Post-Orchiectomy Surveillance Is Sufficient for Men With Stage I Seminoma

At the 2013 meeting of the American Society of Clinical Oncology (ASCO), investigators of a large Danish study (abstract 4502)-which they say represents “the largest cohort ever published of stage I seminoma patients followed on a surveillance program” and which followed patients for a median of 15 years post surgery-have concluded that surveillance alone following surgery for stage I seminoma is sufficient, sparing patients in this setting from the unnecessary expense and associated toxicities of chemotherapy and radiation treatment.

Testicular cancer is the most common solid tumor among young men, and seminoma accounts for about 50% of testicular cancer cases. About 4,000 new cases of stage I seminoma-cancer localized to the testicle and with no clinical, imaging, or biochemical evidence of disease-will be diagnosed in the US this year. Stage I seminoma is typically treated with orchiectomy and followed by surveillance, which consists of 5 years of scheduled physical exams, chest X-rays, CT scans, and blood tests. According to an ASCO press release, surveillance is the follow-up strategy of choice in Denmark, whereas in the US, about half of stage I seminoma patients are managed with surveillance alone post-orchiectomy, while the remainder are treated with either radiotherapy or carboplatin chemotherapy following surgery.

The Danish study (abstract 4502) was presented at ASCO by Mette Saks Mortensen, MD, a PhD student at the Department of oncology at the Copenhagen University Hospital, Copenhagen, Denmark, and the research was supported in part by The Danish Cancer Society, The Danish Cancer Research Foundation, and the Preben and Anna Simonsen Foundation.

A clinical database was used to identify a total of 4,683 patients who had germ cell cancer diagnosed from 1984 to 2007. Among these patients, 1,822 with stage I seminoma were being managed with active surveillance post-orchiectomy. The investigators gathered possible prognostic factors for relapse from patient files and pathology reports. Linking the clinical database to the Danish National Patient Registry and Danish Register of Causes of Death enabled them to follow the patients’ relapse and mortality data.

Median follow-up was 15.4 years (range, 0–28 years). There were 355 relapses (19.5%), which were treated with radiotherapy in 216 patients, chemotherapy in 136 patients, and surgery in 3 patients.

The median time to relapse was 13.7 months. The investigators reported that 72.4% (257 patients) relapsed in 1 to 2 years, 20.3% (72 patients) relapsed in 2 to 4 years, and the remainder relapsed after more than 4 years. Statistically significant predictors of relapse included tumor size > 4 cm (about 1.5 inches), evidence of invasion, and a human chorionic gonadotropin (HCG) level > 200 IU/L.

However, the investigators found that stage I seminoma patients have excellent 10-year disease-specific survival of 99.5%: only 10 patients (0.55%) died of testicular cancer or treatment-related causes. “This means only 4 of 1,000 patients with stage I seminoma will die 10 years after their treatment,” commented ASCO President-elect Clifford Hudis, MD, from Memorial Sloan-Kettering Cancer Center.

In conclusion, Dr. Mortensen commented that the three predictors of relapse uncovered in the study “can help us identify ‘high-risk’ patients who may need adjuvant therapy instead of surveillance.” She said that, “in general, seminoma stage I patients can safely be followed on a surveillance program,” and she and her coauthors noted in their written abstract that “[S]everal international guidelines are now in agreement” that surveillance is the preferred management option in this setting.