Aust. Radio!. (1979J,23. 136

The Radiotherapy of Non-Seminomatus Germinal Tumours of the Testis T. F. SANDEMAN,M.D., Ch.B., D.M.R.T., F.R.A.C.R., F.R.C.R. ConsultantRadiotherapist, Peter MacCaNum Hospital, 481 Little Lonsdale Street, Melbourne, 3000. From the age of 20 to 35 years the commonest malignancy in males is testicular in origin. When the community has finished training its male citizens it must expect some return on its investment. The loss of these young men i s thus of some importance to society at the most impersonal level. Add to that the destitution of families who become a community responsibility and it is apparent that testicular cancer can be a social blight, For the individual of course the challenge is greater than most in oncology. To save a patient at the start of his career, to preserve him for the sake of his youngand growingfamily is a rewarding

experience reinforced at many more follow up visits than the usual run of cancer patients. Seminoma is really too easy. Any radiotherapy centre not achieving an 80% overall survival rate with 90% for localised cases, should be examining its treatment methods. The non-seminomatous tumours are the controversial ones. Although the magnitude of the problem does not match that of breast cancer the heat engendered in the arguments for and against the surgical removal of the retroperitoneal nodes is no less than that surrounding radical mastectomy. In general the Atlantic has separated the surgical approach to the West with radiotherapy being entrenched to the East. Aus-

TABLE 1 Coniparison of Classification of Testicular Gem1 Cell Tumours Dixon and Moore (1952)

Pugh and Cameron (1976)

Collins and Pugh (1964)

Mostofi and Price (1973)

Seminoma

Seminoma classic spermatocytic

Seminoma classic spermatocytic

Seminoma typical anaplastic spermatocytic

Embryonal carcinoma

Malignant teratoma anaplastic (MTA)

Malignant teratoma, undifferentiated

Embryonal carcinoma adult polyembryoma

Malignant teratoma, intermediate, with no differentiated or organoid elements (MTIB)

Teratoma, immature ~

Teratoma with embryonal carcinoma (“teratocarcinoma”)

Choriocarcinoma

Malignant teratoma, intermediate, with differentiated or organoid elements (MTIA)

Malignant teratoma, intermediate

Teratoma, differentiated (TD)

Teratoma, differentiated

Teratoma, mature

Maliiant teratoma, trophoblastic (MTT)

Malignant teratoma, trophoblastic

Choriocarcinoma

Orchioblastoma

Yolk sac tumour

Embryonal carcinoma with teratoma (“Teratocarcinoma”)

Endodermal Sinus Tumour I -.

Embryonal carcinoma, infantile (juvenile)

The pathological classification used compared with the others in common usage.

136

Australasian Radiology, Vol. XXIII, No. 2, July, 1979

RADIOTHERAPY OF NON-SEMINOMATUS GERMINAL TUMOURS OF THE TESTIS TABLE 2 Pathological Sub Types Endodermal Sinus Tumour Teratoma Intermediate Teratoma Undifferentiated Teratoma Trophoblastic Unspecified Combined Tumour

Slides Reviewed

4 (MTU (M-W (MTT) (MTQ)

69 15 0 31 -

4 I9 15 16 20 31 -

190

231

I1

tralia has tended to follow the United Kingdom. This contribution therefore cannot answer the question as to which approach is best. It can only present the Melbourne experience and draw attention to one facet which has not been previously emphasised. MATERIAL AND METHODS From 1928 to 1975, 581 cases of testicular tumour were referred t o the Peter MacCallum Hospital. They were coded for computer analysis. Of these 502 were relevant, the remainder being treated elsewhere, of nongerminal origin, or, no primary being found. There were 271 seminomas

and 231 non seminomatous, 37 of them being combined tumours. The pathological classification adopted was that of Pugh and the British Testicular Tumour Panel (1976). Its relationship to other systems is shown in Table 1. All the available material was reviewed. For most of the patients whose sections were not obtained for re-appraisal the pathological report was clear. A proportion could not be accurately subclassified (Table 2). In early years staging was seldom performed adequately. Inferior vena cavography was used from 1960 t o 1970. Lymphangiography was routinely used in the latter years. No patient had

