Radiotherapy for Stage IIA/B Seminoma

[Palex80]

Hello everybody.

Standard treatment would be hockey-stick (dog-leg) radiotherapy to 30 Gy for Stage IIA and 36 Gy for Stage IIB disease.

In the Roach handbook an approach is described with 25,5 Gy hockey-stick (dog-leg) + Boost to macroscopic disease up to 30/36 Gy.

This approach is clearly based on the experience gained by the MRC trial, which demonstrated that lower radiation doses (20 Gy) are sufficient to control microscopic disease in Stage I seminoma.

To the best of my knowledge there have been no trials or publications, which showed that the mentioned approach in the Roach handbook is also safe for Stage II seminoma. All trials on Stage II disease did 30/36 Gy upfront hockey-stick (dog-leg).

Two questions:

1. Does anyone know of a trial in Stage II disease that tried the Roach approach?
2. How many of you do hockey-stick (dog-leg) 20-25,5 Gy and then boost macroscopic disease to 30/36 Gy and how many do upfront hockey-stick (dog-leg) 30/36 Gy?

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[medgator]

Do you treat all of your stage IIBs with XRT? What about if they've got bulkier nodes?

 

[G'ville Nole]

Nothing that I've found, But in the German multi-center phase II trial (Classen et al., JCO 2003) that used a 30 Gy hockey stick for IIA and 36 Gy for IIB, there were four recurrences in the entire cohort, three of which were mediastinal, with one marginal miss.

What I take from this is that recurrences as a result of underdosing microscopic disease (well, aside from giving it no dose) are really not a significant issue. I think treating to 25 Gy and boosting gross disease to 35 Gy is a reasonable synthesis of these two approaches.

 

[Palex80]

Do you treat all of your stage IIBs with XRT? What about if they've got bulkier nodes?

Not necessarily.
This is the major discussion point we have with our medical oncologists.
One can treat these patients with BEP as well. However the results of BEP-chemotherapy in Stage IIB aint that good either actually (87% 5y-PFS in the trial by Garcia-del-Muro).

 

[Butch]

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