Stage I testicular seminoma following orchidectomy—to treat or not to treat

Abstract

ADJUVANTPOSTORCHIDECTOMY radiationhasbeenstandardcare for stage I seminoma since the early decades of this century [ 1, 21 and a wealth of experience shows this policy to be effective and safe [3]. In bygone days when there was no curative alternative to radiotherapy, faith in radiographic retroperitoneal staging procedures was never sufficient to risk disease progression by withholding radiotherapy from patients with stage I disease. And, since the morbidity of retroperitoneal lymph node dissection contra-indicated its use in this disease, the true incidence of micrometastatic nodal involvement in stage I was never elucidated. Thus, it was uncertain what proportion of patients actually benefited from adjuvant irradiation. Now, with the additional armamentarium of effective chemotherapy [4, 51, surveillance has emerged as an investigational possibility and several preliminary studies have been reported [6-81. In this issue of the European ~oumal of Cancer (pp. 1931-1934), the report by von der Maase et al. is the Iirst such study, substantial both in the number of patients and in their follow-up, to afford a reliable appraisal of the virtues and limitations of surveillance as a management policy and to provide insights into the pathobiology of this disease. Whereas pathological findings in the primary tumours have little prognostic significance for patients receiving adjuvant radiotherapy, they assume some importance if treatment is withheld. Von der Maase et al. delineate tumour size, histological subtype, tumour necrosis and invasion of the rete as significant determinants of metastatic propensity. In multivariate analysis, tumour size was the only feature independently correlated with disease relapse. Patients whose primary tumour was 6 cm or larger (25% of all) had a relapse frequency of 34%, compared with a frequency of 14% in those with smaller tumours. Indirect confirmatory evidence that certain features of the primary tumour are indeed markers of biological aggression comes from studies that show a higher incidence of larger tumours [9], more frequent rete and cord invasion [9, lo] and a higher incidence of vascular invasion [9] in stage II than in stage I seminoma. Unpublished data in the University of Texas M.D. Anderson Cancer Center database reveal that the primary tumour was significantly larger in stage II disease (21 patients, size range 2-19 cm, mean size 7.1 cm, median size 6.5 cm) than in stage I disease (137 patients, size range 1-12.5 cm, mean size 4.9 cm, median size 4.4 cm) (P = 0.001). This supports the conclusion of von der Maase et al. that larger tumours are more likely to have metastasised than smaller ones. However, the authors make no mention of spermatic cord invasion, which we reported to occur more often in stage II than in stage I disease, and to have an adverse effect on the outcome of irradiated patients with stage I disease [lo]. It is hoped rhat this factor, as well as data on preand postorchidectomy chorionic gonadotrophin levels will be