- Email: [email protected]
Stage I Germ Cell Tumours: Achieving Cure at Minimal Cost
392
Letters / Clinical Oncology 22 (2010) 390e392
Stage I Germ Cell Tumours: Achieving Cure at Minimal Cost Sir d In his editorial on the management of stage I germ cell tumours, Huddart [1] dismisses the extent to which changes in radiotherapy techniques in seminoma will have reduced the risk of second malignancy. In the past, treatments for seminoma and non-seminoma included doses up to 55 Gy, whole abdominal and chest ‘baths’ and prophylactic irradiation of the chest often delivered using kilovoltage or cobalt machines. Many of the patients studied by Travis et al. [2] between 1943 and 1991 received such treatments and the study was not limited just to seminoma patients treated with a ‘dog-leg’ field to 30 Gy. It would be surprising indeed if the risk of a second malignancy was not substantially reduced by para-aortic radiotherapy to 20 Gy and no doubt with modern radiotherapeutic techniques the volume irradiated could be reduced even further. Even surveillance has some risk from the number of computed
tomography scans that are required. To my mind, paraaortic radiotherapy still remains a valid choice for patients who are unable or unwilling to attend for years of surveillance. G. Read Department of Clinical Oncology, Rosemere Cancer Centre, Royal Preston Hospital, Sharoe Green Lane North, Preston PR2 9HT, UK
References [1] Huddart RA. Stage I germ cell tumours: achieving cure at minimal cost. Clin Oncol 2010;22:1e5. [2] Travis LB, Fossa SD, Schonfield SJ, et al. Second cancers among 40,576 testicular patients: focus on long term survivors. J Natl Cancer Inst 2005;97:1354e1365.
Ó 2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clon.2010.02.007
Stage I Germ Cell Tumours: Achieving Cure at Minimal Cost Sir d I agree with Dr Read's comments [1] that improvements in radiotherapy technique have probably reduced the risk of second malignancy compared with the wide field techniques discussed by Dr Read. However, a number of studies [2,3] have included patients treated predominantly by dogleg radiotherapy and have shown elevated risks of second malignancy. Using para-aortic radiotherapy may reduce this risk further (one study estimated by half [4]), but an elevated risk (greater than that seen for the use of diagnostic imaging) will remain. I do not deny that radiotherapy is a valid option for patients unable or unwilling to comply with other options. However, I note that in a recent paper we found it very difficult to identify non-compliers with follow-up [5]. Furthermore, the TE19 trial [6] identified patients to have a 4% risk of recurrence after para-aortic radiotherapy. Therefore, follow-up, probably with some imaging, is still required. I stand by the view that for most stage I seminoma patients surveillance or adjuvant carboplatin are the most appropriate options.
References [1] Read G. Stage I germ cell tumours: achieving cure at minimal cost. Clin Oncol 2010;22. [2] van den Belt-Dusebout AW, de Wit R, Gietema JA, et al. Treatment-specific risks of second malignancies and cardiovascular disease in 5-year survivors of testicular cancer. J Clin Oncol 2007;25:4370e4378. [3] Zagars GK, Ballo MT, Lee AK, Strom SS. Mortality after cure of testicular seminoma. J Clin Oncol 2004;22:640e647. [4] Zwahlen DR, Martin JM, Millar JL, Schneider U. Effect of radiotherapy volume and dose on secondary cancer risk in stage I testicular seminoma. Int J Radiat Oncol Biol Phys 2008;70 (3):853e858. [5] Moynihan C, Norman AR, Barbachano Y, et al. Prospective study of factors predicting adherence to medical advice in men with testicular cancer. J Clin Oncol 2009;27:2144e2150. [6] Oliver RT, Mason MD, Mead GM, et al. Radiotherapy versus single-dose carboplatin in adjuvant treatment of stage I seminoma: a randomised trial. Lancet 2005;366(9482): 293e300.