TABLE 3 Staging System The Primary

1

Patient No’ O f I

The Nodes

I

No. o Patien 16

eluded) not invading vessels or spermatic cord

T2 Vascularinvasionin the testis or spermatic cord. Local recurrence in the scrotum or inguinal Canal

M o Chest x-ray clear

41

M i Involvement in the chest only

22

M2 Involvement beyond the lungs

of tumour in the abdominal nodes

59

Total Cases

N2 Palpable nodal abdominal disease

1 )

16

N3 Palpable neck nodes

TX Insufficient information or no orchidectomy

42

MX No chest x-ray per-

NX No obtained radiological in the evidence absence

formed in the absence of M2 conditions

of N2 or N3 conditions

231

231

15

231

The anatomical staging system used and the numbers in each stage. To this can be added Bo, B1, B2 signiiying the presence or absence of biochemical markers (Sandeman and Matthews).

Australasian Radioiogv, Vol. XXIII. No. 2,July, 19 79

I37

T. F. SANDEMAN SURVIVAL BY STAGE OF PRIMARY

SURVIVAL BY STAGE OF NODES

100

80 0

0

> .>

60

-

v)

(u

m

0

c.’

8 (u

0

2

a

40

20

-

-

1 1 1

8

1 1 1 1 1 I

1

8 8 8 88

T2

(5)

Llllllllll

FIGURE 1.-The survival curves of 37 radically treated Teratoma (Intermediate) patients plotted by the status of the nodes on the left atid by the absence (T, ) or presence (T,) of vascular invasion in the testis or cord on the right.

routine tomography of the chest or biopsy of impalpable scalene lymph nodes (Buck, Schamber et al, 1972). The staging system employed was developed on the lines of the U.I.C.C.’s TNM (1974) proposal but differed in detail from the suggested methods. It is shown in Table 3 (Sandeman & Matthews, 1978). Since retroperitoneal node sampling was not performed this is purely a clinical and radiological assessment except for the primary tumour. T2 in the Peter MacCallum Hospital method represents invasion of vascular structures in the testis or spermatic cord. This group, no matter what the stage of the nodes, had a poorer prognosis than those where this phenomenon was not detected (Figures 1-3). The technique of radiotherapy and the vigour with which it was pursued changed over the period 138

of study. Orthovoltage bridges either covering most of the abdomen or to a restricted area of the para-aortic chain were associated with moderate survivals overall (Table 4). The advent of megavoltage led t o restriction of the field and intensification of the dosage. A review of the results (Sandeman 1964) suggested a greater than expected incidence of marginal recurrence and for a short period the whole abdomen was covered with boosting of the central region and relevant iliac fossa. However, this was associated with a number of cases of hypertension and it too was abandoned in favour of a pyramidal shaped field which covered the psoas muscles and the renal hilum on both sides. For a time the opposite para-aortic region was covered to a vertical line 40mm across the mid line but as some cases seemed to demonstrate lymph node involvement in the opposite iliac fossa (Karparov and Australasian Radiology, VOL XXIII, NO. 2, July, I979

RADIOTHERAPY OF NON-SEMINOMATUS GERMINAL TUMOURS OF THE TESTIS

SURVIVAL BY STAGE OF NODES

SURVIVAL BY STAGE OF PRIMARY

100

-

80

- (12) --

-> 0

>

L 3

v)

w

rn

60

CI 0

c W

U L

W

n

40

20

-

23 T e r a t m Undifferentiated Patients Treated Rodicallv I

1

I

I

I

1

1

2

3

4

5

6

1

YEARS

2

3

4

5

6

FIGURE 2.-The suniyal curves of 23 radically treated Teratoma (Undifferentiated) patients plotted by nodal stage on the left and the stage of the primary on the right.

Actuarial Sumval Rate at 5 years. AU stages included.

Treatment Technique

Orthovoltage Large Bridge Small Bridge Whole Abdomen Megavoltage Whole Abdomen plus boost Inverted T or L Pyramid

Scminoma Total Patients

S.R.

Teratoma Total Patients

16 24 4

81% 79% 50%

4 13 0

39%

22 45 128

86% 82% 89%

17 17 87

S.R.

