Issues in the management of stage I testicular seminoma

Purpose: In view of the reluctance to accept surveillance as an alternative to adjuvant radiation therapy in clinical stage I seminoma (due to concerns regarding increased resource utilisation and the potential for late relapse), we analyzed our experience with the two approaches in terms of long term outcome and cost. Materials and Methods: Between January 1981 and December 1994, 470 patients with stage I testicular seminoma were treated at our institution. Of these, 245 patients received post-operative RT (25 Gy) to the retroperitoneal lymph nodes, and 225 have been managed with surveillance following orchidectomy. Two patients were included in this series twice, both had RT previously for seminoma, were on placed on surveillance for a contralateral seminoma and were analyzed for outcome of both primary tumours. The surveillance protocol involved follow-up including CT abdomen and pelvis at 4 monthly intervals for 3 yrs, q 6 months for 4 yrs, and q 1 yr for 3 yrs. The costs associated with both approaches were estimated in 1994 Canadian dollars (C$). Results: With a median follow up of 6.1 years in the surveillance patients, and 7.0 years in the adjuvant RT cohort, the 5-year actuarial survival for all patients was 97% and the cause specific survival (CSS) was 99.8%. Of the 225 patients on surveillance 35 patients have relapsed to date; 5 of those developed a second relapse. One patient has died of disease. Of the 245 patients treated with adjuvant RT, 13 patients have relapsed and none had a second relapse. The CSS was 100%. Twelve patients on surveillance (5.3%) and ten patients treated with post-operative RT (4.1%) have received chemotherapy as part of their management. One hundred and ninety patients on surveillance have received no post-orchidectomy treatment to date. Surveillance was more expensive with an average additional cost per patient per year of Can$ 262.00 for 10 years. Conclusions: Both adjuvant radiation therapy and surveillance give excellent results in stage I seminoma. The documented increased risk of second malignant tumours following radiation therapy must be taken into account when considering the additional cost of surveillance. The routine use of post-operative RT in stage I seminoma should be considered and a surveillance program offered to all patients as an alternative management option