In a young man with a painless firm testicular mass suspected to be seminoma, how should the disease be diagnosed, staged, and managed (including surveillance, single‑dose carboplatin, radiotherapy, or BEP chemotherapy) and what follow‑up schedule is recommended?

Management of Suspected Seminoma in a Young Man

Diagnosis must be established by radical inguinal orchiectomy—never by scrotal biopsy or scrotal approach—with histopathologic confirmation of seminoma and pre-operative serum tumor markers (AFP, β-hCG, LDH) to confirm pure seminoma (AFP must be normal). 1, 2

Initial Diagnostic Workup

Pre-Orchiectomy Assessment

• Obtain serum tumor markers before any surgical intervention: AFP (must be normal for pure seminoma), β-hCG (may be mildly elevated in 10-20% of seminomas), and LDH 1, 2
• Discuss sperm cryopreservation before orchiectomy, as subsequent chemotherapy or radiotherapy can permanently impair fertility 1, 2
• Perform scrotal ultrasound to characterize the testicular mass 3

Surgical Diagnosis

• Radical inguinal orchiectomy (not scrotal approach) with early ligation of the spermatic cord is mandatory for both diagnosis and treatment 1, 2
• The inguinal approach prevents lymphatic spread and avoids increased risk of local recurrence 1

Post-Orchiectomy Staging

• CT chest, abdomen, and pelvis are mandatory for complete staging 1, 2
• Full blood count, urea, creatinine, electrolytes, and liver function tests 1
• Consider contralateral testis biopsy in patients with testicular atrophy (<12 mL) and age <30 years to detect carcinoma in situ 1
• Bone scan only if bone-related symptoms or elevated alkaline phosphatase in metastatic disease 1

Risk Stratification

Stage I Disease (70-75% of patients)

Risk factors for relapse: 1

• Tumor size ≥4 cm and/or rete testis invasion = 32% relapse risk
• One risk factor = 15% relapse risk
• No risk factors = 12% relapse risk

IGCCCG Prognostic Classification for Metastatic Disease

• Good prognosis (seminoma): Normal AFP, any β-hCG, any LDH, no non-pulmonary visceral metastases; 5-year survival ≈86% 1, 4
• Intermediate prognosis (seminoma): Normal AFP, any β-hCG, any LDH, with non-pulmonary visceral metastases; 5-year survival ≈72% 1, 4

Stage-Specific Management

Stage I Seminoma (Localized Disease)

Surveillance is now the preferred approach for all Stage I patients, regardless of risk factors, as it minimizes treatment burden while maintaining >99% survival. 1

Alternative options (only if surveillance not feasible):

• Single-dose carboplatin AUC 7: Dose = 7 × (GFR + 25) for one cycle 1
• Adjuvant radiotherapy: Para-aortic strip (T10-L5) 20 Gy in 10 fractions over 2 weeks, though this carries long-term risk of secondary malignancy 1

Critical caveat: All three approaches (surveillance, carboplatin, radiotherapy) achieve similar survival (≥98%), but surveillance avoids overtreatment in 88% of patients who never relapse 1

Stage IIA Seminoma (Nodes 1-2 cm)

Para-aortic and ipsilateral iliac radiotherapy to 30 Gy in 15 fractions is standard treatment. 1

• Chemotherapy (3 cycles PEB or 4 cycles PE) is an equivalent alternative with different toxicity profile but potentially lower risk of secondary malignancy 1
• Consider fine-needle biopsy to verify nodal involvement before initiating systemic chemotherapy 1

Stage IIB Seminoma (Nodes 2-5 cm)

For nodes 2.5-5 cm, chemotherapy with 3 cycles of BEP (bleomycin, etoposide, cisplatin) is preferred over radiotherapy. 1

• BEP regimen (5-day schedule): Cisplatin 20 mg/m² days 1-5, etoposide 100 mg/m² days 1-5, bleomycin 30 mg (absolute dose) days 1,8,15 1
• BEP regimen (3-day schedule): Cisplatin 50 mg/m² days 1-2, etoposide 165 mg/m² days 1-3, bleomycin 30 mg days 1,8,15 1
• If bleomycin contraindicated (poor pulmonary function, older age): 4 cycles of EP (etoposide + cisplatin) 1, 4
• Radiotherapy (36 Gy in 18 fractions) is an alternative but less preferred 1

Stage IIC/III Seminoma (Nodes >5 cm or Metastatic)

Cisplatin-based chemotherapy is mandatory: 1, 4

• Good prognosis: 3 cycles BEP (3- or 5-day schedule) 1, 4
• Intermediate prognosis: 4 cycles BEP (5-day schedule) 1, 4
• Administer every 21 days without dose reduction or delay 4
• Monitor renal function and electrolytes before each cycle due to cumulative cisplatin nephrotoxicity 4

Post-Chemotherapy Management

Residual Mass Assessment

• Residual mass >3 cm with normal markers: PET scan ≥6 weeks post-chemotherapy is recommended 1
  • PET negative: Surveillance only 1
  • PET positive: Consider surgical resection 1
• Residual mass ≤3 cm with normal markers: Surveillance is appropriate (PET optional) 1
• Rising markers or growing mass: Initiate salvage chemotherapy 4

Follow-Up Schedule

Stage I on Surveillance

• Years 1-2: Clinical exam and tumor markers every 3 months; chest X-ray every 3 months; CT abdomen every 6 months 1
• Years 3-5: Clinical exam and markers every 6 months; chest X-ray every 6 months; CT abdomen annually 1
• Continue surveillance for at least 5 years with regular abdominal imaging 1

Stage I After Adjuvant Treatment (Carboplatin or Radiotherapy)

• Year 1: Clinical exam and markers at 1 month, then every 3 months; chest X-ray every 3 months; CT abdomen at 6 and 12 months 1
• Years 2-5: Clinical exam and markers every 6 months; chest X-ray annually; CT abdomen at years 2 and 5 1

Stage IIA-IIB After Treatment

• Years 1-2: Clinical exam and markers every 3 months; chest X-ray every 3 months; CT abdomen/pelvis every 6 months 1
• Years 3-5: Clinical exam and markers every 6 months; imaging as clinically indicated 1

Stage IIC-III After Chemotherapy

• First month: Chest X-ray and CT scan to assess response 1
• If normal post-treatment CT: Follow as Stage I 1
• If abnormal CT: Repeat CT every 6 months until normalized or stabilized 1

Critical Pitfalls to Avoid

• Never perform scrotal orchiectomy or biopsy—this alters lymphatic drainage and increases recurrence risk 1, 2
• Never diagnose seminoma if AFP is elevated—this indicates non-seminomatous component requiring different management 1, 2
• Do not omit pre-orchiectomy tumor markers—post-operative markers cannot be used for IGCCCG risk stratification 1, 2
• Avoid radiotherapy in young patients when alternatives exist—long-term risk of secondary malignancy is significant 1
• Do not delay chemotherapy cycles or reduce doses in advanced disease—this compromises cure rates 4
• Surveillance requires excellent patient compliance—if adherence is questionable, consider adjuvant carboplatin over radiotherapy 1