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  Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 54  |  Issue : 1  |  Page : 385-387
 

Testicular seminoma: Are clinical features and treatment outcomes any different in India?


1 Division of Clinical Oncology, Genitourinary Clinic, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
2 Division of Statistics and Cancer Epidemiology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India

Date of Web Publication1-Dec-2017

Correspondence Address:
Dr. F V James
Division of Clinical Oncology, Genitourinary Clinic, Regional Cancer Centre, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_100_17

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 » Abstract 

AIM: This study aims to identify clinical features, treatment outcomes, and prognostic factors for relapse and survival in patients with testicular seminoma. MATERIALS AND METHODS: Retrospective analysis of all patients with pure seminoma treated at our center during over a decade (January 2005–December 2014) was carried out. Patient demographics, tumor characteristics, and treatment details and pattern of recurrence were recorded in a structured format, and disease-free survival and overall survival were calculated. RESULTS: Sixty-three patients' case records were included in the analysis. Ten patients developed disease in the undescended testis. All patients underwent orchiectomy as the initial treatment procedure. Majority of the patients were Stage I (57.14%) followed by Stage II (39.6%). Among the patients with Stage I, 55.5% received adjuvant chemotherapy while 22.2% received adjuvant radiation and the rest opted for surveillance. The compliance for active surveillance was very poor. Among patients with Stage II disease, majority (80%) were treated with adjuvant chemotherapy and the rest with radiation. At a median follow-up of 49 months, there were four recurrences of which three were salvaged successfully, and one patient remained alive with disease. There were no disease-related deaths. CONCLUSIONS: Testicular seminoma remains to be relatively low and majority of them presented with Stage I disease and single agent carboplatin appeared to be the preferred adjuvant treatment. Advanced disease patients were treated with etoposide and cisplatin/bleomycin, etoposide and cisplatin chemotherapy and the clinical outcome is comparable with the Western literature.


Keywords: Carboplatin, seminoma, surveillance


How to cite this article:
Anjanappa M, Kumar A, Mathews S, Joseph J, Jagathnathkrishna K M, James F V. Testicular seminoma: Are clinical features and treatment outcomes any different in India?. Indian J Cancer 2017;54:385-7

How to cite this URL:
Anjanappa M, Kumar A, Mathews S, Joseph J, Jagathnathkrishna K M, James F V. Testicular seminoma: Are clinical features and treatment outcomes any different in India?. Indian J Cancer [serial online] 2017 [cited 2020 Mar 31];54:385-7. Available from: http://www.indianjcancer.com/text.asp?2017/54/1/385/219528



 » Introduction Top


Testicular cancer represents 1% of malignancies in men.[1] The incidence varies across the globe with reportedly higher occurrence in the developed and Western countries. India has the lowest age-standardized incidence of 0.5/100,000 men.[2]

The primary treatment of any testicular germ cell tumor involves high inguinal orchiectomy. Further treatment depends on the histology, stage and risk stratification of the disease. Seminoma is the most common type of tumor arising from the testis with pure seminoma accounting for 40%. Treatment options after orchiectomy in Stage I seminoma are chemotherapy with carboplatin, radiotherapy, or surveillance.[3],[4],[5] The survival outcomes are similar regardless of the treatment approach. For Stage IIA, the preferred treatment is radiotherapy, and for Stage IIB, IIC and advanced stage disease, combination chemotherapy with bleomycin, etoposide, and cisplatin (BEP) or etoposide and cisplatin (EP) is recommended.[6]

The prognosis and survival for testicular seminoma are excellent. For Stage I, seminoma the cure rates are 99%, and for Stage II, the 5-year survival is over 90%.[7],[8]

Purpose

This study was done to identify clinical features, treatment outcomes, and prognostic factors for relapse and survival of patients with testicular seminoma treated primarily at our center in India.


 » Materials and Methods Top


All patients with histologically proven seminoma of testis treated at our center from January 2005 to December 2014 were identified from the Hospital Cancer Registry database. A retrospective analysis of these case records was done after Institution Review Board approval.

A comprehensive case record review was done to collect data on demographic characteristics, tumor size, and pathology details, treatment details, recurrence, and follow-up. Patients with histological diagnosis of pure seminoma only were included. Patients who presented with recurrence to our center after initial treatment elsewhere were excluded from the study.

Statistical analysis

The disease-free interval was calculated from the date of diagnosis to the date of documented recurrence and survival was calculated from date of diagnosis to death of the patient. Disease-free survival (DFS) and overall survival were estimated using Kaplan–Meier method.


 » Results Top


A total of 80 patients with pure seminoma were identified from the registry, and 17 patients were excluded due to the recurrent disease at the time of registration (15 patients) and reporting for second opinion only (2 patients).

