How is seminomatous testicular cancer in a young adult male staged, treated, and followed up?

Management of Seminomatous Testicular Cancer in Young Adult Males

Diagnosis

Diagnosis must be established through radical inguinal orchiectomy with histopathologic confirmation, not through scrotal biopsy or scrotal approach surgery. 1, 2

• Perform serum tumor markers (AFP, β-hCG, LDH) before orchiectomy to establish baseline values 1, 3
• Pure seminoma never secretes AFP—any AFP elevation indicates non-seminomatous components regardless of imaging appearance 4
• β-hCG may be elevated in pure seminoma (from syncytiotrophoblasts), but AFP must remain normal 4
• Repeat tumor markers 7 days post-orchiectomy and monitor until normalization to determine half-life kinetics 1, 3
• Critical pitfall: Obtain sperm banking before orchiectomy, as fertility is often compromised in this population 1, 3

Staging

All patients require CT chest, abdomen, and pelvis for complete staging after orchiectomy. 1

Essential staging components:

• Full blood count, creatinine, electrolytes, liver function tests 1
• Post-orchiectomy tumor markers at appropriate half-life intervals to establish nadir values 3
• CT abdomen/pelvis with IV contrast to assess retroperitoneal lymphadenopathy (nodes >1 cm are highly suspicious) 3
• Chest imaging: chest X-ray is acceptable for seminoma to minimize radiation exposure in young patients 3
• Bone scan only if bone symptoms or elevated alkaline phosphatase present 1
• Consider contralateral testis biopsy if testicular atrophy (<12 ml) and age <30 years (2-5% have carcinoma in situ) 1

Risk stratification (IGCCCG):

• Good prognosis: Normal AFP, any HCG, any LDH, no non-pulmonary visceral metastases 1
• Intermediate prognosis: Normal AFP, any HCG, any LDH, with non-pulmonary visceral metastases 1

Treatment by Stage

Stage I (Localized Disease - 75% of cases)

For low-risk patients (tumor <4 cm without rete testis invasion), surveillance is the preferred approach to avoid treatment-related toxicity. 1

Risk stratification for Stage I:

• Low risk (12% relapse): Tumor <4 cm and/or no rete testis invasion 1
• High risk (32% relapse): Tumor >4 cm with rete testis invasion 1
• One risk factor present: 15% relapse risk 1

Treatment options (all achieve similar survival ~99%):

1. Surveillance (preferred for low-risk): At least 5 years with regular abdominal imaging 1
2. Adjuvant carboplatin: Single cycle at AUC 7 [dose = 7 × (GFR + 25)] 1
3. Adjuvant radiotherapy: Para-aortic strip (T10-L5) 20 Gy/10 fractions over 2 weeks 1

Important consideration: Radiotherapy carries long-term risk of secondary malignancy, making it less favorable in young patients 1

Stage IIA (Lymph Nodes 1-2 cm)

Para-aortic and ipsilateral iliac radiotherapy to 30 Gy in 2 Gy fractions is standard treatment. 1

• Alternative: Chemotherapy with PEB × 3 cycles or PE × 4 cycles (if contraindications to bleomycin) 1
• Consider needle biopsy verification before initiating systemic chemotherapy 1

Stage IIB (Lymph Nodes 2-2.5 cm borderline to 2.5-5 cm)

Chemotherapy with PEB × 3 cycles is now preferred over radiotherapy due to lower relapse rates and avoidance of secondary malignancy risk. 1

• Borderline IIB (2-2.5 cm): Para-aortic and ipsilateral iliac radiotherapy to 30 Gy remains an option 1
• Standard IIB (2.5-5 cm): Chemotherapy is standard; radiotherapy to 36 Gy only for patients refusing or unable to receive chemotherapy 1

Stage IIC/III (Advanced Disease)

Chemotherapy with BEP (bleomycin, etoposide, cisplatin) is mandatory treatment. 1

Chemotherapy regimens:

• Good prognosis: BEP × 3 cycles (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) 1
• Intermediate prognosis: BEP × 4 cycles 1
• Consider omitting bleomycin in older patients or those with poor lung function (higher pneumonitis risk) 1

Post-chemotherapy management:

• Residual masses <3 cm: PET scan optional, follow-up if PET negative 1
• Residual masses >3 cm: FDG-PET CT at minimum 6 weeks post-chemotherapy 1, 5
• PET-positive residual masses require interdisciplinary discussion for further management 1, 5

Follow-Up Protocols

Stage I (Surveillance or Post-Adjuvant 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

• Abdominal imaging should be performed regularly but not every 3-4 months due to low detection rates and radiation exposure concerns 6
• Pelvic CT may be indicated at years 1,2, and 5 for patients treated with para-aortic strip radiotherapy 1
• Most relapses occur within first 2-6 years 6

Stage IIA-B Post-Treatment:

• If normal post-treatment CT: Follow as Stage I 1
• If abnormal post-treatment CT: Repeat CT every 6 months until normal or stabilized 1

Metastatic Disease Post-Chemotherapy:

• Chest X-ray and CT scan at 1 month after treatment 1
• Restrictive use of CT imaging due to secondary malignancy risk in this young, highly curable population 6

Critical Pitfalls to Avoid

• Never assume pure seminoma if AFP is elevated—this automatically indicates NSGCT components 4
• Never perform scrotal orchiectomy or biopsy—only radical inguinal approach 1, 2
• Never delay sperm banking discussion—must occur before any treatment 1, 3
• Never over-interpret small retroperitoneal nodes—accuracy declines in limited disease 3
• Avoid routine CT scans every 3-4 months during follow-up—detection rates are low and radiation exposure risk outweighs benefit in this curable population 6
• Do not perform PET scan for residual masses <3 cm—not indicated 1
• Wait minimum 6 weeks post-chemotherapy before PET scanning for residual masses >3 cm 1, 5

Long-Term Survivorship Considerations

With 5-year survival rates of 99% for Stage I, 92% for Stage II, and 85% for Stage III 7, treatment decisions must balance oncologic control with:

• Secondary malignancy risk (particularly from radiotherapy) 1, 6
• Cardiovascular disease risk from chemotherapy 7
• Fertility preservation 1, 3
• Hypogonadism monitoring 7
• Psychosocial effects including anxiety and depression 7