More than half of painless solid swellings of the body of the testis are malignant, with a peak incidence in men aged 25 to 35 years. Most testicular cancers are germ cell tumours and half of these are seminomas, which tend to affect older men and have a good prognosis.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments in men with stage 1 seminoma (confined to testis) who have undergone orchidectomy? What are the effects of treatments in men with good-prognosis non-stage 1 seminoma who have undergone orchidectomy? What are the effects of maintenance chemotherapy in men who are in remission after orchidectomy and chemotherapy for good-prognosis non-stage 1 seminoma? What are the effects of treatments in men with intermediate-prognosis seminoma who have undergone orchidectomy? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 29 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: chemotherapy (maintenance, adjuvant, single-agent carboplatin, 3 or 4 cycles, different number of cycles of adjuvant, using bleomycin added to vinblastine plus cisplatin, using etoposide plus cisplatin with or without bleomycin, adding higher doses to a 2-drug chemotherapy regimen using cisplatin or vinblastine); radiotherapy (different adjuvant regimens [20 Gy in 10 fractions to para-aortic area, 30 Gy in 15 fractions to para-aortic area and iliac nodes], different drug combinations, 30–36 Gy in 15–18 fractions); and surveillance.
More than half of painless solid swellings of the body of the testis are malignant, with a peak incidence in men aged 25 to 35 years.
Most testicular cancers are germ cell tumours and about half of these are seminomas, which tend to affect older men and have a good prognosis.
In men with seminoma confined to the testis (stage 1), standard treatment is orchidectomy followed by radiotherapy, chemotherapy, or surveillance. All 3 management options are associated with cure rates approaching 100% because of successful salvage therapy.
Adjuvant chemotherapy reduces the risk of relapse after orchidectomy compared with surveillance, but is associated with short-term adverse effects (nausea, diarrhoea, and indigestion) and possible long-term risks of reduced fertility and development of second malignancies.We don't know which is the most effective chemotherapy regimen, or the optimum number of cycles to use. The high cure rate with standard therapy makes it difficult to show which alternative therapy is superior.Toxicity is lower, but efficacy the same, with adjuvant irradiation of 20 Gy in 10 fractions compared with 30 Gy in 15 fractions, or with irradiation to para-aortic nodes compared with ipsilateral iliac nodes.
In men with good-prognosis non-stage 1 seminoma who have had orchidectomy, radiotherapy may improve survival and be less toxic than chemotherapy, except in men with large-volume disease, in whom chemotherapy may be more effective.
Combined chemotherapy may be more effective than single agents, but 3 cycles seem to be as effective as 4 and with less toxicity.A standard radiotherapy treatment comprises 30 to 36 Gy in 15 to 18 fractions (2 Gy per fraction), although we don't know whether this is more effective than other regimens.
In men who are in remission after orchidectomy plus chemotherapy for good-prognosis, non-stage 1 seminoma, further chemotherapy is unlikely to reduce relapse rates or increase survival.
Chemotherapy increases survival in men with intermediate-prognosis seminomas who have had orchidectomy; although evidence for this is derived mostly from treatment of intermediate-prognosis non-seminoma, it is likely to be generalisable to intermediate-prognosis seminoma.