recommendations. Ongoing work continues to be performed to reduce radiation field and dose in combination with chemotherapy while still maintaining excellent outcomes.

On thin ice: barriers to adoption of surveillance for patients with stage I testicular seminoma. Survey of US radiation oncologists

ABSTRACT Purpose: Most men with stage I testicular seminoma are cured with surgery alone, which is a preferred strategy per national guidelines. The current pattern of practice among US radiation oncologists (ROs) is unknown. Materials and Methods: We surveyed practicing US ROs via an online questionnaire. Respondent's characteristics, self-rated knowledge, perceived patient compliance rates with observation were analyzed for association with treatment recommendations. Results: We received 353 responses from ROs, of whom 23% considered themselves experts. A vast majority (84%) recommend observation as a default strategy, however this rate drops to 3% if the patient is believed to be noncompliant. 33% of respondents believe that survival is jeopardized in case of disease recurrence, and among these respondents only 5% support observation. 22% of respondents over-estimate the likelihood of noncompliance with observation to be in the 50-80% range. Responders with a higher perceived noncompliance rate are more likely to recommend adjuvant therapy (Fisher's exact p<0.01). Only 7% of respondents recommend observation for stage IS seminoma and 45% administer adjuvant RT in patients with elevated pre-orchiectomy alpha-fetal protein levels. Conclusions: Many US ROs over-estimate the likelihood that stage I testicular seminoma patients will be noncompliant with surveillance and incorrectly believe that overall survival is jeopardized if disease recurs on surveillance. Observation is quickly dismissed for patients who are not deemed to be compliant with observation, and is generally not accepted for patients with stage IS disease. There is clearly an opportunity for improved physician education on evidence-based management of stage I testicular seminoma.

Long-term cardiovascular complications in stage I seminoma patients

Purpose. The cure rate of stage I seminoma patients is close to 100% and so the recent focus of clinical research has shifted onto the prevention of treatment-related complications. We assessed long-term cardiovascular complications and identified risk factors for cardiovascular events (CVEs) in stage I seminoma patients. Methods. This retrospective cohort study included 406 consecutive stage I seminoma patients. Primary endpoint was CVE rate. Results. During a median follow-up of 8.6 years, we observed 23 CVEs in 406 patients [10-year CVE risk 5.6% (95% CI 3.2 to 8.8)]. In univariable competing risk analysis, higher age, positive smoking status, history of diabetes and hypertension were significantly associated with the occurrence of CVE. In multi-state analysis, new onset of diabetes, hypertension and hyperlipidemia during follow-up predicted for an excessively increased CVE risk. In multivariable analysis adjusting for age and smoking, the development of hypertension and hyperlipidemia after tumor-specific treatment prevailed as risk factors for CVE. Regarding adjuvant treatment modalities, patients receiving adjuvant radiotherapy had a significantly higher probability of CVE than patients receiving adjuvant carboplatin [16% vs. 0%; risk difference (RD) = 16%, 95% CI 6 to 25%, p = 0.001]. This difference prevailed after adjusting for age, follow-up-time, diabetes, hypertension and smoking (RD = 11%, 95% CI 1 to 20%, p = 0.025). Conclusion. We identified a panel of baseline risk factors and dynamically, occurring predictors of CVE in stage I seminoma patients. This information may be used for targeting comorbidity management in these patients. The observed association of adjuvant radiotherapy with higher CVE risk warrants further investigation (AU)

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Stage IIA and IIB testicular seminoma treated post-orchiectomy with radiation therapy versus other approaches: a population-based analysis of 241 patients

Objectives To evaluate post-orchiectomy utilization of radiation therapy (RT) versus other management approaches in stage IIA and IIB testicular seminoma patients. Materials and Methods Two hundred and forty-one patients with stage IIA and IIB testicular seminoma were identified between 1988 and 2003 using the Surveillance, Epidemiology, and End Results (SEER) database. Results Median follow-up was 10 years. Patients with stage IIA disease underwent RT more frequently than those with stage IIB disease (72% vs. 46%, respectively; P<0.001). There was no significant change in RT utilization for stage IIA or IIB disease between 1988 and 2003 (P = 0.89). Conclusions Between 1988 and 2003, stage IIA patients underwent RT more often than stage IIB patients in the United States. There was no significant change in RT utilization for stage IIA or IIB disease during this time period. Based on reports describing excellent progression-free survival with cisplatin-based chemotherapy, this approach has increased in popularity since 2003 and may eventually become the most popular treatment approach for both stage IIA and IIB testicular seminoma. .

