Reply to monitoring of seminoma patients with serum markers

In our stage I seminoma surveillance cohort, 75 of 527 patients experienced relapse.1 Of the 11 patients (15%) who relapsed with abnormal blood work, only one had an elevated tumor marker (lactate dehydrogenase) evident prior to radiological evidence of relapse. Of relevance, 10 of the 11 patients had normal blood work within the previous 9 months (8 within 6 months), which may be related to the fact that elevated tumor markers are associated with bulky disease in pure seminomas, unlike that in nonseminomas, where tumor markers can be elevated with microscopic disease. Given the high proportion of patients in our study with normal tumor markers within 6 to 9 months of relapse (ie, 72 of 75 patients; 96%), regular tumor marker measurement is unlikely to impact early detection even in a more protracted contemporary computed tomography scanning schedule (eg, every 6 months). Approximately 10% (7 of 65) of our patients who relapsed within 3 years had a false-positive rise in tumor markers that resolved to normal levels on repeat measurement and ultimately were normal at the time of relapse. Due to the retrospective nature of our study, we were not able to determine the true number of false-positive elevations seen in patients who never relapsed, but presumably this might lead to unnecessary concern and excess radiation exposure for such patients, given the repeated interval imaging that would result. Our cohort had a lower rate of elevated human chorionic gonadotropin at diagnosis (ie, prior to orchidectomy) than that reported by Hotakainen et al (9% versus 17%), because it is possible that such patients may not have been offered surveillance given previous concern that it was a poor prognostic factor.2-4 We therefore continue regular tumor marker measurement in such patients, which will facilitate future analysis. In our opinion, based on our data and the discussion above, routine measurement of tumor markers in seminoma surveillance is of little value even in the setting of more contemporary imaging schedules, and to the contrary, may lead to excess imaging and concern in those patients found to have a falsely elevated tumor marker. We do agree with Hotakainen et al that the radiation exposure burden of repeated imaging is not negligible, and have adopted a less frequent schedule than we reported. We look forward to the results of the UK Medical Research Council TRial of Imaging and Schedule in Seminoma Testis (TRISST; MRC TE24) comparing magnetic resonance with computed tomography imaging for stage 1 seminoma surveillance, which has included routine tumor marker measurement.5 The authors made no disclosure. Danny Vesprini, MD, MSc1,2 Padraig Warde, MB, BCh1,3 Peter Chung, MB, ChB1,3 1Department of Radiation Oncology, University of Toronto, Toronto, Canada 2Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada 3Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Canada

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