Seminoma: Stage I

Overview

Patients with Stage I seminoma have a primary cancer that is limited to the testes and is curable in more than 95% of individuals.

The primary treatment of Stage I seminoma is surgical removal of the cancer by orchiectomy. Following surgery, patients may receive chemotherapy or radiation therapy to reduce the risk of cancer recurrence, or close surveillance to detect recurrence at an early stage.

The following is a general overview of treatment for Stage I seminoma. Cancer treatment may consist of surgery, radiation, chemotherapy, targeted therapy, or a combination of these treatment techniques. Combining two or more of these treatment techniques–called multi-modality care–has become an important approach for increasing a patient’s chance of cure and prolonging survival.

In some cases, participation in a clinical trial utilizing new, innovative therapies may provide the most promising treatment. Treatments that may be available through clinical trials are discussed in the section titled Strategies to Improve Treatment.

Circumstances unique to each patient’s situation influence which treatment or treatments are utilized. The potential benefits of multi-modality care, participation in a clinical trial, or standard treatment must be carefully balanced with the potential risks. The information on this Web site is intended to help educate patients about their treatment options and to facilitate a mutual or shared decision-making process with their treating cancer physician.

Adjuvant Therapy

It is important to understand that a few patients with Stage I seminoma already have small amounts of cancer that have spread into the lymph nodes and cannot be detected with any of the currently available tests. Undetectable areas of cancer are referred to as micrometastases. The presence of micrometastases causes cancer recurrence following treatment with surgery alone. An effective treatment is needed to cleanse the body of micrometastases in order to improve a patient’s duration of survival and potential for cure. The delivery of cancer treatment following local treatment with surgery is referred to as “adjuvant” therapy and may include chemotherapy or radiation therapy.

Following surgical orchiectomy (removal of the affected testicle), approximately 15% of patients with a Stage I seminoma will experience cancer recurrence if they are not treated with additional therapy. By administering relatively low doses of chemotherapy and/or radiation therapy to the retroperitoneal and inguinal lymph nodes after surgery, the chance of cancer recurrence can almost be completely eliminated.

Historically, most patients have been given radiation treatment following orchiectomy; however, recent clinical trials suggest that chemotherapy may be more advantageous.  One of these clinical studies involved 125 patients who received either one or two courses of chemotherapy with Paraplatin^® (carboplatin) after orchiectomy.1 Cancer recurred in 8.6% of patients who received one course of Paraplatin; all were cured with further chemotherapy. None of the patients who received two courses of Paraplatin experienced a cancer recurrence. In another study, 107 patients with Stage I seminoma received two courses of Paraplatin after orchiectomy; during an average of six years of follow-up, none of the patients experienced a cancer recurrence.2 These studies suggest that adjuvant treatment with two doses of Paraplatin is as effective as radiation therapy, and may be better tolerated.

Treatment of Patients with Surgery and Surveillance

An acceptable alternative to adjuvant therapy is to give no additional treatment after surgery and to perform surveillance. The principle of surveillance is to perform frequent evaluations after surgery in order to detect an early cancer recurrence and then initiate further treatment. Evaluations consist of chest X-rays, CT scans, and checking for cancer markers.

A review of previously published studies found that 17% of seminoma patients managed by surveillance experienced a cancer recurrence. Nearly all of these patients were cured with subsequent treatment.3

The advantage of surveillance is that the 85% of patients who are not destined to relapse are not exposed to radiation, which is associated with a low but definite risk of developing a second cancer, or chemotherapy. However, prolonged surveillance is necessary, because 20% of relapses occur four or more years after diagnosis. The size of the primary cancer may be an important prognostic factor, as patients with cancers larger than 6 centimeters (2 ½ inches) have a higher risk of relapse without adjuvant radiation therapy.

In summary, adjuvant radiation, chemotherapy or surveillance are all appropriate treatment options. Adjuvant treatment may be the option of choice for patients with a higher risk of cancer recurrence, such as those with vascular invasion observed on examination under the microscope or for patients who have primary cancers over 5 cm (2 inches) in size. Adjuvant chemotherapy may also be a consideration for those who do not want to risk the potential long-term side effects of radiation therapy (second cancers) or the anxiety associated with the frequent surveillance testing after surgery to detect early recurrences of cancer.

Questions to ask your physician

• What is my risk of cancer relapse without adjuvant therapy?
• What are the short-term and long-term side effects of adjuvant therapy given to prevent relapses?
• How frequently do I need to have surveillance examinations if I choose not to have adjuvant therapy?

Strategies to Improve Treatment

The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. Future progress in the treatment of testicular cancer will result from the continued evaluation of new treatments in clinical trials.

Patients may gain access to better treatments by participating in a clinical trial. Participation in a clinical trial also contributes the cancer community’s understanding of optimal cancer care and may lead to better standard treatments. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. Areas of active investigation aimed at improving the treatment of Stage I seminoma include the following:

Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed. For more information, go to Managing Side Effects.

Adjuvant Therapy vs. Surveillance: Current clinical trials for patients with Stage I seminoma are focused on determining who will benefit from adjuvant therapy and who will benefit from surgery alone followed by careful surveillance and treatment with chemotherapy when relapse occurs.

References

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