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 seminoma, treatment is stage-dependent: Stage I disease is optimally managed with active surveillance or single-agent carboplatin (AUC × 7 for 1-2 cycles), with radiotherapy reserved only for patients unwilling or unable to pursue these options; Stage IIA-B requires dogleg radiotherapy (30-36 Gy) or chemotherapy; and Stage IIC-III mandates cisplatin-based chemotherapy (BEP regimen). 1, 2

Stage I Seminoma Management

Risk Stratification

• Low-risk patients (tumor <4 cm without rete testis invasion) have a 12% relapse risk on surveillance 1
• Intermediate-risk patients (one risk factor present) have a 15% relapse risk 1
• High-risk patients (tumor >4 cm with rete testis invasion) have a 30-32% relapse risk 1, 2

Treatment Options in Order of Preference

Active Surveillance (Preferred for Low-Risk)

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

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

• Dose: AUC × 7 for 1-2 cycles (calculated as dose = 7 × [GFR + 25]) 1, 2
• Relapse rate of only 3-4% 2
• Significantly reduces contralateral testicular cancer risk (2 cases vs 15 cases with radiotherapy) 2
• Less toxic than radiotherapy with lower long-term cardiovascular disease risk 2
• Particularly advantageous in patients >40 years who face higher bleomycin pneumonitis risk if relapse requires chemotherapy 2

Adjuvant Radiotherapy (Reserved Option)

• Para-aortic strip (T10-L5) including para-aortic nodes and ipsilateral renal pelvis: 20 Gy in 10 fractions over 2 weeks 1
• If previous inguinal/scrotal surgery: extend to "dogleg" radiotherapy (includes ipsilateral iliac and inguinal lymph nodes), same dose 1
• Carries long-term risk of second malignancy and cardiovascular toxicity 1, 3
• Should be reserved only for patients unwilling or unable to pursue surveillance or carboplatin 2

Critical Pitfall

• Sperm cryopreservation must be offered before any chemotherapy or radiotherapy as these treatments can permanently impair fertility 1

Stage IIA-B Seminoma

Primary Treatment

• Dogleg radiotherapy: 30-36 Gy in 15-18 fractions to involved site 1
• Alternative: Chemotherapy as for Stage IIC (3 cycles BEP) is an active alternative 1

Stage IIC-III Seminoma

Standard Chemotherapy Regimen

• Good prognosis (Stage IIC-IIIB): 3 cycles of BEP 1, 4

  • 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, and 15 1

• Intermediate prognosis (Stage IIIC): 4 cycles of BEP 1, 4

Bleomycin Considerations

• Consider omitting bleomycin in patients >40 years or those with poor lung function due to higher pneumonitis risk 1
• If bleomycin contraindicated: use 4 cycles of EP (etoposide/cisplatin) or VIP (etoposide/ifosfamide/cisplatin) with G-CSF 4

Post-Chemotherapy Management

• Complete response: no further treatment needed, including no consolidation radiotherapy 4
• Residual mass <3 cm: follow-up only 4
• Residual mass ≥3 cm: FDG-PET scan at least 6 weeks post-chemotherapy 4
  • If PET negative: follow-up only 4
  • If PET positive: consider surgical resection rather than radiotherapy 4

Relapse Management

After Surveillance

• Stage IIA-B relapse: dogleg radiotherapy 30-36 Gy in 15-18 fractions OR chemotherapy 1, 2
• Stage IIC-III relapse: 3 cycles BEP 2

After Dogleg Radiotherapy

• 4 cycles BEP with lower dose etoposide (360 mg/m²/cycle) 1

After Chemotherapy

• Standard salvage chemotherapy 4
• For small localized relapses: radiotherapy may be considered 4
• Surgery should be integral part of salvage strategy for localized or late relapse 4

Follow-Up Protocols

Stage I (Post-Treatment)

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

Stage III (Post-Chemotherapy)

• Physical examination and tumor markers: every 2 months year 1, every 3 months year 2, every 4 months year 3, every 6 months years 4-5 4
• Chest X-ray: every 4 months year 1, every 6 months year 2, annually years 3-5 4
• CT abdomen/pelvis as needed until complete response, then according to chest X-ray schedule 4

Key Clinical Pearls

• Monitor renal function and electrolytes before each chemotherapy cycle due to cumulative cisplatin nephrotoxicity 5
• Chemotherapy should be given without delay or dose reduction at 21-day intervals 5
• Nearly 100% cancer-specific survival is achievable across all stages with appropriate treatment 3, 6
• PET scan may help identify residual active cancer in post-treatment masses 1
• Consider biopsy or resection for large residual or growing masses 1