Seminoma with bulky abdominal disease.

The most significant issue addressed in the article by Laukkanen et al.’ is the role of radiation therapy in the management of Stage IIB testicular seminoma. Although the authors present a justification for the use of radiotherapy in this subgroup of patients, their article also illustrates many of the reasons why the management of patients with bulky retroperitoneal metastases continues to remain controversial. Intercomparison of results among different series dealing with bulky abdominal disease is hampered by the lack of a universally accepted criterion defining Stage IIB. The most commonly used criteria are (a) palpability, (b) largest dimension > 5 cm, (c) largest dimension > 10 cm. Although the Royal Marsden Hospital criterion6 of a mass > 5 cm is widely used, we have found that the 10 cm dimension is a more appropriate criterion.15 In our Stage II experience the incidence of relapse after radiation or chemotherapy was 0% (O/S) for patients with disease 2 cm but ~5 cm, 0% (O/l 3) for disease > 5 cm but 10 cm in largest dimension. The 10 cm criterion was also significant in the Norwegian Radium Hospital series.2 Laukkanen et al. use palpability as their criterion for bulky disease. This, while most readily available in retrospective reviews, is the least objective and precise criterion. Since the hazard for relapse is an increasing function of disease volume, objective and consistent criteria are essential, especially when dealing with small numbers of patients. Small numbers of patients pose problems for all investigators of this disease. Stage IIB seminoma is indeed very rare and many large centers report patient accruals both in radiotherapy series6,“,13,‘5 and in chemotherapy reports4’9’ IO. 12 that average to only 1 or 2 patients per year. Despite some 35 years of patient accrual (1948-1983), Laukkanen et al. could present only 23 patients with Stage IIB disease. The long time span encompassed by this study led to the inclusion of patients managed without the benefits of sensitive tumor imaging techniques, without tumor markers (especially alpha fetoprotein) and even in some cases without megavoltage irradiation. The inclusion of such patients, especially those receiving orthovoltage irradiation, in current reports adds nothing to the elucidation of the role of radiotherapy in this disease in 1987. No matter how good sporadic results might have been, few investigators today would be persuaded that the problem of management of Stage IIB disease is really so simple as to be amenable to orthovoltage treatment. Laukkanen et al. attempt to show that results did indeed improve as technologic advances were incorporated into the management of Stage IIB: 3 of 4 patients relapsed after treatment during the orthovoltage years, 4 of 14 patients relapsed after megavoltage irradiation without CT scanning, and 0 of 6 patients relapsed after CT scan-assisted megavoltage irradiation. However, due to the small number of patients, these trends were not statistically significant and the authors are left in the unsatisfactory position of having to justify the value of modern irradiation more on general principles than on demonstrably superior results. There is no doubt that the results reported by Laukkanen et al. (91% survival at 5 years) are excellent. The difficulty is in understanding exactly why their results are so good in order that we all could reproduce them. Numerous radiotherapy series have documented long-term survival rates between 54% and 73% in Stage IIB pa-