R.A. Huddart Institute of Cancer Research and Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK E-mail: [email protected]
Ó 2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clon.2010.03.003
Letters / Clinical Oncology 22 (2010) 390e392
Stage I Germ Cell Tumours: Achieving Cure at Minimal Cost Sir d In his editorial on the management of stage I germ cell tumours, Huddart [1] dismisses the extent to which changes in radiotherapy techniques in seminoma will have reduced the risk of second malignancy. In the past, treatments for seminoma and non-seminoma included doses up to 55 Gy, whole abdominal and chest ‘baths’ and prophylactic irradiation of the chest often delivered using kilovoltage or cobalt machines. Many of the patients studied by Travis et al. [2] between 1943 and 1991 received such treatments and the study was not limited just to seminoma patients treated with a ‘dog-leg’ field to 30 Gy. It would be surprising indeed if the risk of a second malignancy was not substantially reduced by para-aortic radiotherapy to 20 Gy and no doubt with modern radiotherapeutic techniques the volume irradiated could be reduced even further. Even surveillance has some risk from the number of computed
tomography scans that are required. To my mind, paraaortic radiotherapy still remains a valid choice for patients who are unable or unwilling to attend for years of surveillance. G. Read Department of Clinical Oncology, Rosemere Cancer Centre, Royal Preston Hospital, Sharoe Green Lane North, Preston PR2 9HT, UK
References [1] Huddart RA. Stage I germ cell tumours: achieving cure at minimal cost. Clin Oncol 2010;22:1e5. [2] Travis LB, Fossa SD, Schonfield SJ, et al. Second cancers among 40,576 testicular patients: focus on long term survivors. J Natl Cancer Inst 2005;97:1354e1365.
Ó 2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clon.2010.02.007
Stage I Germ Cell Tumours: Achieving Cure at Minimal Cost Sir d I agree with Dr Read's comments [1] that improvements in radiotherapy technique have probably reduced the risk of second malignancy compared with the wide field techniques discussed by Dr Read. However, a number of studies [2,3] have included patients treated predominantly by dogleg radiotherapy and have shown elevated risks of second malignancy. Using para-aortic radiotherapy may reduce this risk further (one study estimated by half [4]), but an elevated risk (greater than that seen for the use of diagnostic imaging) will remain. I do not deny that radiotherapy is a valid option for patients unable or unwilling to comply with other options. However, I note that in a recent paper we found it very difficult to identify non-compliers with follow-up [5]. Furthermore, the TE19 trial [6] identified patients to have a 4% risk of recurrence after para-aortic radiotherapy. Therefore, follow-up, probably with some imaging, is still required. I stand by the view that for most stage I seminoma patients surveillance or adjuvant carboplatin are the most appropriate options.
References [1] Read G. Stage I germ cell tumours: achieving cure at minimal cost. Clin Oncol 2010;22. [2] van den Belt-Dusebout AW, de Wit R, Gietema JA, et al. Treatment-specific risks of second malignancies and cardiovascular disease in 5-year survivors of testicular cancer. J Clin Oncol 2007;25:4370e4378. [3] Zagars GK, Ballo MT, Lee AK, Strom SS. Mortality after cure of testicular seminoma. J Clin Oncol 2004;22:640e647. [4] Zwahlen DR, Martin JM, Millar JL, Schneider U. Effect of radiotherapy volume and dose on secondary cancer risk in stage I testicular seminoma. Int J Radiat Oncol Biol Phys 2008;70 (3):853e858. [5] Moynihan C, Norman AR, Barbachano Y, et al. Prospective study of factors predicting adherence to medical advice in men with testicular cancer. J Clin Oncol 2009;27:2144e2150. [6] Oliver RT, Mason MD, Mead GM, et al. Radiotherapy versus single-dose carboplatin in adjuvant treatment of stage I seminoma: a randomised trial. Lancet 2005;366(9482): 293e300.
R.A. Huddart Institute of Cancer Research and Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK E-mail: [email protected]
Ó 2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clon.2010.03.003