0%

Combined Tumours Total Patients S.R.

0%

-

1 3 1

100% 0%

53% 59% 55%

1 7 17

0% 14% 74%

T.F. SANDEMAN TABLE 5 Intestinal Daniage Orthovoltage Large Bridge Small Bridge Whole Abdomen

4/21 3/40 21 5

Megavoltage Whole Abdomen plus boost lnverted T or L Pyramid

6/40 0169 31232

Haeniatdogicd h i a g e

1

0121 0140 21 5

0140 5/69 11232

0169 01232

The complication rate of the abdominal irradiation techniques.

TERATOk4 BY T b

N

STAGES

TABLE 6 Recurrence within the abdomen after adequate treatment (40.0 Gy in 4 weeks)

100-

Stage of Recurrent Cases

80

60

Teratoma Intermediate Teratoma Undifferentiated Teratoma Trophoblastic Combined Tumours Intrafield recurrence rate after adequate treatment (pyramidal technique to at least 40.OGy in 4 weeks) by pathological subtype.

Pacedziev 1975) and there was little or no increase in morbidity, the fields were extended (Figure 4). The complication rate for all techniques is shown 40 in Table 5. The dosages used for radical treatment were, for seminoma 25 Gy to 35 Gy in 4 weeks depending on the stage and for the non seminomatous 2c tumours, 40 Gy in 4 weeks. Prophylactic treatment of the chest, mediastinum and neck was added in recently treated advanced seminomas but not for teratomas. Recurrences within the treated areas were comparatively rare and could be related to dosage (Figure 5). For the modern pyramidal I I I I I technique only 3 of 76 patients recurred solely 1 2 3 4 5 within the irradiated area in the abdomen (Table YEARS 6). All other recurrences were primarily extra abdominal and almost universally in the lungs. FIGURE 3. -Survival curves of teratoma patients accordattempt was made to reevaluate the lyming to the status of the nodes and the primary. All cases where this information was available have been included. phographic findings in the light of Tyrell and Patients with blopd borne metastases have been excluded. Peckham's report on the influence of the size Of 140

Australasian Radiology, Vol. XXIII, No. 2, July, I979

RADIOTHERAPY OF NON-SEMINOMATUS GERMINAL TUMOURS OF THE TESTIS

FIGURE 4.- The pyramidal field in current use at the Peter MacCallum Hospital. The edges must include the hilum of each kidney on a planning IVP see figure 9. -

the lymph node deposit on radiosensitivity (Tyrell and Peckham 1976). Unfortunately most of the dead patients’ films had been destroyed in the moving of the radiology department. Those that were available were obviously a biased sample but the only death occurred in a patient who had small deposits (Table 7). Extending the search to

Alive 2cm or less More than 2 cm Films discarded but reported +ve

the whole series including other radiation techniques, abdominal recurrence certainly seems commoner when a palpable massispresent. Further growth of tumour adjacent to the irradiated area occurred in 6 cases, only one being treated with a pyramidal field (Table 8). Relating survival to histology and nodal stage

Deceased

6 6

1 0

-

14

Abdominal Recurrence -

1 (removed benign) 1

T. F. SANDEMAN ABDUMfNAt RECURRENCE IN TREATED AREA

SERINDWA @-

Ty

PATIENT ALIVE AND WELL AFTER DISSECTION

PATIENT ALIVE AND WELL AFTER RE-TREATMENT

OR ENDOXAN

TI 7,-

IQ

I

4000-f

TI

I

I

I

“1 1000

L

I

I TQ

I

I

I

I

I I

I

I

I

I

I

I

I

I

I

1

I

I

I

I I

I

I

Ny SO

SD

-

I TQ 10

I I

I

I

I I

I

I

I I

I

I

I

1I

No

I

11

I

I

Y)

i

I

I

I

I I

1

I

I

I

I

I

I

I

N2

Nx

Seninma Unspecified Seminm Differentiated o r Typical

NO cl TQ TI TU TT

N1

-

N2

Nx

Crmbined Seminonu and Teratona l n t e r m d i d t e Unspecified T e r a t m I n t e m d i a t e Teratama Undifferentiated Teratoma Trophoblartic Teratoma

FIGURE 5. -Recurrences within the irradiated area related to stage of nodes and dosage (all cases are included).

for radically treated patients, shows that there was very little difference between the teratoma

TABLE 8 Abdominal Recurrences - all cases without chest metastases

The abdominal recurrences according to N stage for all cases of non-seminomatous testis tumours. One N2 suntives following surgical removal of a “benign teratoma” after x-ray therapy.

