Seminomas account for approximately 50% of all cases of testicular cancer.
Stage I seminoma makes up about 35% of all germ cell testicular cancers.
Seminomas consist of germ cells that have been transformed and resemble gonocytes but have a differentiation block.
Seminomas, account for 50% of all germ cell tumors, tend to be less aggressive than non-seminomatous tumors and follow a relatively predictable course.
While approximately 80% of patients with seminomatous germ cell tumors present with stage I disease, 66% of patients with nonseminomatous GCT’s present with stage II or III disease.
Stage IIA and and stage IIB are defined by metastatic lymph nodes below the diaphragm of up to 5 cm in size and account for about 10% of all cases.
Fewer than 5% of patients with seminoma have distant metastasis at presentation.
Fewer than 5% of patients with Seminoma have distant metastases at presentation.
Seminoma is a very sensitive to radiation and chemotherapy and visceral metastases are uncommon.
When seminomas spread, they usually spread to the retroperitoneal lymph nodes.
The incidence of seminoma has been increasing in the majority of the cases are diagnosed as clinical stage I.
Overall survival for all testicular cancers is improved from 83-96% percent over the last 3 decades.
The survival rates of patients remain high, even those who have the most advanced stages of the disease, with an overall survival at 5 years of approximately 79%.
About half of patients with testicular cancer have pure seminoma disease.
These tumors generally have a lower stage at diagnosis then nonseminomatous germ cell tumors, are generally less advanced and associated with better survival.
Most common histology in testicular cancers in older population and rare in those younger than 10 years.
70-80% of patients with pure seminomatous disease have stage I disease.
Patients with pure seminoma have elevated levels of B-HCG but not AFP.
Patients with seminoma may have elevated beta hCG or LDH.
The presence of an elevated AFP level indicates non-seminomatous elements.
Until recently postorchiecctomy radiation the para-aortic lymph nodes was the standard of care.
A survival rate of 100% is an expected outcome, no matter what treatment option is chosen.
Stage I associated with a relapse rate of 3-5% after radiation and orchidectomy.
Most patients with stage I seminoma are cured by orchiectomy alone.
Options after initial orchiectomy in pure seminoma include active surveillance, radiation, or chemotherapy with 1-2 cycles of carboplatinum.
Indications for surgery, beyond the initial orchidectomy is limited and the most common indication is resection of residual retro peritoneal masses after chemotherapy
Post-chemotherapy surgery is difficult owing to a desmoplastic reaction and loss of tissue planes, which increase operative Mobility and limit the role of full retroperitoneal lymph node dissection. radiation.
If radiotherapy is selected, 20 Gy is delivered to the ipsilateral retroperitoneal lymph nodes, and if the patient has a history of prior surgery in the inguinal, pelvic, or scrotal area then the radiation field is expanded to include the inguinal lymph nodes.
Most patients today elect active surveillance, given the low chance of disease recurrence.
Present day survival of 99%, disease specific, irrespective of management.
Following radiation for stage I disease there is a small increase in the risk of second cancers, cardiovascular morbidity and peptic ulcer disease.
Surveillance for stage I disease is a safe and effective alternative management.
Surveillance allows 80-85% of patients to avoid any postorchidectomy treatment, and for those that do relapse radiation therapy and those requiring chemotherapy survival rates do not differ from that of patients treated with adjuvant radiotherapy.
Initial management of a pure seminoma involves a radical inguinal orchiectomy, as it is both diagnostic and therapeutic
Majority of clinical stage I relapses occur in the retroperitoneum in the infradiaphragmatic lymph nodes.
Patients followed for stage I disease have a recurrence rate of 15-20%, with most treated successfully with salvage chemotherapy.
Of more than 5000 stage I seminomas, independent of treatment, the risk of recurrence is highest the first 2 years and decreases thereafter.
One course of carboplatin compared to para-aortic radiation for stage I disease associated with an equivalent 3-year relapse free interval (5.2 vs. 4.1%, with reduced secondary neoplasms.
In stage I disease treated with one course of adjuvant carboplatin 74% of recurrences were in the para-aortic nodes, a markedly different pattern of recurrence than with adjuvant radiation therapy.
In patients treated with adjuvant carboplatin for stage I disease there was reduction in the incidence of contralateral primary testicular tumors, suggesting that one cycle of chemotherapy may be able to prevent in-situ cancer from progressing.
The likelihood of developing a second germ cell tumor is only 2%, therefore carboplatin in stage I disease to prevent a second primary tumor is not a reccommended strategy.
Single agent carboplatinum is less effective than etoposide plus cisplatin in advanced seminoma and has an unacceptably high rate of relapse in clinical stage IIA and IIB seminoma.
Adverse prognostic factors for relapse in stage I disease includes tumor size of greater than 4 cm and involvement of the rete testis.
Lymphovascular invasion does not predict for relapse for stage I seminoma compared with its importance with nonseminomatous GCTs.
Tumor size of greater than 4 cm and a rete testis invasionn are risk factors predicting relapse.
Surveillance studies show that 13% of patients with stage I seminoma relapse, with a median time 2 relapse of 14 months and 92% of recurrences are seen within 3 years.
Surveillance Is a preferred option for patients with pT1-pT3 tumors.
Postoperative management of men with clinical stage I testicular includes adjuvant radiation, or single agent chemotherapy, or surveillance.
53 Surveillance for postorchiectomy stage I include serum tumor markers every 3 to 6 months for the first year, every 6 to 12 months for years 3 and 3 and annually thereafter.
