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.

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.

Overt testicular disease at diagnosis in childhood acute lymphoblastic leukemia: Prognostic significance and role of testicular irradiation.

Objective. To analyze the prognostic impact of overt testicular disease (OTD) at diagnosis and role of testicular irradiation in the same. Methods. Data of 579 boys treated at our center over 16 years was reviewed. Results. Fourteen (2.4%) males had OTD. 10 (71.4%) of these had high-risk disease. Patients with OTD, had a significantly higher incidence of mediastinal-adenopathy (p=0.001), hyperleucocytosis (p=0.004) and CNS disease at presentation (p<0.0001) compared to patients in continuous complete remission (CCR). 4 of the 11 patients with OTD, who opted for therapy, had relapse; 2 are in CCR. Although, survival in patients with OTD was inferior (p=0.183) compared to patients without OTD, it was not an independent prognostic factor (p=0.47). In the entire study cohort, symptom-diagnosis interval (p=0.006), white cell (p=0.001) and platelet count (p=0.001) at presentation were significantly associated with survival (Cox multivariate regression analysis). Conclusions. OTD was not an independent prognostic factor, despite association with high-risk features. Survival outcome was inferior. The observations indicate the need of revaluation of the present protocol with incorporation of intermediate dose and subsequently high-dose methotrexate (after assessment for toxicity and tolerance), risk-stratified therapy and plausibly omission of testicular irradiation.

Radiotherapy for stage I seminoma of the testis.

Background : After orchiectomy in stage I seminoma the standard is adjuvant radiation therapy. We analyzed the patients retrospectively to evaluate the contributions of the treatment volume and dosage to treatment outcomes. Materials and Methods : Between January 1999 and December 2005, 91 stage I seminoma patients with a median age 36 (range;22-62) applied to our center, who were treated using anterior-posterior parallel opposed fields with linear accelerator or Co60 after orchiectomy. Twenty-five (27.5%) patients received irradiation to the paraaortic and ipsilateral pelvic nodes, and 66 (62.5%) patients only received to paraaortic nodes. Results : With a follow up time of median 57 months (range; 27-104), paraaortic nodes treated group had 4 relapses (6%) - 3 of them pelvic, one of them both pelvic and paraaortic. Both paraaortic and ipsilateral nodes irradiated patients had only one relapse (4%) (P = 0.726). While the 5 year overall survival (OS) is 98.8%, it is 100% in the dog-leg group and 98.4% in the paraaortic group (P = 0.548). Univariate analyses of OS and Disease Free Survival (DFS) showed that there is no statistically significant difference related to factors as age, histologic subgroup, tumor size, rete testis involvement, radiotherapy (RT) fields, dose ranges and the therapy device. Conclusion : Adjuvant RT approach is the preferred for non-compliant low risk patients as well as intermediate and high risk patient in stage I seminoma. 20 Gy/ 10 fractions/ 2 weeks RT is the adequate treatment.

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.

Tumores de células germinativas / Germinative cell tumors

O trabalho aborda os tumores de células germinativas na infância, destacando sua importância, incidência, embriologia, marcadores tumorais, características clínicas nos diferentes sítios em que se localizam, estadiamento dos tumores gonadais e extragonadais e seu tratamento

Rabdomiosarcoma de epididimo / Epididymal Rhabdomyosarcoma

Se presenta un tumor mesenquimatoso maligno originado en las estructuras paratesticulares, que corresponde a un radiomiosarcoma de epidismo. Se destaca su baja incidencia en la literatura mundial y su manejo terapeútico multidisciplinario (cirugia, radioterapia, quimioterapia). Fue intervenido en el Servicio de Urología de Antártida Hospital Privado, en el año 1993 y se presenta su evaluación y seguimiento hasta la fecha

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

Valoración de la eyaculación y la fecundidad posteriores al tratamiento quirúrgico del carcinoma testicular con linfadenectomía retroperitoneal / Evaluation of ejaculation and fertility after surgical treatment of testicular carcinoma with retroperitoneal lymphadenectomy

