Especially with cases of large-volume seminoma, it is common to find a residual mass on scanning the patient after a course of chemotherapy. However, approximately 90% of these masses do not contain residual malignancies and appear to be fibrotic remnants (Figure 20-3).30,31 Attempted resection can be hazardous because of extensive dense scar tissue involving the great vessels and retroperitoneal tissues. The analysis from the Memorial Sloan-Ketter-ing Cancer Center suggested that there was a higher risk of residual malignancy if the residual mass was > 3 cm in diameter.32 This suggestion has led, at some centers, to a policy of particularly close surveillance or adjuvant radiotherapy for this subset of patients.33 However, other investigators have not found that recurrence was more likely when the residual mass was 3 cm in diameter.34 Furthermore, retrospective data from 302 patients treated in 10 European centers with chemotherapy for metastatic seminoma indicated that 174 of those patients had residual disease at the completion of chemother-apy.35 Approximately half of these patients had been treated with postchemotherapy radiotherapy, with selection based mainly on institutional practice. Outcome analysis revealed no significant difference in progression-free survival whether or not adjuvant radiotherapy was employed. Thus, most centers would now follow a policy of close observation after chemotherapy for seminoma, considering the use of adjuvant radiotherapy only in those for whom the response is uncertain, or when there is radiologic or marker evidence of progression. Positron emission tomography results may be an indicator of persisting malignancy (see Chapter 6).36
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