Adjuvant Radiotherapy Outcome of Stage I Testicular Seminoma: A Single Institution Study

PURPOSE: To analyze treatment outcome and side effects of adjuvant radiotherapy using radiotherapy fields and doses which have evolved over the last two decades in a single institution. MATERIALS AND METHODS: Forty-one patients received radiotherapy after orchiectomy from 1996 to 2007. At our institution, the treatment field for stage I seminoma has changed from dog-leg (DL) field prior to 2003 to paraaortic (PA) field after 2003. Fifteen patients were treated with the classic fractionation scheme of 25.5 Gy at 1.5 Gy per fraction. Other patients had been treated with modified schedules of 25.05 Gy at 1.67 Gy per fraction (n=15) and 25.2 Gy at 1.8 Gy per fraction (n=11). RESULTS: With a median follow-up of 112 months, the 5-year and 10-year survival rates were 100% and 96%, respectively, and 5-year and 10-year relapse-free survival rates were both 97.1%. No in-field recurrence occurred. Contralateral seminoma occurred in one patient 5 years after treatment. No grade III-IV acute toxicity occurred. An increased rate of grade 1-2 acute hematologic toxicity was found in patients with longer overall treatment times due to 1.5 Gy per fraction. The rate of grade 2 acute gastrointestinal toxicity was significantly higher with DL field than with PA field and also higher in the 1.8-Gy group than in the 1.5-Gy and 1.67-Gy groups. CONCLUSION: Patients with stage I seminoma were safely treated with PA-only radiotherapy with no pelvic failure. Optimal fractionation schedule needs to be explored further in order to minimize treatment-related toxicity.

Seminoma gonadal retroperitoneal como causa poco frecuente de oclusión intestinal mecánica: presentación de caso

Introducción: las neoplasias testiculares de células germinales están entre el 1-3 por ciento de los tumores del hombre y el 4 por ciento de todos los tumores del sistema genitourinario. La frecuencia de estas neoplasias ha venido en aumento y se han hecho más frecuentes en varones jóvenes de 20 a 40 años, con una edad promedio de 32 años, con incidencia en la etapa más productiva del individuo. Presentación de caso: se presenta el caso de un paciente masculino de 53 años, atendido por urgencia, en el servicio de cirugía del Hospital General Provincial Docente Carlos Manuel de Céspedes en junio del 2013, con el diagnóstico de oclusión intestinal mecánica. Discusión: el cáncer de testículo supone el paradigma de un tumor curable, y actualmente se siguen diseñando nuevas estrategias de tratamiento para conseguir, por un lado, una mejor supervivencia en aquellos pacientes de peor pronóstico y, por otro, intentar reducir las toxicidades tardías. La enfermedad se diagnostica en estadio clínico I en el 70 por ciento de los casos, con ausencia de metástasis regional y a distancia, con una tasa de curación mayor de 95 por ciento independiente de si se administra o no terapia adyuvante post orquiectomia. Conclusión: con esta presentación se pretende presentar un caso poco frecuente de oclusión intestinal mecánica, actualizar el conocimiento acerca de los tumores testiculares y llamar la atención acerca de la importancia del adecuado examen físico de los genitales en las consultas, por parte de pediatras, médicos de familia, clínicos y cirujanos, que permitan un diagnóstico precoz de las criptorquidias y otras malformaciones genitales para evitar el desarrollo del cáncer gonadal fácilmente diagnosticable con un uso correcto del método clínico(AU)

Introduction: the testicular neoplasias of germinal cells are between 1-3 percent of tumors in men and 4 percent of all tumors of the genital urinary system. The frequency of these neoplasias has increased and it has become more frequent in young men of 20 to 40 years, with an average age of 32 years and an incidence in the most productive stage of the person. Case presentation: it is presented the case of a 53 year old patient, assisted in the emergency service of surgery at Carlos Manuel de Céspedes General Teaching Province Hospital in June, 2013, with the diagnostic of mechanical intestinal occlusion. Discussion: testicular cancer is a paradigm of a curable tumor and nowadays there are designed new strategies of treatment to obtain, on one hand, a better survival in the patients with worse prognosis, and on the other hand, the late toxicities are attempted to be reduced. The disease is reduced in clinical stage I in 70 % of the cases, with the absence of regional metastasis in the distance, with a healing rate over 95 %, no matter if the post orchiectomy adjuvant therapy is provided or not. Conclusion: with this presentation it is intended to present an infrequent case of mechanical intestinal occlusion, updating the knowledge about the testicular tumors and emphasizing the importance of the proper physical examination of genitals in the consultations, performed by pediatricians, family doctors, clinics and surgeons, who favor a precocious diagnosis of cryptorchidism and other genital anomalies, to avoid the gonadal cancer, easily diagnosed with a proper use of the clinical method(EU)

Seminoma estadio I radioterapia adyuvante: resultados a 3 años / State I seminoma adjuvant radiation therapy: results of 3 years

