Prophylactic Mediastinal Irradiation Research Articles

Adverse effects after radiotherapy for early stage (I,IIa,IIb) seminoma

Background and purposeThe evaluation of adverse effects after radiotherapy for early stage (I,IIa,IIb) seminoma. Patients and methodsA retrospective analysis of 164 patients with stage I, IIa, IIb seminoma treated with post-orchidectomy irradiation, between 1974 and 1990 was performed. Patients had been treated with infradiaphragmatic radiotherapy only (IDRT) in 48%, and prophylactic mediastinal and left supraclavicular irradiation (supradiaphragmatic radiotherapy, SDRT) was performed additionally in the remaining 52% of patients. Median follow-up was 12 years. The incidence of late morbidity was evaluated with respect to treatment-related factors like: PTV, number of fields irradiated each day, beam energy, total dose and dose per fraction. Afterwards, the dose distribution in normal tissues-based on dose per fraction at 3cm depth and total dose at 3cm depth, was evaluated in relation to late morbidity. ResultsOverall 5-year and 10-year survival was 92 and 86%. For IDRT, dose per fraction at midline and dose per fraction from AP field at 3cm depth were not significantly associated with Gastro-Intestinal morbidity. For SDRT, dose per fraction at 3cm depth from AP field was significantly associated with cardiac morbidity (mean-1.98Gy in patients without and 2.27Gy in patients with cardiac morbidity P=0.006), however total dose at 3cm was not significantly associated with cardiac morbidity. Dose per fraction at 3cm depth from AP field significantly (P=0.047) influenced cardiac morbidity probability in multivariate logistic regression, which included patients' age, smoking habits and total dose at 3cm. ConclusionsExcessive dose maximum in normal tissues from each fraction to anterior mediastinum is associated with increased cardiac morbidity.

Radiotherapy for stage ii testicular seminoma. zagars gk., m.d., and pollack a., m.d., ph.d.: Int j rad onc biol phys (2001) 51(3):643–49

PURPOSE: To compare the outcome of patients with Stage II seminoma treated with prophylactic mediastinal irradiation, without any supradiaphragmatic irradiation, and with prophylactic left supraclavicular irradiation (PLSCI). METHODS AND MATERIALS: Between 1960 and 1999, 73 men with Stage II seminoma received postorchiectomy radiotherapy. Before 1984, 36 received prophylactic mediastinal irradiation (Series I); between 1984 and 1992, 17 received no supradiaphragmatic irradiation (Series II); and after 1992, 20 received PLSCI (Series III). The outcomes in these series were compared. RESULTS: The abdominal tumor sizes were as follows: Series I, ≤2 cm, n = 4; >2 and ≤5 cm, n = 12; >5 and ≤10 cm, n = 16; Series II, ≤2 cm, n = 1; >2 and ≤5 cm, n = 12; >5 and ≤10 cm, n = 4; and Series III, ≤2 cm, n = 1; >2 and ≤5 cm, n = 14; >5 and ≤10 cm, n = 5 ( P = .75). The median duration for follow-up was 14.4, 9.3, and 4.5 years for Series I, II, and III, respectively. The 6-year freedom from relapse was 94%, 71%, and 95% for Series I, II, and III, respectively. The differences between Series I and II ( P = 0.014) and between II and III ( P = 0.042) were significant. Three patients in Series II had a relapse in their left supraclavicular fossa—a failure pattern abrogated by PLSCI. CONCLUSIONS: PLSCI significantly diminishes the likelihood of relapse for Stage IIA, IIB, and IIC seminoma (mass ≤ 10 cm).

