What is the initial treatment for pure seminoma?

Initial Treatment for Pure Seminoma

The initial treatment for pure seminoma is radical inguinal orchiectomy, which serves as both diagnostic and therapeutic intervention. 1 After orchiectomy, further management depends on disease stage, with surveillance being the preferred option for stage I disease.

Diagnosis and Initial Evaluation

• Diagnosis should be based on histology of testicular mass removed by inguinal orchiectomy 1
• Before orchiectomy, obtain:
  • Tumor markers (AFP, β-HCG, LDH) to confirm pure seminoma and assess risk
  • Full blood count, renal function, electrolytes, and liver function tests
• Pure seminoma should not have elevated AFP; if AFP is elevated, manage as nonseminoma 1
• Imaging required:
  • Abdominopelvic CT scan to assess retroperitoneal nodes
  • Chest CT if abdominopelvic CT shows retroperitoneal adenopathy or abnormal chest X-ray 1
  • Brain MRI or bone scan only if metastases to these organs are suspected

Primary Treatment

1. Radical inguinal orchiectomy:

   • Performed through inguinal incision 1
   • Avoid any scrotal violation 1
   • Testis is resected with spermatic cord at level of internal inguinal ring 1
   • Discuss sperm banking before surgery if fertility is a concern 1

2. Post-orchiectomy management for Stage I disease (80-85% of patients are cured by orchiectomy alone 1):

   • Surveillance (preferred option, category 1) 1

     • Disease-specific survival is 99% regardless of management strategy 1
     • Relapse rate is 15-20% at 5 years, mostly in infradiaphragmatic lymph nodes 1
     • Requires regular follow-up with abdominal imaging for at least 5 years 1

   • Alternative options (if surveillance not feasible):

     • Adjuvant carboplatin (AUC 7) for 1-2 cycles 1
     • Adjuvant radiotherapy to para-aortic strip (20 Gy in 10 fractions) 1
       • Note: Radiotherapy carries long-term risk of second malignancy 1

3. Post-orchiectomy management for Stage II-III disease:

   • Stage IIA-B:

     • Dogleg radiotherapy (30-36 Gy in 15-18 fractions) 1
     • Alternative: Chemotherapy as for stage IIC 1

   • Stage IIC-III:

     • Chemotherapy with 3-4 cycles of BEP (bleomycin, etoposide, cisplatin) 1

Risk Factors and Considerations

• Tumor size >4 cm and rete testis invasion were previously thought to be risk factors for relapse, but validation studies have not confirmed this 1
• NCCN guidelines discourage risk-adapted management based solely on these factors 1
• Discuss sperm banking prior to chemotherapy or radiation treatment 1

Follow-up After Treatment

• For patients on surveillance: Chest X-ray and clinical examination at 1 month, then 3-monthly for 2 years, then 6-monthly to 5 years 1
• Pelvic CT may be indicated in patients treated by para-aortic strip at years 1,2, and 5 1

Common Pitfalls to Avoid

1. Misclassifying seminoma with elevated AFP as pure seminoma (should be managed as nonseminoma)
2. Scrotal violation during surgery (should always use inguinal approach)
3. Overtreatment of stage I disease (surveillance is appropriate for most patients)
4. Inadequate follow-up during surveillance protocol
5. Failure to discuss fertility preservation options before treatment

Pure seminoma has an excellent prognosis with disease-specific survival of 99% for stage I disease, regardless of management strategy chosen 1.