Evaluar los resultados obtenidos con radioterapia adyuvante. Se analizaron 40 historias clínicas de pacientes con diagnóstico de cáncer de testículo estadio I; todos recibieron radioterapia adyuvante entre abril de 1992 y mayo de 2004. El tipo histológico fue seminoma. El diagnóstico y la estadificación se efectuaron con ecografía testicular, determinación de marcadores tumorales, tomografía axial computada de abdomen y pelvis y radiografía de tórax. Los pacientes fueron tratados con unidad de cobalto 60 y acelerador lineal de 6 MV de fotones. Volúmenes: región ganglionar lumboaórtica y pelviana ipsilateral vs. lumboaórtica solamente. Dosis diaria: 1,8 Gy Dosis total: 30,6 Gy. El seguimiento se efectuó durante 3 años con radiografía de tórax y tomografía axial computada de abdomen y pelvis a los doce meses y luego un control clínico completo una vez por año. Se definió la tasa de recidiva en ganglios pelvianos ipsilaterales (0 por ciento vs. 6,25 por ciento), progresión a distancia (8,3 por ciento vs. 0 por ciento) y supervivencia global (100 por ciento vs. 100 por ciento) a tres años de seguimiento. Nuestro resultado es similar a lo publicado en la bibliografía internacional. Teniendo en cuenta el escaso número de pacientes, no se evidenció cambios en la supervivencia global en el agregado de radioterapia a ganglios pelvianos ipsilaterales. La radioterapia a ganglios lumbo-aórticos es el tratamiento habitual, siendo necesario optimizar la modalidad de la radioterapia con técnicas en tres dimensiones o intensidad modulada para disminuir la toxicidad a largo tiempo.

To evaluate the results obtained with adyuvant radiotherapy. We analyzed 40 clinic histories of testis cancer stage I diagnosed patients were studied. All of them received adyuvant radiotherapy between April 1992 and May 2004. The most common histological type was seminoma. The diagnosis and the staging were done through testicular ultrasound, serum tumor markers determination, abdomen and pelvis CT, and chest Rx films. The patients were treated with Cobalto 60 unit and linear accelerator of 6 Mev of photons. Volume: Para-aortic and paracaval lymph node region and ipsilateral illiac node region vs. para-aortic and paracaval lymph node region only. Daily dose: 1.8 Gy total doses 30.6 Gy. Followup was done during 3 years with chest Rx and abdomen and pelvis CT at 12 months, and a whole clinic check-up once a year. Recurrence rate in ipsilateral iliac nodes (0 % vs. 6.25 %) distance progression (8.3 % vs. 0%) and global survival (100 % vs. 100 %) in three years follow-up was established. Our results are similar to the ones published in world literature. Bearing in mind the scarce number of patients, changes in global survival were not shown when radiotherapy in ipsilateral illiac nodes was added. Radiation therapy in para-aortic and paracaval lympth nodes is the standard treatment, there is being necessary to optimize the radiotherapy modality with other radiation therapy techniques: In three dimension and modulated intensity to diminish the long term toxicity.

Management consideration in nonpulmonary visceral metastatic seminoma of testis

To develop a more appropriate therapeutic strategy for treatment of nonpulmonary visceral metastatic testicular seminoma based on the International Germ Cell Consensus Classification, we reviewed the medical records of patients with nonpulmonary visceral metastatic testicular seminoma who were treated over a 20-year period. Only 15 (2.2%) of the 686 cases of testicular seminoma were nonpulmonary visceral metastatic seminoma. The median age of patients was 38 years (range, 22-53 years). Ten (67%) of the patients had an initial diagnosis of supradiaphragmatic or visceral metastatic disease. In addition to nonpulmonary visceral metastasis, all patients had lymph node metastasis as well, the majority of which involved the retroperitoneal lymph nodes. The median and mean progression-free survival durations after chemotherapy for advanced disease were 19 months and 63.7 months, respectively. Six patients (40%) survived, five relapsed after radiation therapy and four died of chemorefractory disease not dependent on the specific regimen. Although the number of cases reviewed in this study was small, we conclude that the choice of chemotherapeutic regimen among the current treatments for nonpulmonary visceral metastatic seminoma of testis primary does not present a different outcome. Therefore, multimodality therapies using new strategies or new agents are well indicated.

Seminoma de testiculo: evolución de 20 años / Semioma: 20 years of evolution

Se hace la presentación de un caso de seminoma testicular en un paciente de 2 años de edad, intervenido quirúrgicamente y sometido a radiaciones. Actualmente tiene 22 años y está en perfecto estado de salud(AU)

Seminoma estadio 1: ¿radioterapia u observación? / Seminoma stage 1: radiotherapy or observation?

La mayoría de los pacientes son seminoma estadio I son tratados con orquiectomía y radioterapia a los ganglios retroperitoneales. Esto se debe a que el seminoma es extraordinariamente sensible a la radioterapia y los resultados son excelentes, con una sobrevida libre de enfermedad de alrededor del 99 por ciento. Sin embargo, recientemente algunos oncólogos han propuesto tratar los enfermos solamente con orquiectomía y observación. Es fundamental para esta nueva modalidad de tratamiento que los enfermos que presenten progresión de la enfermedad puedan ser tratados oportunamente y adecuadamente con radioterapia o quimioterapia