One specific indication for primary RPLND is

(“dogleg” radiotherapy), but this has now been

where there are problems with patient compli­

replaced with para­aortic treatment following

ance in attendance. This is known to present

studies showing no differences in survival/

problems in certain circumstances, particularly

recurrence rates and reduced toxicity if the radi­

when the distance patients have to travel to

ation field is limited to the para­aortic area.15

referral centers is great.

Grade 1 complications such as nausea, vomiting,

and GI ulceration are often seen with para­aor­

Adjuvant Treatment for High Risk

tic XRT and a transient drop in sperm count can

occur in a proportion. The decrease in sperm

Many centers now use adjuvant reduced­inten­

count will usually recover within 1 year. Using

sity chemotherapy for high­risk cases,most com­

the low dose para­aortic regimen, acute toxicity

monly with bleomycin, etoposide, and cisplatin

is reduced and the effect on sperm count within

(BEP). Chemotherapy using a single cycle of BEP

the first 18 months is less profound. The dose of

has been shown to be superior to primary RPLND

para­aortic radiation has also been reduced fol­

(1% recurrence rate for chemotherapy vs 7.5%

lowing publication of data comparing 20 Gy in

for nerve sparing surgery),34 and 2 cycles of BEP

10 fractions versus 30 Gy in 15.16 This study

have been proven to be superior than 1 (recur­

showed equivalence for both doses in relation to

rence rate 0% for 2 cycles vs 3.5% for 1 cycle).14

recurrence rates, with long­term radiation­

Another pragmatic approach adopted by many

induced toxicity occurring in less than 2%.

groups is to observe high­risk cases closely and

Moderate chronic gastrointestinal (GI) side eff­

treat relapsing patients with standard 3 cycle BEP

ects occurred in about 5% of patients, but with

on the understanding that while approximately

moderate acute GI toxicity in about 60%.

47% with vascular invasion will relapse,9,14 over

The main concern surrounding adjuvant radio­

50% will remain free of disease without the need

therapy is the increased incidence of radiation­

for additional therapy. This strategy is viewed as

induced secondary non­germ­cell malignancies.

safe on the basis that disease­free survival is

This represents a small but significant risk.17

equivalent whether the chemotherapy is given

early or late,with long­term survival in the region

of 98% in this group of patients.

Adjuvant Low Dose Chemotherapy

Clinical Stage 1 Seminoma

Studies using single agent chemotherapy with

carboplatin as an alternative to radiotherapy

have now shown that this therapeutic strategy is

Risk-Stratified Adjuvant Treatment

effective treatment for this type of disease. Pilot

studies by Oliver et al. reported the relapse rate

Because of the retroperitoneal relapse rate of

for patients treated with single dose carboplatin

15–19%, the exquisite radio sensitivity of semi­

using a dose schedule known as “AUC7” was 4%

noma and the lack of serum tumor markers,

(median follow­up of 51 months) and that 99%

adjuvant low dose abdominal radiotherapy has

of patients remained disease free. These results

been used widely as an adjuvant treatment for

were consolidated in the MRC TE19 study

this condition. However, more recent strategies

of carboplatin monotherapy versus adjuvant

involving the use of single agent chemotherapy

radiotherapy in clinical stage 1 seminoma.

with carboplatin have been adopted and these

Results showed no statistical difference in

have been supplemented even more recently by

recurrence rates. After a mean follow­up of

the use of surveillance strategies.

>4 years, the relapse rate with a single cycle of

carboplatin at 3 years was 5.2%.18 There were,

however, relapses occurring after more than

Adjuvant Radiotherapy

2 years and further long­term analysis of data

is required to assess the true long­term out­

Irradiation of the para­aortic and pelvic lymph

come, particularly relating to toxicity and other

nodes has been the most favored adjuvant treat­

late sequelae such as the induction of second

ment. The traditional standard approach

malignancy, acquisition of drug resistance

involved irradiation of the para­aortic nodes

in recurrences, the effect on fertility, and the

with inclusion of the ipsilateral inguinal nodes

impact on quality of life.

546

Practical Urology: EssEntial PrinciPlEs and PracticE

Surveillance in Clinical Stage 1

they received surveillance only following

Seminoma

orchiectomy. Only 6% of these patients relapsed

after a median follow­up of 3 years. The remain­

Strategies have

now

emerged from

Canada

ing patients, with one or both risk factors, were

treated with adjuvant carboplatin, and showed a

using a similar approach to those adopted for

relapse rate of 3.3%.20 Studies of this type repre­

many years

in

clinical

stage

1

NSGCT.

sent a significant way forward in targeting post­

Observation

of

clinical

stage 1

seminoma

orchidectomy treatment for patients with

patients has shown that about 16% of patients

clinical stage 1 seminoma who have a high risk

are at risk for recurrent disease: the median

of occult metastatic disease at the time of orchi­

time to relapse is 12–15 months with 96% of

dectomy. Strategies to reduce immediate adju­

these occurring

in

the

retroperitoneum

or

vant treatment in as many patients as possible

inguinal region. In a

multivariate

analysis

of

will confine treatment and treatment­related

several retrospective

observation

studies,

a

risk to those who need intervention most. This

tumor size >4 cm and the presence of rete testis

approach has been used to show that if the risk

invasion remain adverse prognostic signs: these

of relapse in patients managed with surveillance

define a high­risk group for relapse. If both fac­

is under 10%, the number of follow­up investi­

tors are present, patients have a risk of relapse

gations can be reduced.7 It is, however, notable

during surveillance of 32%. If both factors are

that in the Canadian surveillance series, patients

absent, a low­risk group can be defined with a

needed up to 20 CT scans as part of their sur­

relapse risk of only 12%.19 Prospective studies

using risk factors have now also been performed,

veillance protocol and relapses occurred after

more than 5 years of follow­up. Studies attempt­

for example, by the Spanish Testicular Cancer

ing to reduce the number of CT scans and also

Group. One­third of the patients in this group’s

to replace CT with MR are currently ongoing

study had neither of

the defined risk factors

(e.g., MRC TE20).

(rete testis invasion and a tumor size >4 cm):