Changing paradigms in the adjuvant treatment of stage I seminoma?

Despite excellent long-term results, routine postoperative radiotherapy of the regional lymphatics has been questioned as sta nda rd treatment in the management of stage I seminoma. Alternative strategies focus on sparing acu te and late treatment morbidity, including carcinogenesis, without comprisi ng cure rates. Surveillance strategies have shown to be a viable alternativ e, avoiding therapy for 75-80% of all patients; the same high level of surv ival is achieved by the use of primary chemotherapy and/or radiotherapy for recurrence. However, in comparison with routine irradiation, there is prol onged psychological stress for the patients, danger of extensive relapse an d lower cost-effectiveness due to the necessity of intensive follow-up proc edures. In nonrandomized studies, elective chemotherapy with single-agent c arboplatin was equally effective regarding tumor control in short-term anal yses. The question whether or not this treatment has advantages over radiot herapy in terms of treatment toxicity and long-term outcome is not proven a nd must be clarified in ongoing randomized prospective trials. During the l ast decade, the total radiation dose was gradually reduced by lowering trea tment doses to 25 Gy. In addition, target volumes were restricted to the pa raaortic lymph nodes, thus avoiding radiation damage to the remaining testi cle. Even at follow-up periods in excess of 5 years the incidence of pelvic lymph node relapses remains below 4%. To date, limited low-dose radiothera py following orchiectomy has to be considered as the standard method of tre atment outside clinical trials.