142

intermediate and the teratoma undifferentiated groups (Table 9). When chest metastases were treated radically 2 of 7 patients with teratoma intermediate disease survived 5 years later compared with 2 of 9 teratoma undifferentiated cases (Figure 6).

DISCUSSION The only new piece of the teratoma jigsaw reported here is the profound influence exerted by the finding of vascular invasion within the tumour or in the spermatic cord. For germinal tumours as a whole, the T stage as used at the Peter MacCallum Hospital correlates well with the nodal and blood borne metastatic stage (Figures 7 and 8). This carries through to survival, particularly for the teratomas where there is a greater separation by T stage than by N stage. Even comparing similar nodal stages a clear prognostic division can be detected (Figure 3). There are Australasian Radiology, Vol. XXIII, No. 2, July, 1979

RADIOTHERAPY OF NON-SEMINOMATUSGERMINAL TUMOURS OF THE TESTIS

FIGURE 6 (a) FIGURE 6A-B.-Chest X-ray before and after radiotherapy for metastases from a teratoma intermediate.

FIGURE 6 (b)

obvious implications for therapeutic manoeuvres beyond the routine in such cases. The radiotherapeutic results reported show a reasonable improvement in the light of experience. When compared with those published recently (Table 10) there seems to be a reasonably wide range of survival rates for both stages. Part of this may be due to more rigorous criteria for assessing lymphograms since a tighter staging procedure can apparently improve the results in both stages (see Sandeman and Matthews 1978 and Castro’s results in Table 11). Vander Werf-Messing(1976) reported exceptional survival rates for stage I but less favour-

able figures for stage 11. The reason for this may be in the better staging. Rotterdam is the only series in this group to allot fewer patients to stage I than stage 11. It may therefore be more realistic to examine the combined stages. When this is done the current series is at least comparable to all but the Peckham and McElwain series from the Royal Marsden Hospital in London and the Maier and Mittemeyer series from the Walter Reed Hospital. Some of the former patients received chemotherapy as a routine so that the protocols are not similar. Those reported from the Walter Reed Hospital are quite the best overall of any non-surgical approach.

TABLE 9 Radical X-ray Therapy - 3 year actuarial survival rate. Total numbers in brackets.

I Nodes clear (NO) RadiologicaUy

I

+ye

(N1)

Abdominal masses(N2)

I

Te ra t oma Intermediate

I

Teratoma Undifferentiated

1

I

Teratoma Trophoblastic

72% (24)

75% (12)

100% (2)

75% (8)

58% ( l i f

41% (11)

66% (3)

0% (3)

50% ( 2)

I

-

-

I

-

-

I

The 3 year actuarial survival rate for radical x-ray therapy by the current technique.

Austrahsian Radiology, Vol. XXIII, No. 2, July. 1979

I43

T. F. SANDEMAN

Percentago d cams wlth Lymphatic metortuser

Percentage

of cases

with btoad

borne spread

M2 Mi

Mo

281 CASES

T2 113 CASES

T2 281 CASES

113 CASES

FIGURE 7. -The influence of T stage on N stage. FIGURE 8. -The influence of T stage on M stage.

