OncoLog, Volume 57, Number 10, October 2012 Page: 6
This periodical is part of the collection entitled: Texas State Publications and was provided to The Portal to Texas History by the UNT Libraries Government Documents Department.
Extracted Text
The following text was automatically extracted from the image on this page using optical character recognition software:
Cqmpas
[Continued from page 51Advances such as computed tomography-based planning
and proton radiation therapy have resulted in a more precise-
ly targeted delivery of radiation. However, some risk remains,
so although radiation is still used elsewhere, it is no longer a
preferred option at MD Anderson in patients with no known
lymph node involvement. Dr. Hoffman instead discusses the
option of active surveillance with all her patients with early-
stage disease for whom it is an option.
"Currently, if I treat an early-stage seminoma patient with
radiation at all, I use proton therapy," Dr. Hoffman said. Pro-
ton beams have a lower entrance dose than conventional
photon radiation, deliver the therapeutic dose over a discrete
area, and have no exit dose. Therefore, proton radiation
treatment of the para-aortic lymph nodes delivers a lower
dose to adjacent organs, including the pancreas and gastroin-
testinal tract. "Although proton therapy has not been around
long enough to gauge its long-term effects and has not been
compared head-to-head with conventional radiation delivery,
we know that it reduces the unnecessary radiation dose to
tissues outside the target field, which should decrease long-
term side effects," she said.
RPLND is a standard option for patients with stage IA or
IB non-seminomas, in whom the surgery usually provides
definitive treatment.
RPLND is usually done through a large transabdominal
midline incision and involves removing lymphatic tissue
from around the great vessels. In the past, the operation
involved a full bilateral dissection and usually resulted in
nerve damage that caused loss of ejaculation and emission
capability. Today, smaller dissection fields are used to spare
these nerve bundles and retain as much function as possible.
Standard options for patients with stage IA non-semino-
mas are pre-emptive RPLND or active surveillance. Some
patients who opt for active surveillance will not need further
treatment, and those who undergo RPLND when disease
recurs have outcomes similar to those of patients who under-
go early surgery.
Patients with stage IB non-seminomas who require or
want additional treatment rather than surveillance must
choose between RPLND and chemotherapy. "The surgery
is a large and serious operation-an extensive abdominal
surgery," Dr. Pisters said. "Most patients prefer the chemo-
therapy."
For these reasons, Dr. Pisters said, RPLND has fallen
out of favor as a treatment for most of the early-stage testicular
cancers discussed here and is rarely used at MD Anderson.
The exception is a small subset of patients who have a ter-
atoma with malignant transformation-a rare but very aggres-
sive histologic type for which RPLND is the only option.
Chemotherapy is a standard option for patients with stage IA
or IB seminomas or stage IB non-seminomas. Accordingto Lance Pagliaro, M.D., a professor in the Department of
Genitourinary Medical Oncology, chemotherapy is a safe
and effective alternative to RPLND or radiation therapy.
For seminomas, the standard adjuvant chemotherapy is
carboplatin, which has relatively mild side effects and can
be administered on an outpatient basis either as a single dose
or in two doses 3 weeks apart. A large randomized trial found
equivalent rates of relapse-free survival in patients receiving
single-dose carboplatin and patients receiving radiation ther-
apy after orchiectomy.
"Two questions arise, however," Dr. Pagliaro said. "The
first is whether we can improve outcomes with two cycles
instead of one, and the second is what are the effects after
10 or 20 years or longer?" Answering these questions will
require data from follow-up visits over many years. In the
meantime, noting that most recurrences are prevented
with the first dose, he considers single-dose therapy safer.
In the event of a recurrence during active surveillance
or after chemotherapy, treatment outcomes are excellent,
but either radiation therapy or intensive combination
chemotherapy is required.
"I regard surveillance as the least morbid option for semi-
nomas," Dr. Pagliaro said. "Most are cured without the need
for further treatment. Plus, we don't have sufficient data
about the long-term risks of some postoperative treatments."
However, Dr. Pagliaro believes that there are patients
with early-stage seminomas for whom a single course of
carboplatin should be strongly considered. These patients
include:
" Patients with tumors larger than 4 cm classified as pT3.
"These patients have a higher risk of recurrence-about
1 in 3," he said.
" Patients 50 years or older, in whom seminomas are more
common. These patients have fewer concerns about fertil-
ity or long-term sequelae.
" Patients of any age who are concerned about future access
to health care. This includes men in their teens or early
20s who are currently covered by their parents' insurance
policies and whose future insurance coverage is uncertain.
Chemotherapy is also an option for patients with stage IB
non-seminomas. For these patients, the most important risk
factors are histological type and evidence of LVI. For patients
who are considered to be at high risk of recurrence, the
chemotherapy options are one or two cycles of bleomycin,
etoposide, and cisplatin (BEP). "This is the same chemother-
apy that is used for recurrence, but less is given if used up
front," Dr. Pagliaro said. "Although two cycles have not been
proven clearly superior to one, we know that two cycles
reduces recurrence risk from 50% with surveillance to 2%,"
he said.
No study so far has compared one versus two cycles of
BEP directly. However, a large risk-adapted trial that com-
[Continued on page 8]6 OncoLog October 2012
Upcoming Pages
Here’s what’s next.
Search Inside
This issue can be searched. Note: Results may vary based on the legibility of text within the document.
Tools / Downloads
Get a copy of this page or view the extracted text.
Citing and Sharing
Basic information for referencing this web page. We also provide extended guidance on usage rights, references, copying or embedding.
Reference the current page of this Periodical.
University of Texas M.D. Anderson Cancer Center. OncoLog, Volume 57, Number 10, October 2012, periodical, October 2012; Houston, Texas. (https://texashistory.unt.edu/ark:/67531/metapth639634/m1/6/: accessed March 19, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.