Radiotherapy for stage II testicular seminoma

Purpose: To compare the outcome of patients with Stage II seminoma treated with prophylactic mediastinal irradiation, without any supradiaphragmatic irradiation, and with prophylactic left supraclavicular irradiation (PLSCI).Methods and Materials: Between 1960 and 1999, 73 men with Stage II seminoma received postorchiectomy radiotherapy. Before 1984, 36 received prophylactic mediastinal irradiation (Series I); between 1984 and 1992, 17 received no supradiaphragmatic irradiation (Series II); and after 1992, 20 received PLSCI (Series III). The outcomes in these series were compared.Results: The abdominal tumor sizes were as follows: Series I, ≤2 cm, n = 4; >2 and ≤5 cm, n = 12; >5 and ≤10 cm, n = 16; Series II, ≤2 cm, n = 1; >2 and ≤5 cm, n = 12; >5 and ≤10 cm, n = 4; and Series III, ≤2 cm, n = 1; >2 and ≤5 cm, n = 14; >5 and ≤10 cm, n = 5 (p = 0.75). The median duration of follow-up was 14.4, 9.3, and 4.5 years for Series I, II, and III, respectively. The 6-year freedom from relapse was 94%, 71%, and 95% for Series I, II, and III, respectively. The differences between Series I and II (p = 0.014) and between II and III (p = 0.042) were significant. Three patients in Series II had a relapse in their left supraclavicular fossa—a failure pattern abrogated by PLSCI.Conclusions: PLSCI significantly diminishes the likelihood of relapse for Stage IIA, IIB, and IIC seminoma (mass ≤10 cm).

Hyperfractionated radiotherapy alone for clinical stage I nonsmall cell lung cancer

Among patients with Stage I nonsmall cell lung cancer (NSCLC), those treated with conventional radiotherapy show poorer prognosis than those treated by surgery. To improve the prognosis of such patients, we have used hyperfractionated radiation therapy. Between 1988 and 1993, 49 patients were treated with hyperfractionated radiotherapy with 1.2 Gy twice daily to a total dose of 69.6 Gy. All patients were technically operable, but 29 had medical problems and 20 refused surgery. The median age and Karnofsky Performance Status was 63 years and 90, respectively. No patient received chemotherapy or immunotherapy. Prophylactic mediastinal irradiation was not given. The median survival time was 33 months, and the 5-year survival rate was 30%. The rate at 5 years for freedom from each of relapse, local recurrence, mediastinal lymphnode metastasis, and distant metastasis was 41%, 55%, 89%, and 75%, respectively. Univariate analysis revealed that higher Karnofsky Performance Status score, absence of weight loss before treatment, and T1 stage were associated with better survival, although the T stage became insignificant on multivariate analysis. There were two Grade 3 acute toxicities and three Grade 3 late toxicities, but there was no Grade 4-5 toxicity. The results of this study compare favorably with those of most previous studies employing conventional fractionation. Further studies on hyperfractionation seem to be warranted for Stage I NSCLC.

Over 20 years of progress in radiation oncology: Seminoma

During the past 20 years, significant changes have occurred in the management of seminoma. Survival has improved by approximately 10%, and now 97% of patients are cured. Reductions in the numbers of patients irradiated, the volumes irradiated, and the doses used should reduce morbidity. The 1973 Patterns of Care Study (PCS) and the planned new study proffer statements of consensus on optimal care and evaluate compliance with guidelines. Specific changes in investigation, including measurement of the serum tumor markers beta human choriaonic gonadotropin (betaHCG) and alphafetoprotein (AFP) and computed tomography (CT) or magnetic resonance imaging (MRI) evaluation of the retroperitoneum, better evaluate disease extent. For stage I disease, a reduction in the total dose of infradiaphragmatic irradiation to 2,500 cGy is recommended. An option for surveillance reduces unnecessary therapy in 80% and may improve fertility. The significance of disease bulk in stage II has been recognized, and treatment has been refined. The maximal radiation dose now recommended for stage II disease is 3,500 cGy. CT definition of radiation target volumes minimizes the risk of geographic miss. Prophylactic mediastinal irradiation is no longer recommended. Chemotherapy, usually now bleomycin, etoposide, and cisplatin, produces high cure rates for stage IID, III< and IV disease and has become the standard managemetn. Controversy still surrounds optimal therapy for stage IIC disease. Unresolved questions include cost benefit and quality of life issues surrounding optimal management for stage I disease, inguinal scrotal irradiation in stage I and II disease, and identification of the least toxic but effective chemotherapy for specific subgroups of patients with advanced disease.

