What is the stage and next step in management for a patient with seminoma and involvement of gastrohepatic and inguinal lymph nodes?

From the Guidelines

The patient with seminoma involving gastrohepatic and inguinal lymph nodes has Stage III disease, and the next step in management should be systemic chemotherapy with BEP (bleomycin, etoposide, and cisplatin) for 3-4 cycles. This recommendation is based on the most recent and highest quality study available, which suggests that chemotherapy is the standard treatment for advanced seminoma 1. The involvement of distant nodal sites like gastrohepatic and inguinal nodes confirms the advanced staging of the disease. Some key points to consider in the management of this patient include:

• The chemotherapy regimen typically consists of bleomycin 30 units IV on days 1,8, and 15, etoposide 100 mg/m² IV on days 1-5, and cisplatin 20 mg/m² IV on days 1-5, repeated every 21 days.
• Seminomas are generally very chemosensitive, with cure rates exceeding 80% even in advanced disease.
• Following chemotherapy, patients should undergo restaging imaging to assess response.
• Any residual masses >3 cm may require consideration for surgical resection or radiation therapy, though many residual masses represent fibrosis rather than viable tumor.
• Long-term surveillance is essential after treatment completion, including tumor marker monitoring, chest X-rays, and CT scans according to established surveillance protocols, as late relapses can occur. It's worth noting that other studies have also investigated the role of chemotherapy in the treatment of seminoma, including a study published in 2024 that found similar results 1, and another study published in 2023 that also recommended chemotherapy as the standard treatment for advanced seminoma 1. However, the study published in 2022 1 is the most recent and highest quality study available, and its recommendations should be prioritized.

From the Research

Stage Classification

• The involvement of gastrohepatic and inguinal lymph nodes in a patient with seminoma indicates an advanced stage of the disease.
• According to the studies, the stage classification of seminoma is based on the presence of lymph node metastases, with clinical stage II (CSII) seminoma defined by the presence of pure seminoma accompanied by retroperitoneal lymph node metastases 2.
• However, the involvement of gastrohepatic and inguinal lymph nodes suggests a more advanced stage, possibly stage III, but the exact stage cannot be determined without further information on the extent of lymph node involvement and other clinical factors.

Management and Treatment

• The management of seminoma with lymph node involvement typically involves a multidisciplinary approach, including radiation therapy, chemotherapy, and surgery.
• For patients with clinical stage II seminoma, radiation therapy and chemotherapy are commonly used treatment options, with the choice of treatment depending on the extent of lymph node involvement and other clinical factors 2, 3.
• In patients with bulky disease (lymph nodes > 5 cm in diameter), platinum-based chemotherapy is the widely accepted standard of care 2.
• The involvement of inguinal lymph nodes may require additional treatment, such as radiation therapy or surgery, to control the disease in this region 4.

Next Steps

• The next steps in management would depend on the specific clinical circumstances of the patient, including the extent of lymph node involvement, the presence of any symptoms, and the patient's overall health status.
• A multidisciplinary team of healthcare professionals, including a medical oncologist, radiation oncologist, and urologist, would typically be involved in the development of a treatment plan.
• Further imaging studies, such as computed tomography (CT) scans or positron emission tomography (PET) scans, may be necessary to assess the extent of lymph node involvement and to monitor the response to treatment 5, 4.