The case records of 63 patients were analyzed. The mean age at presentation was 35.4 (range 20–65) years. Majority of the men (37) had a right-sided testicular tumor. A total of ten patients developed disease in the undescended testis. In addition, two patients had disease after undergoing correction procedure for undescended testis.

Most of the patients had Stage I disease (57.14%) followed by Stage II (39.6%) and Stage III. All patients underwent an initial surgical procedure. Fifty-three men had high inguinal orchiectomy, four had a transscrotal orchiectomy, and further, six patients underwent a laparotomy or a laproscopic procedure for disease in the undescended testis.

Stage I disease

Among the 36 Stage I patients, 20 (55.5%) of them had chemotherapy as adjuvant treatment, 8 (22.2%) received adjuvant radiation and the remaining 8 (22.2%) opted for a surveillance program. The details of chemotherapy and radiotherapy are in [Table 1] and [Table 2]. Radiation was delivered to the para-aortic lymphatics, and only one patient was treated with a dog-leg field to include the ipsilateral iliac lymph node along with the para-aortic lymphatics.
Table 1: Adjuvant chemotherapy in Stage I patients

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Table 2: Adjuvant radiation in Stage I patients

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Among the patients who opted for surveillance, half of them did not report back after decision-making. The four patients who started on surveillance, two were lost on follow-up after 1 year, and the other two patients were compliant.

The pathological tumor size was available in 28 patients. Nine patients had tumor size of ≤4 cm, and the rest were >4 cm.

Metastatic disease

Among patients with Stage II disease, majority (80%) received chemotherapy and the rest were treated with radiation. The chemotherapy regimen used was EP combination for four cycles (in 14 patients) or BEP combination for three cycles (in 6 patients). The radiation dose ranged from 30 to 36 Gy. The two patients with Stage III disease, both were treated with four cycles of EP regimen.

Disease-free survival and overall survival

The median follow-up was 49 months (range 0–137 months). Four patients had a recurrence, the details of which are in [Table 3]. One patient is alive with disease after treatment for recurrence. There were no disease-related deaths.
Table 3: Disease recurrence pattern and treatment

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The DFS of the entire group was 92.3% at 5 years [Figure 1].
Figure 1: Disease-free survival estimate

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 » Discussion Top


In this small series, more than half of the patients presented with Stage I disease and the majority of them received chemotherapy for adjuvant treatment. Similarly, the majority of Stage II patients also received chemotherapy. Overall, there were very few recurrences which were salvaged resulting in 100% survival.

An Indian publication has reported more bulky disease at presentation; however, our series did not show such large tumors.[9]

Cryptorchidism is a known risk factor for testicular malignancy. Ten out of 63 patients had disease in undescended testis. The number of patients with tumor in undescended testis is more compared to Western literature, but the same has been reported in other Indian publications ranging from 12.5% to 14% of tumors.[10],[11],[12] However, it has decreased over time as compared to the previous report from the same institution.[13]

Even though Stage I is the common presentation, the proportion is less compared to Western countries. However, it has improved over our earlier figures.[13] The results of use of carboplatin and prophylactic radiation therapy appear similar in this small series. There is concern regarding the use of surveillance in our part of the world as there were many dropouts in the group. Surgery alone can cure the disease in 80%–85% of Stage I seminoma.[7] The remaining may require either radiation or chemotherapy which provides similar control rates, albeit with different toxicity profile. Alternatively, the emerging trend is to opt for active surveillance, involving more frequent visits, serial monitoring of tumor markers and imaging. Surveillance, therefore, requires strict compliance. Unnecessary treatment can be avoided for the majority.

The risk factors for relapse in Stage I are tumor size more than 4 cm and rete testis invasion.[14] These factors are used for making a decision regarding active surveillance or adjuvant treatment. Considering the tumor size, most patients were advised treatment after orchiectomy in our series. The tumor size correlation with treatment relapse was not possible, first because of very low number of events and second, there were only few patients who did not receive adjuvant treatment. Since the pathological details on rete testis invasion were not reported consistently in our series, this factor was not analyzed.

The proportion of patients with Stage II patients receiving systemic treatment was more compared to treatment with radiation. Patients with Stage IIB or more were treated Chemotherapy. The chemotherapy employed were EP for 4 cycles or BEP chemotherapy 3 or 4 cycles, based on risk group. Four cycles of EP or 3 cycles of BEP has been acceptable for many years in this setting.[15],[16] For intermediate risk patients 4 cycles of BEP and Etoposide, Cisplatin and Ifosfamide are recognized regimens.[6],[17]

The disease recurrence pattern is similar to the available data in the literature. Patients treated with para-aortic radiation for Stage I disease fail in the mediastinum or systemically. On the other hand, patients treated with chemotherapy and on surveillance recur in the para-aortic region. The common sites of disease recurrence in Stage II patients are supraclavicular fossa, lung/mediastinum, and para-aortic nodes.[8]