Long-term evaluation of postorchiectomy radiotherapy for stage II seminoma.

To determine survival, long-term tumor control, and the effects of irradiation for stage II seminoma. Forty-five patients with stage II testicular seminoma were treated between 1966 and 1989. There were 31 patients with stage IIA disease and 14 with stage IIB disease. All patients underwent orchiectomy followed by iliac and paraaortic irradiation (median dose: 30 Gy), with 37 patients receiving prophylactic mediastinal and supraclavicular irradiation (median dose: 30 Gy). Follow-up ranged from 6 months to 20.6 years, with a median of 9.4 years. Uncorrected survival was 98% at 5 years, 84% at 10 years, and 79% at 15 years. Survival corrected for intercurrent disease was 98% at 5, 10, and 15 years. Five patients developed recurrences with four successfully salvaged by chemotherapy and/or irradiation. There were no serious acute toxicities, and no late complications have developed from infradiaphragmatic irradiation. Supradiaphragmatic irradiation was associated with an increased risk of coronary artery disease compared to the age-matched general population. Radiotherapy remains an effective treatment for stage II testicular seminoma, with a 98% adjusted survival rate at 15 years, without serious acute toxicity. Supradiaphragmatic irradiation should not be used in stage IIB patients for whom salvage chemotherapy is an option.

Radiation therapy for stage i and iia testicular seminoma

Purpose : To review the survival, cure rate, treatment morbidity, and late sequelae of histologically confirmed seminoma patients who underwent orchiectomy and radiation therapy at the Radiation Oncology Center, Mallinckrodt Institute of Radiology, from 1964 to 1988. Methods and Materials : There were 128 patients, with a median patient age of 37 years (range, 17–79 years). Follow-up ranged from 1–24 years, with a median of 6.7 years. There were 95 patients with Stage I and 33 with State IIA disease. All patients were treated with orchiectomy followed by iliac and paraaortic irradiation (media tumor dose: 2500 cGy for Stage I and 3400 cGy for Stage IIA patients). Twenty-five of 33 patients with Stage IIA disease received prophylactic mediastinal and left supraclavicular irradiation (median dose, 2700 cGy). Results : For patients with Stage I disease, 5-year disease-free survival, overall survival, and survival corrected for intercurrent disease were 97%, 100%, and 100%, respectively. For patients with Stage IIA disease, the 5-year disease-free survival, overall survival, and survival corrected for intercurrent disease were 93%, 89%, and 97% respectively. Four patients (3%) had recurrences; all were outside the radiation treatment field. Three of four were successfully salvaged with chemotherapy and rendered disease-free; the other patient refused treatment. There were no mediastinal recurrences whether prophylactic mediastinal irradiation was administered or not. Bowel obstruction and necrosis developed in one patient who received 3363 cGy midplane dose to the pelvic paraaortic areas as well as additional intraperitoneal colloidal 198Au (150 mCi) for a ruptured seminoma from an undescended testis. Conclusion : In summary, radical orchiectomy and irradiation of the iliac and paraaortic lymphatics is the treatment of choice for patients with Stage I and IIA testicular seminoma.

Radiation therapy of testicular seminoma: a 15-year survey.

A retrospective review of 69 patients with testicular seminoma, stage I and II, treated by orchiectomy and adjuvant irradiation at McGill University Hospitals from 1972 to 1987 was performed. All patients underwent either lymphangiogram or computed axial tomography scan for evaluation of retroperitoneal disease. There were 52 stage I (75%), 13 stage IIA (11%), 2 stage IIB (3%), and 2 stage IIC (Royal Marsden Hospital staging criteria). Median follow-up time was 6.2 years. The 10-year actuarial survivals were 94% and 93% for stages I and II, respectively. Only two stage I patients failed treatment, and both died from metastatic disease. Interestingly, both developed biopsy-proven metastatic brain disease and had no evidence of intra-abdominal recurrence. In stage II disease, only one patient failed the treatment. There was no serious acute toxicity and no late complications have been encountered. Radiation therapy following orchiectomy is the treatment of choice for stage I and for most stage II patients with testicular seminoma. The controversial aspects of radiographic retroperitoneal staging, the use of prophylactic mediastinal irradiation for stage II patients, and the role of surveillance only for stage I patients are discussed.

