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
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
- 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
- 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
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.
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