The management of stage I testis cancer

For clinical stage I seminoma, conventional management consists of adjuvant RT after orchiectomy. Only 5% of patients relapse. The majority can be salvaged by chemotherapy. The overall survival of 98% is excellent. Seminoma is radiosensitive. A lower dose of RT is required than for NSGCT. Standard therapy presently is 30 Gy in 3 weeks, as suggested by the MRC study. RT is generally well tolerated. There have been recent concerns about second malignancies after 10 to 15 years. Surveillance studies have shown that 18% of patients relapse, the majority in para-aortic lymph nodes. About 15% require salvage RT and 5% salvage chemotherapy. Second relapses are seen in patients treated with RT at first relapse, and occur outside of the radiation field. The main advantage of surveillance is that 80% of patients can be spared slightly toxic overtreatment. The main disadvantage is the need for long-term follow-up, which is expensive and stressful to the patient. Good patient compliance, mandatory to an observation policy, is often difficult on a long-term basis. Seminoma is clearly responsive to chemotherapy. Adjuvant carboplatin in clinical stage I has only been evaluated in two studies. Because reliable prognostic factors have not been established, a high-risk group cannot be identified, and chemotherapy must be given to all patients. Whether or not one cycle of chemotherapy is sufficient requires further confirmation, particularly in view of the results with carboplatin as compared with cisplatin in patients with advanced NSGCT. Results of the randomized MRC trial comparing RT with carboplatin are of interest.