Stage II Seminoma

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Stage II Seminoma

• Mary Gospodarowicz
• P Warde, P Chung
• Department of Radiation Oncology
• University of Toronto
• Princess Margaret Hospital
• Toronto, Canada

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Testis Tumours - 2008

• US 8090 - new cases 380 - deaths
• Cure - _at_ 99 in localized disease
• Potential for very long survival - gt70 yrs
• Long term survival vs. Cure
• Goal
• Disease control
• Minimize morbidity

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Multiple Effective Treatment Modalities
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Seminoma

• Rare and highly curable malignancy
• Common presentations
• 85.8 of seminoma - stage I
• 7.2 of seminoma - stage II
• Changes in management
• Improved diagnosis pathology, imaging
• Improved treatment RT, chemotherapy
• PMH results to illustrate
• changes in management
• outcomes

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Stage II Seminoma PMH Experience

• 1981- 2006
• 163 pts median f-up 7.3 yrs
• Stage IIA - 63 pts
• Stage IIB - 52 pts
• Stage IIC - 48 pts
• 5 7 pts per year

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Stage II Seminoma PMH 1981 - 2006

• OS 94
• CSS 96

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Stage II Seminoma PMH 1981 - 2006

• RFR 86

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Stage II Seminoma PMH Experience
Relapse rate in stage IIA/B vs. stage IIC

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Stage II Seminoma PMH Experience

• Treatment
• RT Chemo All
• Stage IIA 62 1 63
• Stage IIB 38 14 52
• Stage IIC 17 31 48

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Stage II Seminoma PMH Experience
Relapse rate in stage IIC Chemo vs. RT
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Stage II Seminoma PMH Overall outcomes

• 20 relapses
• most in the first 10 years of the study
• 17 in RT pts 3 in chemotherapy pts
• 10 deaths
• 7 seminoma
• 3 other
• HIV/AIDS, lung ca, kidney ca

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Stage II Seminoma PMH - Change in treatment
approach

• Early 1980s RT for all pts
• Late 1980s
• Stage IIA IIB RT
• Stage IIC Chemotherapy
• Recent experience
• Lower risk of relapse

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Stage II Seminoma PMH - Change in treatment
approach

• 1995 - 2006
• 56 patients treated
• Increased use of chemotherapy in stage IIB
• Stage IIA - 17 pts RT, 1 pt S
• Stage IIB - 12 pts RT, 10 pts chemo
• Stage IIC - 16 pts chemo
• 4 relapses
• 1 scrotal relapse in stage IIA RT pt - salvaged
• 3 local failures in chemotherapy pts, 1 DOC

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Stage II Seminoma PMH Chemotherapy Experience

• 46 patients
• Stage IIA IIB 15
• Stage IIC 31
• Usual treatment EP x 4
• 3 pts BEP
• 2 pts with PR had RT
• Only 1 death with progressive disease in stage
  IIC patient

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Stage II Seminoma single vs. multiple nodes
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Stage II SeminomaIssues in Management

• Management of stage IIA-IIB
• RT vs. chemotherapy
• Choice of chemotherapy
• Adjuvant carboplatin with RT
• Management of PR post chemotherapy
• RT, surgery, role of PET
• Late effects
• Second cancers

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Stage II Seminoma - Residual Mass

• Management of residual mass after chemotherapy
• no role for routine radiotherapy
• lt 3 cm - observe with serial CTs
• gt 3cm
• 30 risk of disease in MSKCC series
• resection vs. observation with serial CTs
• role of PET CT excellent ve predictor

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Stage II Seminoma - Summary

• Standard treatment
• IIA/B
• Controversy chemotherapy vs. RT
• Issue treatment burden vs. late effects
• IIC
• EP chemotherapy
• No role for RT in post - chemo residual mass
• Role of PET

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Stage II Seminoma

• Expert treatment
• Several effective treatment options - Cure is
  expected
• Non-expert treatment
• Rare presentation
• Potential for suboptimal treatment approaches
• Populations based approaches important
• Treatment guidelines
• Standards for referral to expert centres
• Quality control
• Population based outcomes

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PMH Testis Group

• Radiation Oncology
• Padraig Warde
• Charles Catton
• Peter Chung
• Betty Tew-George
• Imaging
• Martin OMalley
• Biostatistics
• Tony Panzarella
• Anthea Lau

• Urology
• Michael Jewett
• Medical Oncology
• Jeremy Sturgeon
• Malcolm Moore
• Pathology
• Diponkar Banerjee
• Joan Sweet
• Andrew Evans
• William Chapman

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Thank you