Se comunica la experiencia del Servicio de Urología del HOspital de Especialidades, Centro Médico Nacional de Occidente, IMSS, con el diagnóstico y el tratamiento quirúrgico del carcinoma testicular con linfadenectomía retroperitoneal. Esta experiencia comprende un grupo de 40 pacientes que se diagnosticaron y se trataron dentro del periodo comprendido entre julio de 1991 y diciembre de 1994. Los resultados pusieron de manifiesto una edad promedio de 29.1 años al momento del diagnóstico; más de 60 por ciento de los pacientes tenían más de 25 años. La manifestación clínica más frecuente fue la presencia de una tumoración de consistencia firme en uno de los testículos, que se observó en 60 por ciento de los pacientes estudiados. En 20 por ciento había reacción de tipo inflamatorio sin dolor, y en la proporción restante de 20 por ciento había dolor agudo. En todos los casos se realizó orquiectomía con ligadura alta del cordón afectado, seguida por linfadenectomía retroperitoneal. El carcinoma se produjo en el testículo derecho en 80 por ciento de los pacientes, y el 20 por ciento restante lo hizo en el izquierdo. El estudio histopatológico de los testículos señaló que 40 por ciento de los tumores eran teratomas y 60 por ciento carcinomas embrionarios, El informe histopatológico de los ganglios linfáticos retroperitoneales resecados señaló negatividad a metástasis en todos los pacientes. El tiempo de evolución de la sintomatología al arribo para la primera consulta médica especializada en el servicio fue de seis meses. Una proporción de 90 por ciento de los pacientes experimentaron eyaculación anterógrada después de la linfadenectomía retroperitoneal.

Tumores de testículos: experiência pessoal com 15 pacientes e 16 tumores / Testis tumor: personal experience with 15 patients and 16 tumors

Os autores analisam retrospectivamente 16 casos de tumores de testículo diagnosticados em 15 pacientes de outubro de 1983 a janeiro de 1994. Diagnosticaram-se 14 casos de tumores germinativos de testículo em 13 pacientes. Um dos pacientes foi acometido de seminoma bilateral em épocas distintas. Dos 14 casos, 7 foram seminomas e 7 foram tumores nao-seminomatosos de tipos histológicos diversos. Houve 2 casos de tumores nao-germinativos do tipo linfoma (localizaçao secundária). Analisaram-se aspectos epidemiológicos, clínicos, métodos de diagnósticos, estadiamento e tratamento, bem como os resultados, que sao comparados com os da literatura mundial. O objetivo deste trabalho é demonstrar a experiência pessoal adquirida e comparar os resultados da análise com os das grandes séries disponíveis na literatura.

Post orchiectomy management in stage II testicular seminoma.

Twenty eight patients with stage II A and twenty patients with stage II B testicular seminoma were treated at this institute between January 1982 and December 1988. The three year crude survival observed in this retrospective analysis was 82% and 75% respectively. Post orchiectomy infradiaphragmatic radiotherapy was the mainstay of the treatment. In stage II A 4 patients were administered adjuvant chemotherapy as well. Prophylactic Mediastinal Irradiation (PMI) was not employed as a routine in this subgroup. Eight patients (28%) relapsed (Mediastinal Nodes--4, Pulmonary--3, Scrotal--1). In stage II B twelve patients were treated with primary abdominal radiotherapy and of them 4 were delivered PMI as well. Induction chemotherapy was administered in remaining 8 patients. Seven patients (35%) relapsed (Pulmonary-4, Mediastinal Nodes-3). Mediastinal recurrence was noted only in those who were treated with abdominal radiotherapy alone. Though salvage chemotherapy proved successful in 5 of the seven patients (70%) with nodal relapse, none of the patients with extranodal relapse responded to subsequent chemotherapy. For stage II A we recommend abdominal radiotherapy alone and for stage II B Induction chemotherapy is advised keeping radiotherapy reserved for residual mass. We do not advocate PMI as a routine in stage II testicular seminoma as no survival benefit is observed.

