Management of clinical stage I testicular pure seminoma. Report on 42 patients and review of the literature.

INTRODUCTION: Testis cancer is the most common tumor detected in men aged from 20 to 35 years accounting for 1-2%. About 20-30% of patients presenting with clinical stage I pure seminoma of the testis, which accounts for 45-50% of all germ cell tumors, present with occult metastases in the retroperitoneal lymph nodes. Currently, treatment options for clinical stage I seminoma include adjuvant radiotherapy (RT) as well as surveillance and adjuvant single agent chemotherapy. Herein, we review our experience in the management of 42 patients with clinical stage I pure seminoma of the testis and review the literature concerning this topic. MATERIALS AND METHODS: Between January 1977 and December 2000, of 56 patients with pure seminoma of the testis 42 (75%) were assessed as clinical stage I disease. Adjuvant RT was performed in 41 patients and surveillance in 1. Radiations fields included the para-aortic and ipsilateral pelvic lymph nodes. A radiation dose of 25 Gy in 20 daily fractions was given. All patients were followed up. RESULTS: Average age was 41.2 years (range 24-67). Mean follow-up was 85.3 months (range 12-279). Histopathology assessed classic seminoma in 41 cases (98%) and spermatocytic seminoma in 1 (2%). Small vessel invasion was detected in 8 cases (19%). Overall relapse rate was 4.7%. Overall survival rate resulted 97%. CONCLUSIONS: Adjuvant radiotherapy (RT) is a safe standard of care in controlling microscopic retroperitoneal disease in patients with clinical stage I seminoma. About 3 to 5% of patients undergo relapses, mostly after the first 18 months after orchiectomy. Overall cause-specific survival rates range between 96% to 100%. An alternative optional treatment for compliant patients presenting with low risk factors for relapse is surveillance with recurrences rates ranging between 15% to 20%. Surveillance avoids unnecessary treatment in about 80% of patients, thus it could be offered as a safe alternative option to adjuvant RT since imaging detects relapses at their early stages. Adjuvant chemotherapy with 1 or 2 courses of single-agent carboplatin is being investigated as an alternative adjuvant treatment to RT or surveillance in patients with moderate to high risk factors for relapse. The treatment is well tolerated and recurrence rate is 1%.

Management of testicular seminoma advanced disease. Report on 14 cases and review of the literature.

INTRODUCTION: About 25% of testicular seminomas present with advanced clinical stage disease. The retroperitoneal lymph nodes are more likely to be involved (20%) than distant organs (5%). Herein we review our experience in the management of 14 patients with clinical stage II pure seminoma of the testis and review the literature concerning this subject. MATERIALS AND METHODS: Between January 1977 and December 2000, of 56 patients with pure seminoma of the testis 14 (25%) were assessed as clinical stage II disease. RT was performed for clinical substage IIA-IIB and chemotherapy in for IIC disease. All patients were closely followed up. RESULTS: Average age was 39.3 years (range 23-47). Mean follow-up was 88.6 months (range 28-232). Clinical stage IIA-IIB was detected in 12 patients (86%) and IIC in 2 (14%). Relapse did not occur in any patient. At the last follow-up evaluation, all patients were alive and disease-free. CONCLUSIONS: Radiation therapy is the standard of care in managing seminoma small bulk retroperitoneal disease including substages IIA and IIB. Overall toxicity of RT is mild and treatment is well tolerated. After RT, about 20% of patients may undergo relapses. Chemotherapy is the choice treatment for advanced seminoma presenting with clinical stage IIC-III disease; recently, it has also been advocated for stage IIB when presenting with multiple small lymph nodes. Carboplatin and cisplatin are the most effective agents with complete response rates of 89-91%. Patients developing progressive disease after first-line chemotherapy undergo combined salvage chemotherapy with cisplatin, ifosfamide and vinblastine with complete response rate of 83%. Patients presenting salvage chemotherapy failure are treated with high-dose chemotherapy associated with autologous bone marrow transplantation. Residual retroperitoneal masses after chemotherapy for advanced seminoma may be assessed by imaging as poorly or well defined. Surveillance is indicated for residual masses smaller than 3 cm as well as for poorly defined masses equal or greater than 3 cm. Well defined masses equal or larger than 3 cm are treated with surgery or RT. Ongoing clinical trials for testicular germ cell metastatic disease are focused on reducing toxicity without compromising efficacy as well as exploring new salvage strategies and improving the prospect of cures and survival rates.