Chest radiography has limited use in routine follow-up for stage I seminoma, according to a new study by investigators in Canada. “Chest X-ray was not the first modality to diagnose recurrent disease ... it might be considered safe to remove this from the 'routine' imaging that the patients [with seminoma] undergo on a surveillance program,” says senior author Peter Chung.

Standard management for stage I testicular seminoma includes orchidectomy followed by surveillance or adjuvant therapy (either radiotherapy or chemotherapy). The spread of the disease is somewhat predictable, usually by occult nodal spread. Metastases are most frequently found in the retroperitoneal nodes, and sometimes more distantly in the thorax. Thus, clinicians routinely order abdominal and pelvic CT scans (CT-AP) and use chest radiographs to detect disease relapse.

Credit: Image provided by Peter Chung

Chung and colleagues retrospectively assessed data from 527 men with seminoma to determine which surveillance technique—either CT-AP or chest radiography—first detected relapse. All patients had confirmed stage I seminoma, had undergone orchidectomy and were managed with surveillance, which included physical examinations and routine chest radiographs and CT-AP every 4–6 months for 7 years, and every year thereafter (median follow-up period 72 months). Data were collected between 1982 and 2005 at Princess Margaret Hospital in Ontario, Canada.

Of the 75 patients that relapsed, 73 were diagnosed by CT-AP; one man had an abnormal physical examination with recurrent disease confirmed by biopsy. Chest radiography was normal in all 74 of these men. Chest radiography provided useful clinical information (detection of pulmonary metastasis) in just one patient. CT-AP was also abnormal in this case.

There is great variation between the seminoma surveillance protocols used at different institutions, and the optimal imaging paradigm is yet to be defined. If the results of the study by Tolan et al. are confirmed, chest radiography could be removed from the schedule. “This would mean a modest reduction in X-ray exposure to the patients and also potential cost saving in that an unnecessary test is omitted,” points out Chung.