 » Conclusions Top


Testicular cancer in our hospital is relatively rare. Majority present with Stage I disease and are treated with single agent adjuvant carboplatin. Many of the patients on surveillance defaulted. Active surveillance appears, therefore, not to be a reliable management program in our setting. Patients with more advanced disease are treated with BEP or EP chemotherapy with excellent outcome. The differences noted are higher proportion of undescended testis and unreliability of surveillance. Otherwise, the results appear comparable to the rest of the world.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Purdue MP, Devesa SS, Sigurdson AJ, McGlynn KA. International patterns and trends in testis cancer incidence. Int J Cancer 2005;115:822-7.  Back to cited text no. 1
    
2.
Shanmugalingam T, Soultati A, Chowdhury S, Rudman S, Van Hemelrijck M. Global incidence and outcome of testicular cancer. Clin Epidemiol 2013;5:417-27.  Back to cited text no. 2
    
3.
Warde P, Gospodarowicz MK, Panzarella T, Catton CN, Sturgeon JF, Moore M, et al. Stage I testicular seminoma: Results of adjuvant irradiation and surveillance. J Clin Oncol 1995;13:2255-62.  Back to cited text no. 3
    
4.
Alexander EJ, White IM, Horwich A. Update on management of seminoma. Indian J Urol 2010;26:82-91.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Oliver RT, Mead GM, Rustin GJ, Joffe JK, Aass N, Coleman R, et al. Randomized trial of carboplatin versus radiotherapy for stage I seminoma: Mature results on relapse and contralateral testis cancer rates in MRC TE19/EORTC 30982 study (ISRCTN27163214). J Clin Oncol 2011;29:957-62.  Back to cited text no. 5
    
6.
Oldenburg J, Fosså SD, Nuver J, Heidenreich A, Schmoll HJ, Bokemeyer C, et al. Testicular seminoma and non-seminoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013;24 Suppl 6:vi125-32.  Back to cited text no. 6
    
7.
Mead GM, Fossa SD, Oliver RT, Joffe JK, Huddart RA, Roberts JT, et al. Randomized trials in 2466 patients with stage I seminoma: Patterns of relapse and follow-up. J Natl Cancer Inst 2011;103:241-9.  Back to cited text no. 7
    
8.
Chung PW, Gospodarowicz MK, Panzarella T, Jewett MA, Sturgeon JF, Tew-George B, et al. Stage II testicular seminoma: Patterns of recurrence and outcome of treatment. Eur Urol 2004;45:754-59.  Back to cited text no. 8
    
9.
Bhutani M, Kumar L, Seth A, Thulkar S, Vijayaraghavan M, Kochupillai V. Germ cell tumours of the testis: Clinical features, treatment outcome and prognostic factors. Natl Med J India 2002;15:18-21.  Back to cited text no. 9
    
10.
Raina V, Shukla NK, Gupta NP, Deo S, Rath GK. Germ cell tumours in uncorrected cryptorchid testis at Institute Rotary Cancer Hospital, New Delhi. Br J Cancer 1995;71:380-2.  Back to cited text no. 10
    
11.
Kulkarni JN, Desai SM, Phadke GK, Tongaonkar HB. Improved management of abdominal undescended testicular tumors with bulky confluent retroperitoneal nodal metastases. J Urol 1996;156:1341-4.  Back to cited text no. 11
    
12.
Sarma D, Barua SK, Rajeev TP, Baruah SJ. Role of primary chemotherapy in management of large tumors of undescended testis: Our experience. Urol Ann 2013;5:179-82.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
James F, Mathew A, Anand R. Testicular seminoma: Review of 67 cases from India. ASCO Annu Meet Proc 2005;23 16 Suppl: 4783.  Back to cited text no. 13
    
14.
Warde P, Specht L, Horwich A, Oliver T, Panzarella T, Gospodarowicz M, et al. Prognostic factors for relapse in stage I seminoma managed by surveillance: A pooled analysis. J Clin Oncol 2002;20:4448-52.  Back to cited text no. 14
    
15.
Mencel PJ, Motzer RJ, Mazumdar M, Vlamis V, Bajorin DF, Bosl GJ. Advanced seminoma: Treatment results, survival, and prognostic factors in 142 patients. J Clin Oncol 1994;12:120-6.  Back to cited text no. 15
    
16.
Feldman DR, Motzer RJ. Good-risk-advanced germ cell tumors: Historical perspective and current standards of care. World J Urol 2009;27:463-70.  Back to cited text no. 16
    
17.
Fizazi K, Delva R, Caty A, Chevreau C, Kerbrat P, Rolland F, et al. Arisk-adapted study of cisplatin and etoposide, with or without ifosfamide, in patients with metastatic seminoma: Results of the GETUG S99 multicenter prospective study. Eur Urol 2014;65:381-6.  Back to cited text no. 17
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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