Management of Stage I Seminoma (pT2, cN0M0) After Orchiectomy
Surveillance is the recommended primary management strategy for this patient with stage I seminoma and normal postoperative tumor markers. 1
Primary Treatment Recommendation
Surveillance after orchiectomy should be recommended as the preferred approach because:
- More than 80% of stage I seminoma patients will not experience recurrence and are cured with orchiectomy alone 1
- Surveillance is associated with the lowest risk for both short-term and long-term treatment-related morbidity 1
- Disease-specific survival for stage I seminoma is 99% regardless of management strategy (surveillance, adjuvant carboplatin, or radiotherapy) 1
- Adjuvant treatments reduce relapse risk but do not improve cancer-specific survival compared to surveillance 1
Alternative Treatment Options (Less Preferred)
If surveillance is not feasible or acceptable to the patient, two alternatives exist:
Single-Agent Carboplatin
- Dosing: AUC = 7 × 1 cycle or AUC = 7 × 2 cycles 1
- Reduces relapse rate to approximately 5% at 5 years 1
- Lower risk of contralateral germ cell tumors compared to radiotherapy 1
Adjuvant Radiotherapy
- Dose: 18-20 Gy to para-aortic lymph nodes 1
- May include ipsilateral iliac nodes (30-36 Gy total dose) 1
- Reduces relapse rate but carries risk of secondary malignancies and cardiovascular toxicity 1
Surveillance Protocol
For patients on surveillance, follow this schedule: 1, 2
Years 1-2:
- History & physical examination, AFP, β-HCG, LDH: every 3-4 months 1
- Abdominal/pelvic CT: every 6 months 1
- Chest x-ray: as clinically indicated 1
Year 3:
- History & physical examination, tumor markers: every 6-12 months 1
- Abdominal/pelvic CT: every 6-12 months 1
Years 4-5:
Beyond 5 years:
- Annual follow-up indefinitely due to risk of late relapses 1
Important Clinical Considerations
Relapse Patterns
- Relapse rate with surveillance is 15-20% at 5 years 1
- Most relapses occur in infradiaphragmatic (retroperitoneal) lymph nodes 1
- Median time to relapse is within the first 2 years 1
- Late relapses can occur beyond 5-10 years, necessitating long-term follow-up 1
Risk Factors (Not Used for Treatment Selection)
- Tumor size >4 cm and rete testis invasion were previously considered risk factors 1
- However, validation studies showed these are NOT reliable predictors of relapse 1
- Risk-adapted management based on these factors is discouraged for stage I seminoma 1
Stage IS Consideration
- This patient has normal β-HCG and LDH postoperatively, so does NOT have stage IS disease 3
- If markers had remained persistently elevated after appropriate half-life intervals (β-HCG: 24-36 hours; LDH: 5-7 days), this would indicate stage IS 2, 3
- Stage IS patients may require different management, though recent data suggests similar outcomes 3
Critical Pitfalls to Avoid
- Do not use PET scanning for staging in testicular cancer 1
- Do not assume pT2 status alone mandates adjuvant therapy – surveillance remains preferred 1
- Ensure adequate time has elapsed for tumor marker normalization before finalizing stage (β-HCG half-life: 24-36 hours; AFP: 5-7 days) 1, 2
- Do not dismiss the need for long-term follow-up – late relapses occur in seminoma 1
- Confirm imaging was obtained within 4 weeks and tumor markers within 10 days before making treatment decisions 1
Multidisciplinary Management
All management decisions should be made in a multidisciplinary setting involving experienced clinicians in urology, medical oncology, radiation oncology, pathology, and radiology 1