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 stage-dependent: Stage I disease is optimally managed with active surveillance or single-agent carboplatin (preferred over radiotherapy due to lower long-term toxicity), Stage IIA-B with radiotherapy or chemotherapy, and Stage IIC-III with cisplatin-based combination 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 1
• High-risk patients (tumor >4 cm with rete testis invasion) have a 32% relapse risk 1
• Intermediate-risk patients (one risk factor present) have a 15% relapse risk 1

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 2, 3
• Requires strict adherence: chest X-ray and clinical examination at 1 month, then every 3 months for 2 years, then every 6 months to 5 years 1
• Abdominal imaging every 6 months for years 1-2 is mandatory 2
• Critical caveat: 97% of relapses occur in retroperitoneal or high iliac lymph nodes, with 75% occurring within first 2 years, but late relapses can occur up to 10 years post-orchiectomy 2

Single-Agent Carboplatin (Preferred for High-Risk)

• One to two cycles of carboplatin AUC × 7 reduces relapse rate to only 3-4% 2
• Significantly superior toxicity profile compared to radiotherapy: only 2 cases of contralateral testicular cancer versus 15 cases with radiotherapy in MRC/EORTC trial 2
• Dose calculation: AUC 7 × (glomerular filtration rate + 25) for one cycle 1
• Particularly advantageous in patients >40 years due to lower cardiovascular disease risk and reduced bleomycin pneumonitis risk if relapse requires chemotherapy 2

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

• Para-aortic strip (T10-L5) to 20 Gy/10 fractions/2 weeks 1
• Extend to "Dogleg" radiotherapy (including ipsilateral iliac and inguinal nodes) if previous inguinal/scrotal surgery 1
• Major limitation: carries long-term risk of second malignancy and cardiovascular toxicity 1, 3
• No longer routinely recommended for Stage I seminoma 3

Fertility Preservation

• Sperm cryopreservation should be offered before any chemotherapy or radiotherapy 1, 2

Stage IIA-B Seminoma Management

Primary Treatment

• Dogleg radiotherapy to 30-36 Gy in 15-18 fractions to involved site 1
• Alternative option: Chemotherapy as for Stage IIC (BEP regimen) is equally effective 1

Stage IIC-III Seminoma Management

Standard Chemotherapy Regimen

• Three cycles of BEP (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) for good prognosis patients 1, 4
• Four cycles of BEP for Stage IIIC or intermediate prognosis patients 1, 4

Bleomycin Considerations

• Omit bleomycin in patients >40 years or those with poor lung function due to higher pneumonitis risk 1, 2
• Alternative: Four cycles of PE (cisplatin, etoposide) if bleomycin contraindicated 4
• For intermediate prognosis with bleomycin contraindication: Four cycles of VIP (etoposide, ifosfamide, cisplatin) with G-CSF support 4

Post-Chemotherapy Management

• Complete response requires no further treatment, including no consolidation radiotherapy 4
• Residual masses <3 cm: follow-up only 4
• Residual masses ≥3 cm: FDG-PET scan at least 6 weeks post-chemotherapy 4
  • If PET negative: follow-up only 4
  • If PET positive: surgical resection preferred over radiotherapy 4

Management of Relapse After Initial Treatment

Post-Surveillance Relapse

• Stage IIA-B relapse: Dogleg radiotherapy to 30-36 Gy in 15-18 fractions or chemotherapy 2
• Stage IIC-III relapse: Three cycles of BEP chemotherapy 2

Post-Radiotherapy Relapse

• Four cycles of BEP with lower dose etoposide (360 g/m²/cycle) 1

Post-Chemotherapy Relapse

• Standard salvage chemotherapy for complete response relapses 4
• Radiotherapy may be considered for small localized relapses 4
• Surgery should be integral part of salvage strategy, particularly for localized or late relapse 4

Follow-Up Protocols

After Stage I Treatment

• Chest X-ray and clinical examination at 1 month, 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

After Metastatic Disease Treatment

• Physical examination and tumor markers every 2 months in year 1, every 3 months in year 2, every 4 months in year 3, every 6 months in years 4-5 4
• Chest X-ray every 4 months in year 1, every 6 months in year 2, annually in years 3-5 4
• If normal post-treatment CT: follow as Stage I 1
• If abnormal post-treatment CT: repeat CT every 6 months until normal or stabilized; PET scan may identify residual active cancer 1

Key Clinical Pitfalls to Avoid

• Never use scrotal approach for orchiectomy - always use inguinal approach with early spermatic cord ligation to prevent hematogenous spread 5
• Do not delay or reduce chemotherapy doses - maintain 21-day intervals 5
• Monitor renal function and electrolytes before each cycle due to cumulative cisplatin nephrotoxicity 5
• Surveillance requires excellent patient compliance - non-compliance has been a major failure point in community settings 6
• Do not perform routine consolidation radiotherapy after complete response to chemotherapy in advanced disease 4