Forty four testicular tumor cases were reported in the Jordanian national cancer registry in 2008. Although these neoplasms came short from ranking among the 10 leading cancer subtypes amongst males overall, testicular tumors ranked 7th and 5th amongst males aged 0–19 and 20–49 years, respectively [8
]. Since there are no detailed epidemiological studies addressing seminoma in Jordan, we have compiled a chart depicting the temporal distribution of stage I seminoma cases treated at our center over the years of this study (Figure ).
Number of patients diagnosed per year.
In this small series; we demonstrated the excellent prognosis for patients with early-stage seminoma treated by orchiectomy and adjuvant radiotherapy or active surveillance in a developing country. Unfortunately, there are no previously published reports assessing outcomes of seminoma patients in Jordan and as such we are unable to compare our results with those of another series. Furthermore, to the best of our knowledge, there is only one published study addressing testicular seminoma in a Middle Eastern country [9
]. This report -published in 1986- included a small number of patients treated in a Saudi Arabian center prior to the implementation of modern therapeutic guidelines. Nonetheless, and while acknowledging the limitations of our study including the small sample size and the short follow-up period, we report excellent outcomes in lieu with previously published Western reports.
Radical orchiectomy with ligation of the spermatic cord at the level of the internal inguinal ring is considered the standard treatment of seminoma [2
]. Scrotal violation should strongly be avoided, and as such, testicular biopsy is not advised in patients with solid testicular tumors [10
]. Disappointingly, patients are still occasionally referred to our center with prior history of surgical violation of the scrotum consequent to exploration or biopsy. In our series, these patients were managed by either re-excision or local irradiation to the scrotal scar. After a median follow-up of 28 months (range, 7–74 months), none of these patients developed relapse. This highlights the effectiveness of these approaches in preventing local recurrence.
Para-aortic radiotherapy is considered the standard adjuvant treatment of early stage seminoma with disease-specific survival rates approaching 100% [12
]. The TE10 trial demonstrated the non-inferiority of para-aortic versus dogleg radiotherapy fields [7
]. Most of the patients in our case series were treated by para-aortic fields and only a small proportion (9.9%) received dog-leg fields. In 2005, results of the TE18 trial were published and clearly demonstrated the non-inferiority of lower (20 Gy) as opposed to higher dose (30 Gy) para-aortic radiotherapy [14
]. Since then, we have adopted the recommendation of this trial and 52 out of 70 (74.3%) patients with known radiotherapy details received 20 Gy/10Fx.
Although the para-aortic field has emanated as the standard radiation approach in seminoma patients [15
], Power et al. [16
] reported the occurrence of ipsilateral pelvic relapse in 3 patients that would otherwise have been avoided if the radiation field was extended. In our case series, one out of the 3 patients who developed relapse harbored regional disease. In this patient, para-aortic lymph node metastasis was detected via abdominal CT scan 8 months after the completion of radiotherapy. Co-registration of this image with the radiotherapy simulation CT demonstrated that the relapse was actually in-field. Detailed review of baseline abdominal CT was undertaken in this patient and failed to reveal borderline and/or grossly enlarged or suspicious pelvic or para-aortic masses. The short time interval (from completion of radiotherapy till the appearance of regional relapse) and the spatial location of relapse (inside the radiation filed) support the fact that this patient actually harbored a biologically aggressive tumor from the start.
Due to the overwhelming success of the treatment and the subsequent long-term survival, there has been growing interest in decreasing treatment-related morbidity in seminoma patients [3
]. Long-term complications of radiotherapy include infertility and induction of secondary malignancy [1
]. Travis and colleagues [17
] reported a 1.43 observed-to-expected ratio of developing a second tumor in 29,000 long-term seminoma survivors. Although the absolute number of radiation-induced second malignancy is low [18
], this has led several investigators to attempt substituting radiotherapy for chemotherapy in these patients. The TE19 trial demonstrated the non-inferiority of single-injection carboplatin over para-aortic and/or dogleg radiotherapy at a dose of 20 to 30 Gy [19
]. However, chemotherapy also comes at the cost of undeniable side-effects. Nonetheless, interest in active surveillance has largely been driven by concerns about secondary malignancies associated with radiotherapy [17
]. Subsequent to the short follow-up period and the retrospective nature of this case series, we cannot address the occurrence and/or incidence of second malignancies in our patient population.
Several reports have addressed the safety of surveillance in the management of stage I seminoma [20
]. Although relapse rates of 10-30% have been narrated in patients with stage I seminoma [10
], relapses are usually detected early and salvage therapy is usually successful with long-term survival [1
]. However, since one of the prerequisites of recommending active surveillance in patients with stage I seminoma is strict patient compliance [23
], one could argue against such approach in developing countries such as Jordan where patient compliance is still disappointingly low. In our series, none of the patients under active surveillance developed relapse. However, due to the small number of patients (3 patients), we cannot draw conclusions on the applicability and safety of active surveillance in the management of seminoma patients in our community.
Although no clear predictors of relapse were found, lymphovascular invasion, rete testis invasion and tumor size have all been reported to significantly increase the risk of relapse in patients with seminoma [24
]. In our series, all 3 patients presenting with relapse demonstrated large tumors on initial pathological assessment (4.6, 6, 8 cm). Nonetheless, no clear predictors of relapse were found in our patient population.
Investigators have indicated that more than half of patients with relapse initially exhibit indicative symptoms and abnormal findings on physical examination highlighting the importance of patient education and meticulous medical examination [12
]. Less than 50% of seminoma relapses present with radiological abnormalities [25
]. Furthermore, most cases of relapse are discovered in the first 2 years after treatment. Our study confirms this observation. All the 3 cases of relapse, in our series, were diagnosed 8, 14, and 25 months after completion of radiotherapy. However, late relapse –up to 10 years after treatment- has been previously reported [11
]. Nonetheless, no evidence exists supporting the utilization of routine follow-up with computed tomography beyond 3 years of treatment [12