These authors use elective mediastinal/neck irradiation in all cases. The resultant prolongation of the primary treatment course would probably not be acceptable to many Australian patients. Maier and Mittemeyer claim that pulmonary and haematological complications are not seen with the doses used for seminoma. Although they recommend much higher doses for nonseminomatous tumours they do npt mention any morbidity. Radiation pneumonitis is an obvious danger. Bone marrow depression would seem to be likely but neither are mentioned. Much has been made of the size of the lymph node metastases as a prognostic index of the effect of radiotherapy (Tyrell and Peckham 1976). It is unfortunate that much of the lymphographic evidence in this series could not be reviewed. From the material available a correlation between size of node metastasis and prognosis could not be

I44

confirmed. The survival experience seemed equally divided between large and small nodes. Abdominal recurrences were singularly fewer than in the Royal Marsden series. Examination of the fields illustrated in the article suggests that some of the recurrences could have been marginal rather than within the irradiated field. A narrow strip which could miss the renal M u m is shown. This situation in Melbourne led to the development of the current pyramidal shaped field (Figure 9). Their overall survival rate, in spite of a high incidence of local recurrence or persistent tumour, is a tribute to their follow up management. In 1973 the London Hospital (Chapman et ul 1973) reported the identification of a “favourable group of teratomas” which they claimed were as radiosensitive as seminomas or at least gave overall results as good as or better than seminomas. Close examination of their article reveals that their Australasian Radiology, Vol. XXIII, No. 2, July, 1979

RADIOTHERAPY OF NON-SEMINOMATUS GERMINAL TUMOURS OF THE TESTIS TABLE 10 Orchidectomy plus bdiotherapy I

I

Canada McKay and Sellers

Stage

Patients

1 I1

1201193 111 33

I

Ontario

1966

England Chapman, Blandy et a1

London Hospital

1973

I (MTIA only

Peckham and McElwain

Royal Marsden Hospital

1975

I I1

661 78 171 29

Netherlands Van der WerfMessing

Rotterdam

1976

I I1

261 29 161 35

Walter Reed Hospital

1977

I

251 29 91 11

86% 82% 63%

U.S.A. Maier and Mittemeyer

11

63 37

Australia Atkinson and Ewing

Sydney

1974

I

51

Sandeman

Melbourne

1978

I

64

(Includes all staged cases)

(cumulative) (MTIA only

I1

25 45

I

I

62% 89%) 85% 59%

73%) 79% 54%

}

1

78%

6.370

I

1

I 69%

(cumulative)

The 3 year suMval rate of various series using orchidectomy plus radiotherapy as primary treatment. The Melbourne results include all the cases treated radically over the years.

results for seminoma and for the other major suggesting that her pathological criteria for incluforms of teratoma fall somewhat below those sion may differ. Nevertheless the current report reported elsewhere but they studied patients over confirms that the poor prognosis usually associated a period during which radiotherapeutic expertise with this diagnosis is not deserved. was changing. The overall stage I and I1 results in Irradiation of established lung metastases is Melbourne equal the overall stage I results at the another simple measure of radiosensitivity. Where London Hospital. This suggests that some patho- this was adequately carried out as a planned radical logical quirk may be at work. manoeuvre some survivors were obtained. The proportion of surviving intermediate (2/7) and There seems to be little to choose prognostically undifferentiated teratomas (2/9) is similar and no between the various histological subgroups when conclusion can be drawn apart from the fact that equal stages are compared in the Melbourne series. about one quarter of the patients with teratoma There is of course an overall difference which can can be saved by radiation alone even when metasbe attributed to the more advanced state of tases appear in the lung. For seminomas the patients presenting with the less differentiated proportion is one half. Prophylactic irradiation of tumour types but apart from that the pathological the mediastinum and neck is claimed to add to the report is not an absolute indicator of response to cure rate in all types of testicular tumour (Maier radiation. Van der Werf-Messing’s report drew and Mittemeyer 1977). This is difficult to explain. attention t o the excellent survival that could be as the great majority of metastases appear in the obtained in trophoblastic tumours if no metastases lung parenchyma suggesting deposition at that site were found in the chest. There are rather more by the blood stream and not by lymphatic permeacases proportionately than in any other series, if tion although Van der Werf-Messing (1971) this group is equivalent to choriocarcinoma, argues otherwise. Gilbert et al (1976) claim that Australasian Radiology, Yol. XXIII, No. 2, J d y , 1979

