Seminoma, Q.E.D.

The natural concern of the patient and concomitant interest of the physician have served to focus attention on testicular enlargement secondary to involvement by tumor. Early attempts at cure were logically by surgical extirpation of the primary lesion. The demonstration of radiosensitivity of seminoma as early as 1905 by Béclère (1) prompted consideration of the curative possibility of roentgen rays in these cases. Surgical extirpation, however, because of its relative simplicity and effectiveness, has continued to be the treatment of choice for the primary site. With the demonstration of the mode of dissemination of these tumors via the lymphatic drainage channels in sequential fashion by Chevassu in 1906 (2), possible methods of control of extension were soon explored. The removal of adjacent lymphatics suggested by Osler (14) and the subsequent description of extraperitoneal lymphadenectomy by Chevassu (3) stimulated interest in the surgical approach to the problem. During the subsequent decades, however, the relative ease and dramatic results of irradiation in the seminoma group of tumors engendered enthusiasm and wide adoption of this treatment. This enthusiasm was somewhat dampened by experience. Reports of significant morbidity and mortality from renal damage culminated in the comprehensive review and analysis by Kunkler et al. (13). These writers defined the limits of renal tolerance beyond which an actual decline of survival rates occurred as a result of mortality from radiation damage to the kidneys. With the limits of renal tolerance well established, the radiotherapy technics in the majority of subsequently reported series have provided for sparing, by dose or volume, of enough renal tissue to prevent clinically significant damage. Friedman and Moore (9) and Dixon and Moore (5) summarized the treatment of testicular tumors and its results in a large series of service personnel treated during World War II. These comprehensive reports, along with the review by Friedman (7), stimulated widespread adoption of standardized treatment programs for seminoma, utilizing irradiation to control metastatic extension. Even in the favorable seminoma group, however, recent reported series have indicated “cure” rates far less than optimal levels. Significant numbers of failures are described, but generally with information inadequate for interpretation of this experience. The usual explanations for failure are “aggressiveness,” “resistance,” or ”dissemination prior to institution of therapy.” The author's personal experience with a few cases of seminoma considered “incurable,” which responded in a surprisingly consistent fashion to logical individualized irradiation, prompted the present review.