Surveillance for postorchiectomy stage I include abdominal/pelvic CT every 3,6, and 12 months for the first year, every 6-12 months for years 2 and 3, and then every 12 to 24 months for years 4 and 5.
Initial relapses in the lung have not been reported in patients with stage I seminoma managed by active surveillance and routine chest imaging is only indicated for patients with thoracic symptoms.
The risk of recurrence after adjuvant treatment with carboplatin or radiation resistant 0.3% annually in follow-up in such patients includes serum tumor markers every 6-12 months for the first 2 years and annually thereafter.
Meta-analysis of 2466 patients treated with either radiation or carboplatinum for stage I disease, recurrence rarely occurred after more than 3 years, involving only 0.2 patients.
Stage I seminoma patients treated with radiotherapy or carboplatinum are recommended to have abdominal pelvic CT scans annually for 3 years and chest radiographs obtained only one clinically indicated.
Pure seminoma stage IS refers to persistent elevation of serum tumor markers after orchiectomy and is rare and usually is evidence of metastatic disease.
Radiotherapy and chemotherapy as adjuvant therapy for clinical stage I seminoma have equal efficacy.
While active surveillance avoid over treatment approximately 17% of patients with stage I disease will relapse (Groll).
For most patients with CTclinical stage I seminoma surveillance is the management of choice.
Surveillance is recommended for patients who have undergone previous radiotherapy, have a horseshoe kidney, and inflammatory bowel disease.
For stage I disease and involvement of the rete testis and a primary tumor size of greater than 4 cm or risk factors as noted and an analysis of surveillance studies with 638 patients (Warde P).
Relapse rate is approximately 17% for primary tumors greater than 4 cm without rete testis and patient and 12% for a primary tumor of less than 4 cm and no repeat invasion, and 14% for repeat invasion and primary tumor of less than 4 cm (Warde).
High-risk patients with adjuvant radiation or chemotherapy will still have a relapse rate of 3-to 4% (Dieckmann KP).
In a meta-analysis stage I patients evaluated by active surveillance the relapse rate was 17%, with the disease-specific survival near to 100% (Groll RJ).
In a randomized study of 1477 patients with stage I testicular cancer treated with radiotherapy or one injection of carboplatinum: relapse free survival rates were similar (Oliver RT et al).
Radiotherapy in clinical stage I seminoma has a five-year progression free survival of over 94% in virtually all relapses occur outside the radiation field (Yang GY).
Following radiation therapy for this process the risk of a second malignancy doubles, as compared to the general population with the risk of a solid cancer between 5 and 10% which translates into an additional 6-9 cancers over 25 years after the treatment for every 100 men treated.
Malignancies associated with radiation are usually in the area of the field and include bladder, kidney and skin cancers, but prostate, lung, head and neck cancers have also been reported felt to be secondary to radiation scatter.
Radiation scatter is also associated with cardiotoxicity .
Presently radiation ports have been reduced and now extend no further than the T. 11 vertebrae and mediastinal fields are not included.
As seminoma is one of the most radiosensitive malignancies dose reductions and reductions in radiotherapy field size had been employed: No excess risk of recurrence is seen with 20-Gy dose versus 30-Gy in the European Organization for Research and Treatment of Cancer (Jones).
It is possible that ipsilateral hemipelvis radiation can also be avoided if the patient had not had previous surgery then alter the lymphatics (Fossa SD).
Surveillance management in stage I disease prevents over treatment in >80% of patients, no risk to fertility, no acute toxicity, no risk of cardiotoxicity or second malignancy.
Carboplatin is presently the primary adjuvant chemotherapy treatment alternative for stage I disease.
A single cycle of carboplatinum proved to be noninferior to radiotherapy in terms of relapse rates and survival with a 4 year followup (Oliver RTD).
In the above syudy with a median follow-up of 4 years 74% of recurrences were in the retroperitoneum.
When two courses of carboplatinim were given for stage I disease all but one relapse occurred in the retroperitoneum (Aparicio J et al).
As an adjuvant therapy for clinical stage I disease carboplatin treatment will be given unnecessarily to 80-85% of patients, and for those that relapse post treatment CT surveillance is required, so that any reduction in the relapse rate attributable to carboplatin is not balanced by lesser lifetime radiation exposure or potential risk from less surveillance by CT scans (Brenner DJ, Hall EJ).
Other studies suggest that 2 courses of treatment are necessary with carboplatinum (Dieckmann KP).
With surveillance with stage I seminoma 30% of relapses occur after 2 years and 5% after 5 years (Warde P et al).
If adjuvant radiation therapy is given guidelines recommend a total dose of 20 Gy in 10 daily 2 Gy fractions, given to an infradiaphragmatic area, Including para-aortic lymph nodes and in special circumstances may include ipsilateral ilioinguinal nodes.
Radiation is generally not given to patients with a history of pelvic surgery because of a higher risk of morbidity and prophylaxis the mediastinum is not provided because relapse rarely occurs at that site. A
Extragonadal seminoma, such as those arising from the mediastinum, are treated with chemotherapy regimens.
Standard treatment for stage IIAend stage IIBseminoma include either paratric and ipsilateral pelvic dogleg or hockey stick radiotherapy or cisplatinum based combination chemotherapy with three or four cycles of treatment.
More than 90% of patients can be cured by these approaches, with chemotherapy being the preferred choice and stage IIB disease.