What factors would lead you to consider RT for men with Stage I seminoma?

The Chung validation study did not find that size > 4cm or rete testis invasion are risk factors for relapse and the current NCCN guideline discourages using these criteria. Are there any factors that help with this recommendation?

2 Answers

Mednet MemberInvited Expert

Radiation Oncology · Cedars-Sinai Medical Center

Answered on

I strongly agree that observation should be the first option for Stage I seminoma with normal postop markers. Since cure rate is near 100%, we should be looking for the least morbid managment strategy.

I generally favor observation with an expectation that para-aortic relapses of less than 5 cm should be managed by radiotherapy. If all such relapses are treated with 3 cycles of BEP chemotherapy, then perhaps more prophylactic radiotherapy would be indicated to avoid the non-trivial chemotherapy. My point is that there should be a discussion of how to treat relapses when the post-orchiectomy management plan is created and RT for Stage II-type relapses should be expected, if relapse occurs.

Also, potentially the truly unreliable patient might be a candidate for prophylactic RT or carboplatin.

Additional comments:

While RT is associated with late toxicity, esp 2nd malignancy, we really don't have much long term toxicity data re: "modern" minimalistic PA-only, 20 Gy treatment. The risk of such treatment may be quite low.
At ASCO GU this year, there was a debate between med onc and rad onc re: managment of Stage II seminoma. While there as agreement more or less, med onc recommended BEP and rad onc recommended RT. Interestingly, there was some data for combined modality with carbo, single agent, x 2 (to treat microscopic disease) and RT "boost" to enlarged nodes only. Might be an interesting way to manage Stage II disease. (Ann Oncol. 2013 Aug;24(8):2104-7. Neoadjuvant carboplatin before radiotherapy in stage IIA and IIB seminoma. Horwich A, Dearnaley DP, Sohaib A, Pennert K, Huddart RA)

Mednet MemberInvited Expert

Radiation Oncology · Varian Medical Systems/Allegheny health network

Answered on

Our current recommendation is observation/surveillance for all stage I seminoma, irrespective of risk factors, as the first line of management unless compliance is a concern.

We are looking at the NCDB database for practice pattern and there is a growing positive trend of surveillance as first line, with the majority favoring that. After that, there is almost equal split of use of radiation or chemo as prophylactic treatment in recent times.