What is the recommended evaluation and stage‑specific management for a male patient with testicular seminoma?

Testicular Seminoma: Evaluation and Stage-Specific Management

Initial Evaluation

All patients with suspected testicular seminoma require radical inguinal orchiectomy as the primary diagnostic and therapeutic intervention, with comprehensive staging workup including tumor markers, CT imaging of chest/abdomen/pelvis, and risk stratification according to IGCCCG criteria. 1

Pre-Orchiectomy Workup

• Tumor markers (AFP, β-HCG, LDH) must be obtained before surgery to confirm pure seminoma and enable risk assessment 1

  • Pure seminoma does not secrete AFP; elevated AFP mandates management as non-seminoma regardless of histology 1
  • β-HCG may be elevated in some seminomas due to syncytiotrophoblast cells 1

• Testicular ultrasonography (7.5 MHz transducer) of both testes to assess primary tumor and contralateral testis size 1

• Laboratory studies: Complete blood count, creatinine, electrolytes, liver function tests 1

• Sperm banking should be offered before any treatment if fertility preservation is desired 1

Post-Orchiectomy Staging

• Repeat tumor markers minimum 7 days post-orchiectomy to assess half-life kinetics and confirm normalization 1

• CT chest, abdomen, and pelvis is mandatory for staging 1

  • Lymph nodes >1 cm in short axis are highly suspicious for metastatic disease, particularly in para-aortic/paracaval regions 1

• Bone scan only if bone symptoms or elevated alkaline phosphatase present 1

• Contralateral testis biopsy recommended in patients with testicular atrophy (<12 mL volume) and young age (<30 years) due to 2-5% risk of carcinoma in situ 1

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Stage-Specific Management

Stage I Disease (Confined to Testis)

Surveillance is the strongly preferred management strategy for Stage I seminoma, as it achieves disease-specific survival approaching 100% while avoiding treatment-related toxicity in the 85% of patients already cured by orchiectomy alone. 2, 3

Risk Stratification for Stage I

• Low-risk features: Tumor <4 cm AND no rete testis invasion (12% relapse risk) 1
• High-risk features: Tumor ≥4 cm WITH rete testis invasion (32% relapse risk) 1
• Intermediate-risk: One risk factor present (15% relapse risk) 1

Management Options for Stage I

Option 1: Surveillance (Preferred)

• Indicated for all Stage I patients, especially low-risk 1, 2
• Protocol: Clinical examination and chest X-ray at 1 month, then every 3 months for 2 years, then every 6 months to 5 years 1
• Abdominal CT imaging at regular intervals for at least 5 years 1
• 15-20% will relapse, but salvage treatment achieves near 100% cure 2, 3

Option 2: Adjuvant Carboplatin (Alternative)

• Single cycle carboplatin AUC 7 [dose = 7 × (GFR + 25)] reduces relapse to 0-5% 1, 2
• Achieves similar long-term survival to radiotherapy with less toxicity 1
• Preferred over radiotherapy due to lower risk of second malignancy 1

Option 3: Adjuvant Radiotherapy (Less Preferred)

• Para-aortic strip (T10-L5) to 20 Gy/10 fractions/2 weeks 1
• Reduces relapse to 3-4% but carries long-term risk of second malignancy and cardiovascular toxicity 1, 3
• If prior inguinal/scrotal surgery, extend to "dogleg" field including ipsilateral iliac/inguinal nodes 1
• Pelvic CT may be indicated at years 1,2, and 5 in patients treated with para-aortic strip 1

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Stage IIA-B Disease (Small Retroperitoneal Nodes)

Dogleg radiotherapy to 30-36 Gy/15-18 fractions to the involved site is the standard treatment for Stage IIA-B seminoma. 1

• Radiotherapy: 30-36 Gy to involved retroperitoneal nodes 1
• Chemotherapy alternative: 3-4 cycles of BEP or EP (see Stage IIC regimen) is an active alternative 1

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Stage IIC-III Disease (Bulky or Metastatic)

Cisplatin-based combination chemotherapy with 3-4 cycles of BEP (bleomycin, etoposide, cisplatin) or EP is the standard treatment for advanced seminoma. 1

Chemotherapy Regimen

• 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 1
• EP without bleomycin: Consider omitting bleomycin in older patients or those with poor lung function due to pneumonitis risk 1
• Number of cycles: 3 cycles for good prognosis, 4 cycles for intermediate prognosis 1

Prognostic Classification (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

Post-Chemotherapy Management

• Response evaluation: Chest X-ray and CT scan at 1 month after treatment 1
• If normal post-treatment CT: Follow-up as for Stage I 1
• If abnormal post-treatment CT: Repeat CT every 6 months until normal or stabilized 1
• PET scanning: May help define treatment strategy for residual masses in Stage II/III disease 1

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Relapse After Radiotherapy

Patients relapsing after dogleg radiotherapy should receive salvage chemotherapy with 3 cycles of BEP or 4 cycles of EP with lower-dose etoposide (360 mg/m²/cycle). 1

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Critical Pitfalls to Avoid

• Do not confuse tumor size with testicular size: The 4 cm cutoff refers to tumor dimensions within the testis, not overall testicular volume 4, 5

• Do not perform scrotal biopsy or scrotal orchiectomy: Always use inguinal approach to avoid altering lymphatic drainage and increasing risk of local recurrence 1

• Do not delay marker assessment: Allow adequate time (minimum 7 days) post-orchiectomy for markers to reach true nadir 1, 2

• Do not assume elevated AFP is compatible with pure seminoma: Any AFP elevation mandates management as non-seminoma 1

• Do not overlook fertility preservation: Discuss sperm cryopreservation before chemotherapy or radiotherapy, as both can cause permanent infertility 1, 2

• Do not use chest X-ray alone for staging: CT chest is mandatory for complete staging assessment 1