What is the recommended treatment approach for a young to middle-aged male patient diagnosed with seminoma?

Treatment of Seminoma

For young to middle-aged males with newly diagnosed seminoma, treatment is determined by clinical stage: Stage I disease is optimally managed with active surveillance or single-agent carboplatin chemotherapy (avoiding radiotherapy due to long-term cardiovascular and malignancy risks), Stage IIA-B with either radiotherapy or chemotherapy, and Stage IIC-III with cisplatin-based combination chemotherapy. 1, 2

Stage I Seminoma (Localized Disease)

Risk Stratification

• Low-risk patients have tumor size <4 cm without rete testis invasion (12% relapse risk) 2
• Intermediate-risk patients have either tumor size >4 cm OR rete testis invasion (15% relapse risk) 2
• High-risk patients have tumor size >4 cm AND rete testis invasion (30-32% relapse risk) 1, 3

Treatment Options in Order of Preference

Active Surveillance (Preferred for Low-Risk)

• Achieves equivalent survival outcomes to adjuvant treatment with 15-20% relapse rate, but all relapses are highly curable 1, 4
• Requires strict adherence: clinical examination and tumor markers every 3 months for 2 years, then every 6 months to 5 years 2
• Abdominal/pelvic CT every 6 months for years 1-2, as 97% of relapses occur in retroperitoneal or high iliac nodes 1
• Continue surveillance for at least 5 years, as relapses can occur up to 10 years post-orchiectomy, with 75% occurring within first 2 years 1

Single-Agent Carboplatin (Preferred for Intermediate/High-Risk)

• Carboplatin AUC × 7 for 1-2 cycles is the preferred adjuvant treatment over radiotherapy, particularly in low-to-intermediate risk patients 1
• Reduces relapse rate to only 3-4% compared to 15-20% with surveillance 1
• Significantly less toxic than radiotherapy: reduces contralateral testicular cancer risk (2 cases vs 15 cases with radiotherapy) 1
• Lower long-term cardiovascular disease risk compared to radiotherapy 1
• Dose calculation: AUC = 7 × (GFR + 25) for one cycle 2

Adjuvant Radiotherapy (Reserved Only if Patient Unwilling/Unable for Above Options)

• No longer routinely recommended due to long-term risks: second malignancy and cardiovascular toxicity 2, 3
• If used: para-aortic strip (T10-L5) to 20 Gy in 10 fractions over 2 weeks 2
• Extend to "dogleg" radiotherapy (including ipsilateral iliac and inguinal nodes) if previous inguinal/scrotal surgery 2

Critical Pitfall

• Sperm cryopreservation must be offered before any chemotherapy or radiotherapy, as these treatments can permanently impair fertility 2, 5

Stage IIA-B Seminoma (Small Volume Retroperitoneal Disease)

Primary Treatment Options

• Dogleg radiotherapy to 30-36 Gy in 15-18 fractions to involved site is standard 2
• Chemotherapy (as for Stage IIC below) is an equally effective alternative 2

Stage IIC-III Seminoma (Bulky/Advanced Disease)

Standard Chemotherapy Regimen

• Three cycles of BEP (bleomycin, etoposide, cisplatin) for good prognosis patients 2, 6
• Four cycles of BEP for intermediate prognosis (Stage IIIC) or patients with non-pulmonary visceral metastases 2, 6
• Dosing: etoposide 100 mg/m² days 1-5, cisplatin 50 mg/m² days 1-2 (or 20 mg/m² days 1-5), bleomycin 30,000 IU days 1,8,15 2

Bleomycin Considerations

• Consider omitting bleomycin in patients >40 years or with poor lung function due to increased pneumonitis risk 2
• Alternative: four cycles of EP (etoposide-cisplatin) if bleomycin contraindicated 6
• Monitor renal function and electrolytes before each cycle due to cumulative cisplatin nephrotoxicity 5

Post-Chemotherapy Management

• Patients with complete response require no further treatment, including no consolidation radiotherapy 6
• For residual masses <3 cm: follow-up only 6
• For residual masses ≥3 cm: FDG-PET scan at least 6 weeks post-chemotherapy 6
  • If PET negative: follow-up only 6
  • If PET positive: consider surgical resection rather than radiotherapy 6

Management of Relapse

After Surveillance

• Stage IIA-B relapse: dogleg radiotherapy 30-36 Gy or chemotherapy 2, 1
• Stage IIC-III relapse: three cycles of BEP 1

After Radiotherapy

• Four cycles of BEP with lower dose etoposide (360 mg/m²/cycle) 2

After Chemotherapy

• Standard salvage chemotherapy regimens 6
• Consider radiotherapy for small localized relapses 6
• Surgery should be integral part of salvage strategy for localized or late relapse 6

Follow-Up Protocols

After Stage I Treatment

• Chest X-ray and clinical examination at 1 month, then every 3 months for 2 years, then every 6 months to 5 years 2
• Pelvic CT may be indicated at years 1,2, and 5 for patients treated with para-aortic radiotherapy 2

After Metastatic Disease Treatment

• If normal post-treatment CT: follow as Stage I 2
• If abnormal post-treatment CT: repeat CT every 6 months until normal or stabilized 2
• PET scan may identify residual active cancer 2
• Consider biopsy or resection for large residual or growing masses 2