Results of treatment in irradiated testicular seminoma patients

Excellent treatment results have been achieved historically with postoperative radiotherapy in testicular seminoma. In this retrospective study the treatment results of 211 patients with Stage I–II testicular seminoma treated in Finland during the years 1970–1983 were evaluated. 176 (84%) patients received postoperative radiotherapy alone. In addition to radiotherapy, 26 (12%) patients received chemotherapy during the primary treatment. There were 129 Stage I (61%), 66 Stage IIA-B (31%) and 16 Stage IIC (8%) tumors. The 5-year survival rate was 95% in Stage I, 87% in Stage IIA-B and 73% in Stage IIC. In Stage I, seven relapses (relapse rate 6%) occurred after irradiation; three of them were cured with second-line therapies. None of the relapses occurred within the radiotherapy field. In Stage IIA-B, 31 patients had only parailiacic + aortic irradiation, 25 patients received both parailiacic + aortic and mediastinal irradiation. With both radiotherapy techniques there was no significant difference in the number of relapses (seven and three) and in the remission rate (94% and 96%). Radiotherapy alone was used on four Stage IIC patients and one of them died during the primary treatment. Two of them relapsed, but could be cured with chemotherapy. These results correspond to those reported in the literature and they suggest that prophylactic mediastinal irradiation is unnecessary in Stage IIA-B patients. Stage IIC patients should receive chemotherapy initially.

Testicular seminoma. Results of the Yale University experience, 1964-1984.

Eighty-three testicular seminoma patients were treated with radiation therapy from 1964 through 1984. Seventy-nine (95%) of the 83 patients had early disease that included 61 Stage I, 15 Stage IIA (pelvic or paraaortic lymph node involvement less than or equal to 5 cm), and 3 Stage IIB (pelvic or paraaortic lymph node involvement greater than 5 cm) patients. The 15-year actuarial survival for this group of Stage I and II patients was 95% (+/- 5%). Stage I patients were treated with a mean paraaortic/pelvic dose of 2924 cGy and only one patient developed recurrent disease. This recurrence was at the margin of the radiation field and probably represents a marginal miss. The Stage IIA patients were treated with slightly higher doses (mean, 3335 cGY) to the paraaortic/pelvic region and there were no recurrences. The three Stage IIB patients received tumor doses of 3245 cGy, 4090 cGy, and 4500 cGy, respectively, and there were no recurrences. Low dose prophylactic mediastinal and supraclavicular irradiation (mean, 2320 cGy) was used in 17 (94%) of the 18 Stage II patients and there were no mediastinal or supraclavicular recurrences. Four patients presented with advanced disease (one Stage III, three Stage IV) and the only disease-free survivor was treated with cisplatinum-based combination chemotherapy and radiation therapy. Three patients developed minor complications from the radiation therapy: one patient had persistent scrotal and leg edema and two patients treated with prophylactic mediastinal irradiation had chronic low leukocyte counts. Two of the 79 Stage I and II patients developed a second malignancy: one had bronchogenic carcinoma at the margin of a mediastinal field, and one had diffuse histiocytic lymphoma both in and out of the radiation therapy fields. The 15-year actuarial probability of developing a second malignancy was 3.3%. Radiation therapy after operation is a successful treatment option for most patients with Stage I and II seminoma.

Radiotherapy for stage 2 testicular seminoma: the prognostic influence of tumor bulk.