145

T. F. SANDEMAN TABLE I 1 Lymphadenectomy plus Radiotherapy Patients

2yr plus survival

61 8 41 5 81 14 101 17

57% 59%

1971

67

5 2%

971

161 19 91 16

56%

Stage Castro

M.D. Anderson

Woodhead, Johnson et a1

Wilford Hall USAF

WalSh, Kaufman et al

UCLA

Earle, Bagshaw and Kaplan

Stanford

Maier and Sulak

Walter Reed

Nicholson et a1

San Diego

1969

973 973

1974

111 14 101 17

58%

92/119 561133 37

42% 7%

231 27 61 8

75%

Skinner

UCLA

1977

41 4 31 7

100% 43%

Hussy, Luk and Johnson

M.D. Anderson

1978

83/106 81 18 17 7

47% 18% 43%

161 16 41 8

50%

(Sandwich Therapy) Quivey et a1

San Francisco (Sandwich Therapy)

1977

Combined Stages

64%

5 2%

7 1% 67% 58%

83% 64% 73%

83%

(P) = Pathological Sandwich Therapy - R.T. - Surgery - R. T. (C) = Clinical The 2 or more years suMvd rate reported from various centres for lymphadenectomy plus radiotherapy. Castro’s results are for the same 22 patients staged differently. Note the apparent improvement produced by pathological staging.

prophylactic mediastinal irradiation is not indicated in non seminomatous tumours. Consideration of lymphadenectomy in addition to radiation gives a confusing picture as the staging procedure is now surgical/pathological which biases most series in favour of the surgical management (Table 11). Few surgical series include inoperable cases or post operative deaths in their survival figures. Staubitz (1977) for example in a purely surgical series excludes from his report the 7 cases with unresectable disease above the renal hilum all of whom died within 5 years. If they are added to his stage I1 cases his survival rate slips from 70% to 50%. Although his figure of 93% survival at 3 years for 45 stage I cases is very impressive it might be asked if these patients had to have bilateral lymphadenectomy at all. Of 146

the total of 65 cases reported, 12% developed major surgical complications ranging from wound dehiscence through reexploration for post operative haemorrhage, ureteric obstruction and nephrectomy, to multiple gastrointestinal ulcerations resulting in death. Absence of ejaculation occurred in the majority of these patients. Kedia, Markland and Fraley (1977) reported that 49 of 52 cases operated on had dry orgasms 12 months after high retroperitoneal dissection. Only one of the other 3 subsequently fathered a child. This is in contrast to the patients treated with radiation alone, none of whom complained of any sexual difficulty. Of the total series of 532, 34 patients subsequently fathered 49 children. Some of these have been studied more fully and were reported in 1966 (Sandeman 1966). Australasian Radiology, Vol. XXIII, No. 2, July, I9 79

RADIOTHERAPY OF NON-SEMINOMATUSGERMINAL TUMOURS OF THE TESTIS of the spectrum, until surgical expertise is built up and especially if the patient wishes to have children, the most satisfactory result in early cases will be obtained by high orchidectomy followed by adequate radiotherapy. It is apparent that a group of cases can be identified still at an apparently early stage who do not do well with any current management. These are those exhibiting vascular invasion in the primary tumour and those with radiologically definite retroperitoneal disease. Cytotoxics must play a prominent adjuvant role in the former and probably a primary role in the latter with surgery, plus or minus radiotherapy, to convert the partial remitter to complete remission if this is possible.

FIGURE 9.-Planning IVP showing the extended pyramidal field used to cover an aberrant node over the left iliac crest (vertical arrow) with the probable Tyrell and Peckham field (dotted line) which would miss this. The edge of a large node abutting on the L kidney is arrowed. This would not be fully included in the dotted field.

