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Stage I Seminoma (confined to testes)
The standard treatment is radiotherapy to the para-aortic lymph glands and to the pelvic glands on the side of the tumour. Seminomas are exquisitely sensitive to radiotherapy. The relapse rate is 3-5% and overall survival is 92 – 99%.
Surveillance is an alternative to initial adjuvant radiotherapy. This involves regular follow up with CT scans and Chest X Rays and only irradiating if and when nodes become apparent. The relapse rate on surveillance is 20%. Thus, 80% of patients are cured by orchidectomy alone and will receive unnecessary radiation under standard treatment regimes. The 20% who relapse do so mainly at the para-aortic nodes.
Results of radiation treatment following relapse are good.
A third option in stage I seminoma is a course of Carboplatin chemotherapy. Results with Carboplatin are good and it is a reasonable option for patients with moderate to high risk seminoma who do not want radiotherapy.
Stage IIa Seminoma
The standard treatment is radiotherapy to the para-aortic glands and the pelvic glands on the side of the tumour. 10% of patients relapse post radiotherapy and overall survival is 96%.
Stage IIb, IIc, III and IV Seminoma
The standard treatment is chemotherapy with 4 cycles of Etoposide and Cisplatin. The overall survival is 85%. For patients with widespread disease beyond the lymph glands and lungs the survival is 57%. Fortunately most seminomas present with disease confined to the testicle.
Stage IIb and IIc are sometimes treated with radiotherapy but 18% of IIb and 38% of IIc cases will relapse after this treatment.
Stage I Non-seminoma
The standard treatment is different in the UK and the USA. In the UK (and SA) most patients are treated by regular surveillance. 70% are cured by orchidectomy alone and 30% will relapse. Most relapses take place within 5-6 months and most of these have elevated tumour marker levels. Relapse is treated very effectively with chemotherapy. The overall survival exceeds 95%.
In the USA the standard treatment is a retroperitoneal lymph node dissection. This is a major operation involving surgical removal of all the lymph glands around the aorta and vena cava. Results of retroperitoneal lymph node dissection are excellent with a 96% overall survival. Only the small number of patients who relapse are subjected to chemotherapy.
The major disadvantage of this treatment protocol is that 70% of patients undergo a major operation unnecessarily.
Primary chemotherapy after orchidectomy is a third option in stage I non-seminoma. This avoids the anxiety associated with surveillance, but 50 - 70% of patients who would have been cured by orchidectomy alone receive unnecessary chemotherapy. It may be a good option for high risk patients who are not suitable for surveillance due to social or other reasons.
Stage II, III and IV Non-seminoma
Chemotherapy is standard treatment for non-seminoma that has spread beyond the testes. Most regimes are based on 4 cycles of Bleomycin, Etoposide and Cisplatin. The results of chemotherapy depend on the nature and extent of disease.
Patients with disease confined to the lymph glands and lungs and with only moderately elevated tumour markers are regarded as a good prognostic group. They comprise 84% of all cases of metastatic non-seminoma. The overall survival following chemotherapy is 75 – 90%. The remaining 16% are those patients with spread beyond the lymph glands and the lungs and marked elevation of tumour markers.
The prognosis of this subgroup is poor with a 5 year survival of 40 – 50%.
Previously reviewed by Dr Pieter J le Roux MBChB, FRCS(Eng), FRCSI, FCS(SA)Urol.
Reviewed by Dr David Eedes, Oncologist, February 2011
