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Radiation therapy for testicular cancer


Medical editor Gustav Lehne MD
Oncologist
Oslo University Hospital

General

Adjuvant radiation therapy for testicular cancer is no longer recommended as standard treatment. It can be considered for seminoma stage I og II A.
Patients with nonseminoma should usually not have radiation therapy.

Indications

Seminoma stage I and II A

Goal

To cure the disease


Definitions

 Target Volume

 

 

Target volume definitions from ICRU
(International Commission on Radiation Units and Measurements)

GTV (Gross tumor volume)

Tumor volume

Palpable or visible/demonstrative area of malignant growth.

CTV (Clinical target volume)

Clinical target volume

Tissue volume which contains GTV and/or subclinical microscopic malignancy.

ITV (Internal Target Volume)

Target volum

Volume containing CTV and one inner margin taking into account inner movements and revisions of CTV.  

PTV (Planning Target Volume)

Planning volume

Geometric volume containing ITV and one set-up margin taking into account internal movements, variation in patient positioning, and field modeling.

 

Target volume

GTV (=Gross Tumor Volume)

Is defined as any enlarged metastatic lymph node, that is clinical stage IIA

CTV (=Clinical Target Volume)

CTV of the para-aortic region comprises the combined volume of the inferior vena cava and aorta including visible lymph nodes, the ipsilateral kidney vein without lateral margin, and any GTV with 1,4 cm margins in all directions from the upper border of the T11 vertebral body to the aortic bifurcation. If the ipsilateral iliacal lymh nodes are to be included (for example clinical stage  IIA), CTV must be expanded with the combined volume of the common and the external iliacal vessels down to the upper limit of the foramen obturatorium including all visible lymph nodes and any GTV with 1,4 cm margins in all directions.
In the case of prior inguinal or scrotal surgery or in locally advanced disease (T4 tumor) inguinal lymph nodes with 1,4 cm margins in all directions should be added to the CTV.

ITV (=Internal Target Volume)

ITV (internal target volume) is equal to CTV since the movement of this body part is ignorable

PTV (Planning Target Volume)

PTV (planning target volume) is equal to ITV plus planning margins (penumbra).

 


Preparation

Position/Fixation

  • The patient lies in the supine position
  • Fixation in accordance with local practice to ensure reproducible position throughout the treatment
  • The orchiectomy scar is marked with a lead wire
  • The contralateral  testis is shielded with lead
  • Special gonadal shielding is usually not necessary, but gonadal dosage calculation should be done for patients under 50 years

Technique

Dose planning with CT. Volumtarget is based on the blood vessels, this because spread via lymph vessels follow blood vessels like aorta, vena cava inferior, ipsilateral renal vein and ipsilateral pelvic veins (iliaca communis and externa).

Radiation quality

Minimum 6 MV photons

Organs at risk

Both kidneys are marked as organs at risk. Not more than 25% of each kidney tolerates more than 20 Gy radiation dose.


Implementation

Seminoma stage I

Radiation dose

  • 2 Gy x 10 (total 20 Gy), 5 fractions a week  to the paraaortal lymph nodes.

The radiation field should include ipsilateral iliacal and inguinal lymph nodes, if the tumor is stage T4 or the patient underwent scrotal or inguinal surgery.

Seminoma stage II A

Radiation dose

  • 2 Gy x 15 (total 30 Gy), possibly 1.8 Gy x 15 (total 27 Gy), 5 fractions a week to paraaortal and ipsilateral iliacal lymph nodes.

If  the patient underwent  scrotal or inguinal surgery or if the tumor is stage 4, inguinal lymph nodes is included  in the target volume.


Follow-up

Organs at risk

Kidneys

  • Patients treated with cisplatin-based chemotherapy should not have aminoglycosides the first 3 months after treatment.

Skin

  • Acute dermatitis in the scrotal skin may occur since there are many skin folds and the skin is exposed to moisture during fractions.

Mucosa

  • In the urethra and rectum, mucositis  may occur with dysuria  and  rectal symptoms.

The gastrointestinal tract

  • Nausea, diarrhea, abdominal pain (stomach ache) and fatigue (tiredness).

Long-term risks

  • Irradiation of the testicles in the mentioned doses will cause permanent sterility. Reliable birth control is still recommended during treatment and the first year after. Testosterone production may decline many years after treatment and should be evaluated regularly. 
  • Secondary malignancy caused by radiation therapy.

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