Notwithstanding these objections, if the primary object is to save the patient at all costs the most impressive survival rates are those associated with surgery. Unfortunately the only surgeons or surgical centres reporting their results are those with the greatest experience. It is difficult therefore to judge how well other surgeons fare with only an occasional retroperitoneal dissection. None has published a series culled from the wider world of general surgery. Caldwell(l978) certainly does not agree that routine lymphadenectomy is justified. With the advent of really effective cytotoxic regimes (Einhorn e t a1 1976) there is room for much greater flexibility in the management of early non-seminomatous tumours. Late cases in whom the 5 year survival rate, by whatever method, is less than 50% must clearly be gathered for expert oncological care. Regimes which exclude radiotherapy from consideration until palliation is all that can be offered will not be successful as those in whom, after failure of one or two attacks, allow individualisation of treatment, with radiotherapy playing a prominent role. At the other end Australasian Radiology, Vol. XXIII, No. 2, July, 1979

Some authors claim that prior radiotherapy and/or cytotoxic treatment spoils the response rate. For this reason it would seem important that the most effective and least traumatic modality be used first, if no other can produce reasonable results. Although it is not possible in this review to demonstrate that radiotherapy does not interfere with the action of modern chemotherapeutic regimes a small number of patients survive following treatment of recurrence with Actinomycin D, Methotrexate and Chlorambucil combination. Since 1975, VLB plus Bleomycin have converted several patients to a stage where disease could be covered with radiotherapeutic fields and three such survive, apparently free of disease, for more than 12 months. What is vital is that a central record of all testicular tumour patients is kept. When devetopments are taking place as rapidly as they have in the past few years all the information that can be gathered about this disease should be collected. Fragmentation of the material as the means to treat them becomes available to any physician, will mean that answers to questions will not be obtained for many years or that the patients may be denied some part of the multidisciplinary management which is now available.

SUMMARY 23 1 non-seminomatous germ cell tumours were analysed as to the control which could be obtained in various subtypes of the teratomas (Pugh classification) by radiotherapy. Little difference could be found in the response and survival in equivalent stages between intermediate and undifferentiated teratomas. Trophoblastic tumours gave a surprisingly high survival rate. Vascular invasion of the testis or cord played a more important part in determining the outcome 147

T. F. SANDEMAN

than nodaf involvement. This has been incorporated in the staging system proposed. Radiotherapeutic technique must be carefully watched so that the renal hilum is included. A pyramidal field covering both iliac groups of nodes has been most successful with a low complication rate and a 3 year survival of 79% for those without radiological node involvement and 69% overaI1 for radically treated cases (Stages I and I1 combined). Only 3 of 76 adequately treated cases recurred primarily within the abdominal tjeld and one of these survives following resection of a “benign teratoma”. Radiotherapy still gives the best quality survival for the least risk to life and fertility in early cases. Combination chemotherapy will probably save a high proportion of those who recur. In high risk groups such as those with bulky nodal disease cytotoxics plus surgery will probably prove superior to radiotherapy alone. Adjuvant cytotoxics seems to be indicated for T2 cases (those with vessel invasion).

ACKNOWLEDGEMENTS I would like to put on record my appreciation of the help received from the following: Dr. R. Motteram and Dr. P. Ironside for reviewing the histology, Dr. J. J. Martin for performing and reviewing the radiology, my wife, Dr. J. P. Matthews for statistical advice, Miss D. O’Reilly and her staff for the illustrations, Miss R. Ahrens for typing and the Medical Director, Dr. F. Trinker for permission to publish.

REFERENCES Atkinson, L. and Ewing, D. P. (1974): “The Place of Radiotherapy in Testicular Tumours.” (Abstract). Brit. J. Urol. 46 : 123. Buck, A. S., Schamber, D. T., Maier, J. G. and Lewis, E. L. (1972): “Supraclavicular Node Biopsy and Malignant Testicular Tumors.” J. Urol. 107 : 619. Caldwell, W. L. (1978): “Why Retroperitoneal Lymphadenectomy For Testicular Tumors?” J. Urol. 119 : 754. Castro, J. R. (1969): “Lymphadenectomy and Radiation Therapy in Malignant Tumors of the Testicle other than Pure Seminoma.” Cancer, 24 : 87. Chapman, R. H., Blandy, J. P., Hope-Stone, H. F., Pollach, D. and Dayan, A. D. (1973): “Identification of a Favourable Group of Teratomas.” Proc. Roy. Soc. Med. 66 : 1045. Collins, D. H. and Pugh, R. C. B. (1964): “The Pathology of Testicular Turnours.” Brit. J. Urol. 36 Supp. Dixon, F. J. and Moore, R. A. (1952): “Tumors of the

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