No predictive value of β-hCG in patients with stage I seminoma : Results of a long-term follow-up study after adjuvant radiotherapy

Radical inguinal orchiectomy followed by adjuvant para-aortic radiotherapy has been the standard treatment in stage I seminoma. We have reviewed our experience with reduced total doses (less than 26 Gy) in stage I seminoma to investigate if patients with an elevated beta-human chorionic gonadotropin (beta-hCG) level before orchiectomy possibly require higher total doses of adjuvant radiotherapy (RT). Two hundred and sixty-seven consecutive patients, with newly diagnosed pure seminoma of the testis, were treated with adjuvant RT between 1992 and 2000. All patients had stage I disease. Serum AFP and beta-hCG levels were analyzed prior to and after orchiectomy in case of an elevated beta-hCG level. The measurements were repeated after RT in routine follow-up at regular intervals. Serum beta-hCG was considered as elevated if the values exceeded the normal range (up to 5 U/L). A median total dose of 25.2 Gy (range, 19.8 to 26.0 Gy) was applied to the para-aortic region. Fourteen patients were excluded from this analysis because beta-hCG measurement was not available. Nineteen of the remaining 253 patients (7.5%) had an elevated serum beta-hCG, which returned to normal post-operatively by the start of adjuvant radiotherapy. Median serum beta-hCG level before orchiectomy was 27.7 U/L (range, 5.1 to 420 U/L) in the group of patients with initial elevation of serum beta-hCG. This did not correlate with tumor size or rete testis invasion. After a median follow-up of 6.1 years (range, 3.0 to 11.2 years), 11 out of 267 (4.1%) patients had developed lymph node recurrence, resulting in an actuarial 5-year relapse-free survival of 96%. Median time to relapse was 19 months (range, 11 to 47 months) after RT. Only one relapsing patient initially had an elevated serum beta-hCG level of 34.1 U/L. This patient had nodal relapse within the mediastinum without renewed elevation of the serum beta-hCG level. An elevated pre-treatment beta-hCG level appears to have neither importance nor a predictive value in stage I seminoma. Therefore, we recommend the current adjuvant standard treatment without any modification for all beta-hCG-positive stage I seminoma.