Controversies in the management of testicular seminoma

The 5-year cause specific actuarial survival rate for 178 patients treated for testicular seminoma at The Princess Margaret Hospital 1977 to 1981 is 97%. Controversies exist over how to optimally use and integrate chemotherapy (CT) and radiation therapy (RT) to minimize morbidity and achieve these high cure rates. These are as follows: "surveillance only" for Stage I, the necessity of prophylactic mediastinal RT (PMI) for Stage IIA, initial RT versus CT for Stage IIB, optimal therapy for Stages III and IV, and the significance of elevated serum tumour markers. In Stage I, relapse after abdominopelvic RT (2500 cGy in 20 fractions) occurred in 2 of 150 patients (1.3%). Without routine RT relapse rates are unknown. Only 1/370 Stage IIA patients in the literature treated with infradiaphragmatic RT without PMI developed uncontrolled mediastinal disease. Prophylactic mediastinal RT confers a possible survival benefit of only 0.2% and cannot be recommended. Stage IIB is rare (only 4% of 178 patients). Initial CT produces complete responses in approximately 80% of patients, but its curative potential is unknown therefore consolidation RT or surgery is often given. Initial subdiaphragmatic RT followed by CT for relapse cures at least 85% of patients (5/5 marker negative) and spares 50% of unnecessary CT. Sequential therapy minimizes potential treatment morbidity without compromising cure. Initial CT is recommended for Stages III and IV. The literature survival after RT is only 36% (136/375). The role of consolidation RT is unknown. Optimal management of seminoma implies integration of RT and CT to decrease morbidity and still maintain high cure rates.