Seminoma puro de testículo: experiencia de tratamiento de 44 pacientes / Pure testicular seminoma: experience in treatment of 44 patients

Se revisaron las historias clínicas de 44 pacientes con diagnóstico de seminoma puro de testículo tratados entre 1981 y 1989. Veintiún pacientes (48%) fueron clasificados como estadio Iñ 16 pacientes (36%) como estadio IIAñ 4 pacientes (9%) estadio IIB y 3 pacientes (7%) estadio III. Tenían antecedentes de criptorquidia 7 pacientes (16%); de traumatismo testicular 9 pacientes (20%); orquiepididimitis 1 paciente (2%) y de malformación del aparato urogenital 1 pacientes (2%). El seminoma era típico en 43 pacientes (98%) y de variedad anaplásica en el paciente restante (2%). No hobu casos de seminoma espermatocítico. En 6 pacientes (14%) se halló un invel elevado de subunidad beta de gonadotropina coriónica humana persistente luego de la orquiectomía. Se identificaron en 2 de ellos células gigantes del sinciciotrofoblasto por medio de cortes seriados del espécimen quirúrgico. En todos los casos los niveles de este marcador sérico retornaron a valores normales luego del tratamiento primario radiante y/o quimioterápico. La sobrevida global para la totalidad de los pacientes es 96% a 8 años. Esto corresponde a un 100% para estadios I, IIA y IIB y 33% (1/3) para estadio III. No hubo fallas al tratamiento dentro de los campos de irradiación. Solamente 2 pacientes (5%) presentaron enfermedad recurrente en territorios extralinfáticos. Ambos fueron tratados exitosamente. La terapia fue en general bien tolerada y la toxicidad fue leve a moderada

Cáncer testicular avanzado / Advanced testis cancer

Se presenta la experiencia en 26 pacientes operados por el autor, portadores de cáncer de testículo avanzado, tratados con quimioterapia (Qx), calificados luego de respuesta parcial (RP) o no respuesta (NR) y sometidos a disección lumboaórtica retroperitoneal. Se diveden para su análisis un primer grupo formado por 9 pacientes con tratamiento misceláneo antiguo; 4 de ellos operados en RP y 5 en NR, y un segundo grupo de 17 pacientes; 13 operados en RP y 4 en NR. Se analiza el pobre rendimioento de los pacientes operados en NR, la morbilidad intra y postoperatoria destacando la ausencia de mortalidad en la serie. Todos los pacientes tuvieron un seguimiento mínimo de 3 años, consideradfo como suficiente para evaluar aparición de recidivas en esta neoplasia. En los pacientes operados en RP, luego de tratamiento moderno y suficiente, la resecabilidad fue de 84,61% y la sobrevida de 76,92%, comparada favorablemente con series internacionales, destacando que estas cifras pudieron ser aún mejores si se hubiera contado con Qx adecuada para tratar pacientes con neoplasis viable en el espécimen resecado. El 85% de los pacientes son menores de 30 años y de excelente pronóstico, a pesar de lo avanzado de la enfermedad

La totipotencialidad en los tumores testiculares / The totipotentiality in testicular tumors

Se revisaron los expedientes de 112 pacientes del Servicio de Urología, Hospital de Oncología, Centro Médico Naciona, IMSS, con diagnóstico de tumor testicular que se hubiera sometido a linfadenectomía retroperitoneal y biopsia ganglionar por extirpación o percutánea. Ninguno de los pacientes se había sometido previamente a quimioterapia ni radioterapia. Se encontró que 20.5%de los pacientes tuvieron metástasis de estirpe distinta a la del tejido tumoral primario. Se comentan las teorías que explican este fenómeno y se analizan los casos estudiados.

Radioterapia no seminoma / Radiotherapy in seminomas

Analisam-se os resultados obtidos no tratamento radioterápico de 82 pacientes portadores de seminoma puro do testículo. Os resultados säo considerados satisfatórios para os estádios I, II A e II B, e tecem-se outras consideraçöes terapêuticas para os estádios II C e III