Is RT required in stage I Testicular Seminoma?

On the happy occasion of the republic day I thought of posting this second journal club in Isocentre.
This is a recent article in epub in JCO in 2011.

Tandstad T, Smaaland R, Solberg A, Bremnes RM, Langberg CW, Laurell A, et al. Management of Seminomatous Testicular Cancer: A Binational Prospective Population-Based Study From the Swedish Norwegian Testicular Cancer Study Group (SWENOTECA). Journal of Clinical Oncology [Internet]. [cited 20:04:42];Available from:

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The abstract is as follows

Purpose A binational, population-based treatment protocol was established to prospectively treat and follow patients with seminomatous testicular cancer. The aim was to standardize care for all patients with seminoma to further improve the good results expected for this disease.

Patients and Methods From 2000 to 2006, a total of 1,384 Norwegian and Swedish patients were included in the study. Treatment in clinical stage 1 (CS1) was surveillance, adjuvant radiotherapy, or adjuvant carboplatin. In metastatic disease, recommended treatment was radiotherapy in CS2A and cisplatin-based chemotherapy in CS2B or higher.

Results At a median follow-up of 5.2 years, 5-year cause-specific survival was 99.6%. In CS1, 14.3% (65 of 512) of patients relapsed following surveillance, 3.9% (seven of 188) after carboplatin, and 0.8% (four of 481) after radiotherapy. We could not identify any factors predicting relapse in CS1 patients who were subjected to surveillance only. In CS2A, 10.9% (three of 29) patients relapsed after radiotherapy compared with no relapses in CS2A/B patients (zero of 73) treated with chemotherapy (P = .011).

Conclusion An international, population-based treatment protocol for testicular seminoma is feasible with excellent results. Surveillance remains a good option for CS1 patients. No factors predicted relapse in CS1 patients on surveillance. Despite resulting in a lower rate of relapse than with adjuvant carboplatin, adjuvant radiotherapy has been abandoned in the Swedish and Norwegian Testicular Cancer Project (SWENOTECA) as a recommended treatment option because of concerns of induction of secondary cancers. The higher number of relapses in radiotherapy-treated CS2A patients when compared with chemotherapy-treated CS2A/B patients is of concern. Late toxicity of cisplatin-based chemotherapy versus radiotherapy must be considered in CS2A patients.

What is interesting in this study?

  1. 86.1 % are CS I patients
  2. Significant change in the treatment paradigm from 2000 - 2006
    1. Inital 4 years RT or surveillance was offered
    2. Later 2 years Single agent carboplatin at 7 AUC offered - so in the later two years most patients were being treated with chemotherapy.
  3. RT dose 27 Gy in 1.8 Gy per fraction using L shaped fields
  4. FU 2 years in most patients (96.9%)
  5. Large cohort study from two countries with a high incidence of seminomas
  6. Treating physicians dispensed both CCT and RT
  7. Imaging provided free of cost
  8. In essence no Financial incentive to choose one approach over other.
  9. Meticulous followup

Restricting ourselves to CSI patients

512 patients underwent surveillance:

  • 14.3% relapse rate observed (65)
      • All had abdominal nodal relapse
      • 94% had only abdominal relapse
    • Only 3% relapsed after 5 years
    • Salvage treatment:
      • 56 of 65 treated with EP x 4 (2 received BEP)
        • 2 had significant toxicity (1 MI and 1 Cerebral infarction)
        • 2 underwent further RT to residual disease)
        • 1 had relapse further down the line - treated with RT 27 Gy
      • 6 treated with RT alone
      • Two patients died following treatment for relapse
        • One secondary to a AMI at age of 36 years !!!
        • 2nd secondary to legionella septicemia 2ndary after 4th cycle of EP

481 patients treated with RT (as above)

  • 0.8% relapse - 4 patients
      • 2 in field
      • 1 mediastinum
      • 1 humeral bone mets - BEP x 4 plus 36 Gy RT
    • 3 patients treated with EP x 4 - no deaths till date despite one having 2nd relapse

188 patients received Carboplatin

  • 3.9% patients relapsed - 7 patients
  • All in abdomen - just like surveillance
  • Has the cohort with the shortest follow up
  • All relapses treated with EP x 4 - no 2nd relapse or death.
  • 4.5 times increased risk of relapse as compared to RT after adjusting for prognostic factors.
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