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A risk-adapted treatment policy for clinical stage I seminoma
Testicular cancer
is an infrequent disease accounting for 1-2% of all malignant neoplasms in
men. However, it represents the most common malignancy in males aged 15 to
35 years. More than a half of patients are now diagnosed with pure
seminoma and approximately 75% of them present with stage I disease. Their
probability of 5-year survival approaches 100%. Several treatment options
are available, i.e., prophylactic irradiation, surveillance, and adjuvant
carboplatin, their final efficacy being similar. Then, the objective of
current studies is to maintain these results while minimizing the adverse
effects of treatment (especially acute and late morbidity), preserving
both fertility and quality of life. This can be accomplished either by
employing less toxic therapies or by limiting their use to those patients
with a higher risk of relapse. Conceptually, it does not seem adequate to treat all patients in the same way as most of them would never relapse and treatment for recurrences is curative. Giving irradiation or adjuvant carboplatin to all patients may represent overtreatment, whereas surveillance may be inadequate for those with an expected risk of relapse over 30%. In contrast, an individually-tailored management fits better into the armamentarium of clinicians dealing with this disease, in a similar way than for patients with stage I nonseminomatous germ-cell tumors. Furthermore, reliable prognostic factors have been established (tumor size over 4 cm and rete testis invasion) and a high-risk group can be identified. The Spanish Germ-Cell Cancer Group (SGCCG) study has demonstrated that a risk-adapted treatment policy for clinical stage I seminoma is safe, feasible and effective, even in a nation-wide setting, with relapse rates of 6% on surveillance (low risk group) and 3.3% after 2 courses of carboplatin (high-risk group). The disease-specific survival was 100%. A new SGCCG study is ongoing that restricts adjuvant chemotherapy to patients with both risk criteria so that only 16% to 21% of cases would be treated.
Bibliographical reference:
Department of Medical Oncology, Hospital Universitario La Fe, Valencia, Spain
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