102Radiotherapy dose fractionation Third edition
Background
Stage I seminoma has between a 15–20% risk of relapse; surveillance without treatment
is one option. Relapses principally occur in the para-aortic nodes and the risk can be
quantield using factors related to the primary tumour.
1
A tumour >4 centimetres (cm)
in size is the most important of these; rete testis involvement may also be a predictor.
2
Adjuvant treatment rather than surveillance may be oered in such cases.
A single dose of carboplatin has been shown to achieve results equal to radiotherapy in
terms of overall tumour control and early survival in the TE19 randomised trial.
3
In the UK
this approach has now become the standard (Level 1b).
4
If radiotherapy is considered in this setting then a dose of 20 Gray (Gy) in ten daily fractions
treating the para-aortic node chain only has been shown to be as eective as 30 Gy or larger
elds (Level 1b).
4,5
Radiotherapy may also be considered for selected patients with stage IIA and IIB seminoma
where there are metastatic para-aortic nodes up to 5 cm.
6
A dose of 30 Gy in 15 daily
fractions to the para-aortic nodal chain and ipsilateral iliac nodes is recommended. A boost
of 5 Gy to enlarged lymph nodes may be considered (Level 2b).
4,7,8
An alternative approach
uses a single dose of carboplatin with radiation elds reduced to the involved para-aortic
region only (Level 1b).
4,9
Radiotherapy carries an excess risk of death as a result of radiation-induced cardiac
disease or second cancer.
5
Thirty-year follow-up shows that the relative risk of second
malignancy is 1.4; this translates into an increase in the risk of cancer from 15% for the
normal population to 25% for the seminoma cohort at 30 years (Level 2b).
4,10
Recommendations
Single agent carboplatin will be the usual adjuvant treatment for high-risk stage I
disease seminoma (Grade B)
Stage I seminioma for which adjuvant para-aortic radiotherapy is indicated:
20 Gy in 10 fractions over 2 weeks (Grade A)
Stage IIA or IIB seminoma: para-aortic and ipsilateral iliac radiotherapy (dog leg)
or para-aortic radiotherapy alone after carboplatin:
30 Gy in 15 fractions over 3 weeks (Grade B)
The types of evidence and the grading of recommendations used within this review are based on
those proposed by the Oxford Centre for Evidence-based Medicine.
4
15.
Seminoma
References
103Radiotherapy dose fractionation Third edition
1. Warde P, Specht L, Horwich A et al. Prognostic factors for relapse in stage I seminoma managed by
surveillance: a pooled analysis. J Clin Oncol 2002; 20(22): 448–452.
2. Chung P, Daugaard G, Tyldesley S et al. Evaluation of a prognostic model for risk of relapse in stage I
seminoma surveillance. Cancer Med 2015; 4(1): 155–160.
3. Oliver RT, Mead GM, Rustin GJ 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(8): 957–962.
4. www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009
(last accessed 30/9/16)
5. Jones WG, Fossa SD, Mead GM et al. Randomised trial of 30 versus 20 Gy in the adjuvant treatment of
stage I testicular seminoma: a report on Medical Research Council Trial TE18, European Organisation
for the Research and Treatment of Cancer Trial 30942 (ISRCTN 18525328). J Clin Oncol 2005; 23(6):
1200–1208.
6. Giannatempo P, Greco T, Mariani L et al. Radiotherapy or chemotherapy for clinical stage IIA and
IIB seminoma: a systematic review and meta-analysis of patient outcomes. Ann Oncol 2015; 26(4):
657–656.
7. Oldenburg J, Fosså SD, Nuver J et al. Testicular seminoma and non-seminoma: ESMO Clinical Practice
Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013; 24(Suppl 6): vi125–vi132.
8. Tandstad T, Smaaland R, Solberg A et al. Management of seminomatous testicular cancer: a binational
prospective population-based study from the Swedish Norwegian testicular cancer study group. J Clin
Oncol 2011; 29(6): 719–725.
9. Horwich A, Dearnaley DP, Sohaib A, Pennert K, Huddart RA. Neoadjuvant carboplatin before
radiotherapy in stage IIA and IIB seminoma. Ann Oncol 2013; 24(8): 2104–2107.
10. Zagars GK, Ballo MT, Lee AK, Strom SS. Mortality after cure of testicular seminoma. J Clin Oncol 2004;
22(4): 640–647.