onc brain

Retrospective multicenter imaging review, 4 academic centers, staging scans read by a single abdominal radiologist. Each node transferred to a CT template by its relation to the aorta and renal arteries, with craniocaudal scaling for height.

90 pts, CS IIA/B or recurrent CS I seminoma after orchiectomy, nodes ≤5cm. 40 (44%) relapsed on CS I surveillance at a median 8.5 mo (range 3.2-50.4); 50 (56%) node-positive within 3 mo of diagnosis. 48 (53%) left-sided, 41 (46%) right-sided primaries.

Proposed CTV: 2.5cm lateral/posterior and 2.1cm anterior expansion of arterial vasculature, superior border 1cm above the right or 1.5cm above the left renal artery. Classen acetabular inferior border retained; NCCN 2cm GTV boost and setup margins added on top.

145 nodes, average 1.6 per pt, median size 18 mm. 99% of nodes fell inside the proposed expansion; nodal region was unrelated to CS at presentation (P = 0.16) or primary laterality (P = 0.15).

Classen extended fields (prospective phase II, 2003) are the NCCN- and European consensus-endorsed standard; this map supports Classen's acetabular inferior border but argues the T10/T11 superior border overtreats. MRC TE10 linked smaller fields to less acute GI toxicity and leukopenia. Martin et al. used a 1.4cm aorta/IVC expansion from non-enlarged nodal anatomy.

Single-timepoint CT in many pts, so original nodal position before reaching size criteria was estimated, not observed. Two atypical nodes (1.4%) were excluded from the expansion analysis. Relapses that would emerge outside the reduced field after treatment are unmeasured.

The case for smaller fields rests on second-malignancy risk in a young cohort, with extended fields linked to up to 50% more SMNs than PA strip fields in cited data. The trade the authors accept is a small out-of-field relapse risk, judged salvageable, against lower SMN risk.

Retrospective imaging-defined node map; proposed CTV never tested for relapse or toxicity. Authors themselves limit it to research use pending validation.

Prospective multicentre observational study, 30 German centres, enrolment April 1991 to March 1994. 94 enrolled, 87 assessable, median follow-up 70 mo. Analysed ITT, including 22 pts with major protocol violations.

Histologically confirmed pure testicular seminoma, Royal Marsden stage IIA (<2 cm) or IIB (2-5 cm) after high inguinal orchiectomy. Elevated AFP excluded; βHCG up to 200 IU/L allowed after year 1. 66 IIA, 21 IIB; median age 32.5 and 32.

AP/PA hockey-stick to para-aortic/paracaval and ipsilateral high iliac nodes, gross disease plus 2 cm margin, T11 to acetabular rim. 2.0 Gy/fx: 30 Gy for IIA, 36 Gy for IIB, no boost; 5 pts treated bilateral iliac.

Primary: relapse-free survival at 5 years. Secondary: disease-specific survival (expected at least 95% at 5 yr) and acute/late GI and skin toxicity.

Acute toxicity dominated by grade 1 nausea (53% IIA, 52% IIB); no grade 4. No late GI toxicity, no peptic ulceration, no second malignancy to date; one pt with G1 skin hyperpigmentation.

Prior stage II series used larger portals covering the entire ipsilateral iliac/inguinal chain and contralateral pelvis; this cohort shows the reduced field loses no pelvic control. The source places modified EP (9% relapse, 33% G3/4 leukopenia) and carboplatin alone (15% failure) as no better on control with more toxicity.

Study was not designed to test reduced vs extended portals, so the toxicity advantage is inferred against historic series. Seven pts lost to follow-up were excluded rather than censored, and the IIB cohort is too small for its own protocol-violation analysis.

Failures were all extra-field (mediastinal or lung) except one lateral para-aortic field-edge relapse, and all were salvaged, so DSS was 100%. The authors suggest room for dose reduction below 30 Gy in IIA, though no dose-response relationship was established.

Single-arm observational cohort with no randomised comparator vs chemo; IIB subset small (n=21). Single-arm gate caps the verdict despite 70-mo follow-up.