Outcomes

Recurrence Rates after treatment

Stage I Seminoma

  • Surveillance
    • All patients: 15-20% recurrence within 5 years
    • Low risk patients: 10 - 12% recurrence within 5 years
    • Disease specific survival: 99%
  • Para-aortic Radiotherapy
    • Cure rate: 97-99%
    • Relapses occur in iliac nodes (40%) and mediastinum (25%) and lung (25%)
  • Single dose carboplatin (AUC 7 mg/ml/min)
    • Cure rate: 95-97%
    • Relapses occur in para-aortic nodes in over 80% of cases

Stage IIA/B Seminoma

  • Radiotherapy (dog leg)
    • 95% (IIA) 5 year recurrence free survival
    • 87% (IIB) 5 year recurrence free survival

Stage IIC/IIIA/IIIB/IIIC

  • Chemotherapy (BEP or EPI)
    • Good prognosis (no visceral mets outside of lungs) - 82% 5 year progression free survival
    • Intermediate prognosis (visceral mets outside of lungs (M1b)) - 67% 5 year progression free survival

Residual Mass for Stage II Patients

A small number of patients will have residual mass on follow up CT after treatment with chemotherapy or radiotherapy. The possibilities are:

  • Fibrous scar tissue
  • Residual seminoma
  • Residual non-seminomatous germ cell tumour (usually teratoma)

For lesions < 3 cm, a series from the MSKCC demonstrated no residual tumour.
For lesions > 3 cm, about 30% contained residual tumour. The management of these lesions is complex:

  • Observation may be appropriate as most patients will not have malignancy; however, the possibility of disease progression to unresectability must be considered
  • Surgical resection is possible and may be curative, but is associated with significant morbidity.
  • Radiotherapy has been shown to have no impact on outcomes

Long term toxicity

Radiotherapy

Population studies have identified concerning trends following radiotherapy delivery:

  • In a study of forty thousand testicular cancer survivors who received radiotherapy, the risk of developing a second malignancy was doubled for the twenty five years after treatment
    • This included malignancy in sites not in the radiotherapy fields
    • Results may be confounded by excess risk possessed by patients who have developed a seminoma in the first place.

Other long term toxicities following radiotherapy include:

  • Increased rate of gastro-oesophageal reflux disease, gastritis and peptic ulcer
  • Increased rate of cardiac mortality (non significant trend of about 2x risk, even without prophylactic mediastinal radiation)
    • Mechanism likely to be due to irradiation of coronary vessels in long para-aortic field, or alternatively due to irradiation of renal arteries and resulting hypertension

Chemotherapy

The same study also examined patients with germ cell tumours who received chemotherapy and found a similar risk (double) of developing a malignancy. Combined chemoradiotherapy was associated with a threefold increase in risk. Again, there was no way of separating the second malignancy rate due to patient factors rather than treatment factors.

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