Forty-nine consecutive patients with stage 2 testicular seminoma were treated with primary radiotherapy from 1968 to 1985. Overall diseases-free survival (DFS) for patients with 36 months minimum follow-up was 82% at 3 years. This figure did not decline further with time. Infradiaphragmatic bulk disease was found to be a significant prognostic factor for local and distant relapse as well as for ultimate survival. Patients with either stage 2A or 2B disease (infradiaphragmatic bulk less than or equal to 10 cm size) had a 3-year DFS of 89% compared with a 64% 3-year DFS rate for patients with stage 2C disease (infradiaphragmatic bulk greater than or equal to 10 cm size). The (local plus distant) relapse rate was 4.0% for patients with stage 2A disease, 16.7% for patients with stage 2B disease, and 33.3% for patients with stage 2C disease. The majority of distant relapses were multifocal and prophylactic mediastinal irradiation did not appear to influence either relapse rate nor overall survival. Of seven patients who relapsed, four died of progressive malignancy, two deaths were related to salvage chemotherapy, and only one patient is alive and well following successful chemotherapeutic salvage. On the basis of our experience, we recommend radiotherapy with the use of modern imaging techniques as initial treatment for patients with retroperitoneal masses less than 10 cm size. Aggressive cisplatin-based chemotherapy should be seriously considered for patients with retroperitoneal masses greater than or equal to 10 cm size, or for patients who relapse following radiotherapy.

Testicular Seminoma: The M. D. Anderson Experience. An Analysis of Pathological and Patient Characteristics, and Treatment Recommendations

We treated 240 patients with testicular seminoma at our institution between January 1960 and December 1982. The over-all 5-year survival free of disease for these patients regardless of stage was 93.6per cent. The 165 patients (69per cent) with stage I disease had a 95.5per cent 5-year survival free of disease that remained constant at 20 years. Stage II cancer was diagnosed clinically in 62 patients (26per cent), while 13 (5per cent) presented with more advanced (stages III and IV) disease. The 5-year survival rate free of disease for all patients with stage II cancer was 85per cent. There were 14 pathological and patient characteristics analyzed, 4 of which were statistically significant. All but 1 of these factors (spermatic cord invasion) was related to tumor volume (stage, palpable mass and hydronephrosis). Based on the data of this retrospective review, the Canadian experience without prophylactic mediastinal irradiation and the development of effective chemotherapy, we recommend radiation therapy without prophylactic mediastinal irradiation for patients with stage I or IIA disease and chemotherapy for patients with stage IIB, III or IV disease. In an attempt to improve our results in the latter patients we recently instituted adjunctive radiotherapy for those with a persistent radiographic mass. Our current guidelines for the staging evaluation and followup of patients with this neoplasm also are discussed.

Testicular seminoma: Analysis of treatment and failure for stage II disease

Seventy-three patients with seminoma testis stage II have been retrospectively analyzed with regard to prognostic factors and value of prophylactic mediastinal irradiation and chemotherapy. Although survival differences were seen between stage IIa, IIb and IIc, these were not statistically significant. Neither was there a significant difference between IIc patients with tumors greater than 10 cm and less than 10 cm in diameter. The incidence of HCG-producing seminomas in the present series was 16%. No significant difference in survival nor relapse rate was found between HCG-producing and HCG-non-producing seminomas. Prophylactic mediastinal irradiation did not influence the survival nor the relapse rate and may therefore be omitted. In the present series there was no significant improvement neither in relapse rate nor survival in patients receiving pre-irradiation chemotherapy. However, the total number of patients is small and optimal pre-irradiation chemotherapy still have to be defined.

