Page 5 - Guideline

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Management of testicular germ cell cancer

Table 3. Summary of surveillance studies in stage I seminoma

Median No. patients Cause-specific
Author Year No. patients Relapse, %
follow-up (mo) relapse survival, %
Daugaard 13 2003 60 394 69 17.5 100
Germa Lluch 14 2002 33 233 38 16 100
Horwich 15 1992 62 103 17 16.5 100
Oliver 16 2001 98 110 21 19 100
Ramakrishnan 17 1992 44 72 13 18 100
Von der Maase 18 1993 48 261 49 18.8 98.9
Warde 19 2005 98 421 64 15.2 99.7
Tyldesley 20 2006 33 93 16 17.2 97.8

largest study of second cancers in long-term survivors of ment strategy. The Medical Research Council in the United
testicular cancer was conducted by Travis and colleagues Kingdom has conducted a randomized phase III study of
at the National Cancer Institute Cancer Epidemiology 1447 patients comparing adjuvant radiotherapy and a sin-
Division. 35 This report combined 14 population-based reg- gle course of carboplatin. 37 The relapse rate in both arms
istries including 10 534 patients with seminoma (all stages) of the study was similar at 3 years (3.4% radiotherapy vs.
treated with radiotherapy. Compared with matched cohorts 4.6% carboplatin) with most of the recurrences in the car-
from corresponding registries, the overall relative risk of a boplatin arm occurring in the retroperitoneal lymph nodes.
second non-testicular malignancy was 2.0 (95% CI 1.8–2.2). One possible benefit of adjuvant carboplatin noted in this
For a 35-year-old patient with seminoma, the cumulative setting was a reduction in the incidence of second primary
40-year risk of a second malignancy was 36%, compared testicular GCTs. Data from other single institution series
with 23% in the normal population. These results were indicate that if adjuvant carboplatin is given in this setting,
confirmed in a Dutch population-based study of more than 2 courses of treatment are likely necessary. 22,38 Even with
2700 long-term GCT survivors in which the second malig- 2 cycles of carboplatin, a small but significant percentage
nancy risk with subdiaphragmatic radiation therapy was of patients recur in the retroperitoneum and the usefulness
2.6-fold increased as compared to surgery alone. 36 The of this approach is questionable. The relapse pattern after
increased risk associated with radiation therapy was simi- adjuvant single agent carboplatin mandates that continued
lar to the increased cancer risk seen with smoking. surveillance of the retroperitoneal lymph nodes is required
(similar to surveillance), and the reduction in relapse rates
Adjuvant chemotherapy is only from 15% with surveillance to 5% in those given
adjuvant chemotherapy. Eighty-five percent of patients
Adjuvant chemotherapy using 1 to 2 cycles of carboplatin receive unnecessary treatment and the long-term toxicity
has recently being investigated as an alternative manage- and long-term control rates with this strategy are unknown.

Consensus recommendations
Table 4. Adjuvant radiation therapy studies in stage I
seminoma
Patients should be informed of all treatment options, includ-
Cause-
Years of ing the potential benefits and side effects of each treatment.
Author No. patients Relapse, % specific
study In a patient willing and able to adhere to a surveillance
survival, %
program, this approach should be considered as the man-
Bayens 23 1975-1985 132 4.5 99%
agement option of choice (Fig 1).
Coleman 24 1980-1995 144 4.2 100% A risk-adapted approach with surveillance for low-risk
Fossa 25 1989-1993 478 3.8 100% patients and treatment for those at higher risk of relapse
cannot be recommended at the present time; the prognos-
Jones 26 1995-1998 625 3.5 9.6%
tic model on which this approach is based has not been
Santoni 27 1970-1999 487 4.3 99.4%
validated and has poor discriminative ability.
Warde 19 1981-2002 283 5 100%

CUAJ • April 2010 • Volume 4, Issue 2 E23