Surveillance Should Be the Standard Approach in Patients with Stage I Seminoma

Reviewer: Charles Wood, MD
Abramson Cancer Center of the University of Pennsylvania
Last Modified: October 17, 2005

Presenter: P. R. Warde
Presenter's Affiliation: Princess Margaret Hospital, Toronto, ON
Type of Session: Scientific

Background

Management options for stage I seminoma in the adjuvant setting include radiotherapy, chemotherapy, and surveillance. Although surveillance has become an established treatment strategy over the past decade, radiation continues in widespread use despite a late toxicity profile including decreased fertility, increased cardiac morbidity and mortality, and increased risk of second malignancy. This retrospective study considered outcomes with both radiation and surveillance for all stage I seminoma patients seen at Princess Margaret Hospital over a 22 year period.

Materials and Methods

  • Retrospective review of 704 patients with stage I seminoma seen at Princess Margaret Hospital between January 1981 and December 2002
  • Of these patients, 421 managed with surveillance and 283 treated with radiation
  • Patient preference determined management
  • Surveillance and radiation groups were well-balanced with respect to age, tumor size, rete testis invasion, and cryptorchidism

Results

  • Median follow-up was 9.2 years for all patients (surveillance 8.1 years and adjuvant radiation 10.2 years)
  • 64 patients in the surveillance group relapsed for a 5Y relapse-free rate of 85.5%
  • The majority of relapsing patients in the surveillance group did so in the para-aortic nodes alone (89%) and were treated with radiation (75%), chemotherapy (21%), or surgery (4%); of the patients treated at relapse with radiation, 5 developed a second relapse and were salvaged with chemotherapy
  • There was a 4.6% actuarial risk at 10 years of requiring chemotherapy for a first or second relapse in the surveillance group
  • 14 patients in the radiation group relapsed for a 5Y relapse-free rate of 95.1%
  • Of the relapsing patients in the radiation group, 10 were salvaged with chemotherapy, 3 with radiation (inguinal recurrences), and 1 with surgery
  • There was a 3.9% actuarial risk at 10 years of requiring chemotherapy for a first or second relapse in the radiation group
  • 1 patient died from relapsing seminoma in the surveillance group following failed salvage with chemotherapy

Author's Conclusions

  • 85% of patients in the surveillance group were cured with orchiectomy alone
  • The proportion of patients eventually requiring chemotherapy was similar in both groups
  • Given the late toxicity profile of radiation in this relatively young patient population and the nearly 100% long-term survival, surveillance should be considered the standard of care in stage I seminoma

Clinical/Scientific Implications

This study argues for surveillance in lieu of immediate adjuvant radiotherapy in stage I seminoma patients. However, inherent in its retrospective nature is the lack of randomization between the two groups. Though the authors commented that the groups were well-balanced with regards to prognostic factors, it is highly unlikely that management was based solely on patient preference. The patients in the radiation group could represent a less favorable population that would require adjuvant therapy. The Princess Margaret group has previously published data attempting to identify stage I seminoma patients at higher risk of relapse based on a variety of prognostic factors, though the findings have not been validated. Using this approach to reserve immediate adjuvant therapy for high risk patients is deserving of additional investigation.

Blogs

Don't Assume You Understand
by Bob Riter
July 29, 2015