Radiotherapy in Seminoma: More is Not Better

In this issue, Dr. Thomas et a1.,5 describes the Princess Margaret Hospital experience in 444 patients with seminoma treated with radiotherapy from 1958 to 1976. Overall, there was an 87% five-year survival, including 87% for Stage II-A and 62% for Stage II-B. These results are as good as the results in other published series, but what is unique about this Stage II patient population is that prophylactic mediastinal irradiation was not employed. In Stage II-A disease, there were no mediastinal recurrences in 40 patients, and in Stage II-B, there were IO-46 (22%) mediastinal recurrences. However, seven of these 10 patients were cured with subsequent radiation. The authors have clearly demonstrated that prophylactic mediastinal irradiation is unnecessary to ensure optimal cure rates in Stage II disease. Furthermore, such radioprophylaxis may well be deleterious. Ytredal and Bradfield describe marrow hypoplasia and second malignancies with supraand infradiaphragmatic irradiation compared to abdominal irradiation alone.6 Also, two of 20 Stage I patients treated with prophylactic mediastinal irradiation at M. D. Anderson died from acute leukemia.4 In our experience in previously irradiated patients treated with platinum + vinblastine + bleomycin (PVB), there are major difficulties when abdominal and mediastinal irradiation were employed. There is considerably more severe and prolonged myelosuppression, and furthermore, the incidence of pulmonary fibrosis is significantly increased. These problems have also been encountered in other centers when both infraand supradiaphragmatic irradiation are employed (Peckham, M., oral communication, June, 198 1). Approximately 25% of Stage II patients with semi-. noma will fail to be cured with radiotherapy. Not only is mediastinal prophylaxis unnecessary in these patients, but it may well reduce the probability for cure with subsequent PVB chemotherapy. In 1974, combination chemotherapy with PVB was instituted at Indiana University.’ Patients with disseminated seminoma (Stage III or IV or recurrences in irradiated areas) were treated with the same program, although the vinblastine dosage was lowered 25% because of prior radiotherapy.’ We have recently published our results with PVB in 19 patients with metastatic seminoma.2 The median age was 38 (16-63), and seven (37%) had anaplastic seminoma. Four of these 19 patients had extragonadal seminoma. Only six patients did not have prior radiotherapy, and five achieved complete remission (C.R.) and remain disease-free (NED). The only failure in this group was a patient with massive hepatic metastases. The toxicity in these six patients was considerably less than that seen in the 13 patients with prior radiotherapy. Overall, 12 of 19 patients (63%) achieved a C.R.; with a minimal follow-up of two years, 11 patients (58%) are continuously NED. Similar results with PVB in disseminated seminoma have been achieved in other centers. Pinedo has reported six of eight complete remissions (Pinedo, oral communication, June, 1981) and CortesFunes three of three (Cortes-Funes oral communication, June, 1981). Thus, combining these three series, 21 of 30 (70%) complete remissions were achieved in metastatic seminoma with PVB. These results in metastatic seminoma are quite comparable to our results with the same chemotherapy in non-seminomatous tumors. We do not feel there is any present data to indicate a difference in response rate or potential curability of metastatic seminoma compared to non-seminomatous germ-cell tumors. The chemotherapy for disseminated seminoma should parallel that employed for non-seminomatous germ-cell tumors. We feel all patients with Stage III and IV (as described by Thomas et al.‘) should receive PVB as initial therapy. This is a small group of patients, as only 5-10% of all seminomas present in this manner. However, another 20-30% will present as Stage II disease, and approximately 25% of these patients will relapse after curative radiotherapy and require subsequent chemotherapy. The therapeutic results with orchiectomy and irradiation for clinical Stage I are excellent, with cure rates ranging from 95-100%. Fortunately, 60 to 75% of all

Seminoma of the Testis: Results of Treatment and Patterns of Failure After Radiation Therapy

Four hundred and forty-four patients with the histological diagnosis of pure seminoma were treated at The Princess Margaret Hospital between 1958 and 1976. Using the Walter Reed Hospital staging classification, 338 patients (76.1 %) were Stage I, 86 (19.4 %) were Stage II, and 20 (4.7%) were Stage III. The 5 year actuarial survival rate (5 yr SA) for all stages was 87%, and for Stages I, II and III: 94%, 74% and 32% respectively. In Stage II the 5-year SA was significantly worse when palpable abdominal disease was present (62%, vs 87% when it was absent, p < .02). Prophylactic mediastinal irradiation was not used for patients with Stage II disease. None of 40 Stage II patients without palpable abdominal disease recurred in the non-irradiated mediastinum. Ten of 46 Stage It patients with palpable abdominal disease recurred in the mediastinum; 7 of the 10 were cured with mediastinal irradiation at the time of relapse. Prophylactic mediastinal irradiation appears unnecessary in Stage II patients. The Stage III category includes a subgroup of patients who were curable with radiation therapy: 56 with supradiaphragmatic nodal disease without palpable abdominal or visceral disease were cured. Exploration of new treatment methods appears indicated for the salvage of patients recurring in sites other than the mediastinum or supraclavicular fossa and for patients presenting with visceral disease.

Seminoma of the testis: Results of treatment and patterns of failure after radiation therapy

Four hundred and forty-four patients with the histological diagnosis of pure seminoma were treated at The Princess Margaret Hospital between 1958 and 1976. Using the Walter Reed Hospital staging classification, 338 patients (76.1 %) were Stage I, 86 (19.4 %) were Stage II, and 20 (4.7%) were Stage III. The 5 year actuarial survival rate (5 yr S A) for all stages was 87%, and for Stages I, II and III: 94%, 74% and 32% respectively. In Stage II the 5-year S A was significantly worse when palpable abdominal disease was present (62%, vs 87% when it was absent, p < .02). Prophylactic mediastinal irradiation was not used for patients with Stage II disease. None of 40 Stage II patients without palpable abdominal disease recurred in the non-irradiated mediastinum. Ten of 46 Stage It patients with palpable abdominal disease recurred in the mediastinum; 7 of the 10 were cured with mediastinal irradiation at the time of relapse. Prophylactic mediastinal irradiation appears unnecessary in Stage II patients. The Stage III category includes a subgroup of patients who were curable with radiation therapy: 5 6 with supradiaphragmatic nodal disease without palpable abdominal or visceral disease were cured. Exploration of new treatment methods appears indicated for the salvage of patients recurring in sites other than the mediastinum or supraclavicular fossa and for patients presenting with visceral disease.

Recurrence patterns in the non-seminomatous germinal testicular tumors

The authors have evaluated 80 consecutive patients with non-seminomatous testes tumor by studying local recurrence patterns in both surgical and irradiated regions to judge the relative effectiveness of these therapeutic modalities. Employing this analysis, there were 6 patients of 32 failures in the N0, N1–N2, N3 and N4 categories who migbt have benefited by more intensive irradiation to nodal areas because of a failure to disseminate in less than 1 year. In the N1–N2 patients, 12 of 14 successes were in the 3500–4500 rad region. Recommendations for treatment are as follows: 1. 1. Patients with negative nodes (N0) require adequate retroperitoneal node dissection alone. 2. 2. Patients with resectable histologically involved nodes (N1–N2) should probably receive post-operative radiotherapy to the involved retroperitoneal region with doses of 5000–5500 rad. 3. 3. Unresectable retroperitonal lymph node disease (N3) probably requires a systemic approach with localized irradiation administered to the involved nodes only. 4. 4. Patients presenting with supradipharagmatic disease (N4 or M1b & M1c) have disseminated tumor and radiotherapy is used for palliation of local masses not controlled by chemotherapy. 5. 5. Prophylactic mediastinal irradiation is not routinely indicated in any stage of the disease.

Seminoma of the testicle: Prophylactic mediastinal irradiation versus periaortic and pelvic irradiation alone : D. O. Ytredal, and J. S. Bradfield ( 30: 630, 1972)

Seminoma of the testicle: Prophylactic mediastinal irradiation versus periaortic and pelvic irradiation alone : D. O. Ytredal, and J. S. Bradfield ( 30: 630, 1972)

Seminoma of the testicle: prophylactic mediastinal irradiation versus periaortic and pelvic irradiation alone.

An analysis of 80 patients with seminoma of the testis treated at Brooke General Hospital, from July 1947 to March 1971, is presented. Forty-nine patients with Stage I disease were treated prophylactically to the mediastinum and left supraclavicular area in addition to receiving periaortic and pelvic irradiation. Twenty-two patients with Stage I disease received only periaortic and pelvic irradiation. No recurrences have been observed in Stage I patients with either method of treatment. The crude survival rates for the entire group of 80 patients at 5, 10, and 15 years were 97, 93, and 92%, respectively.