| NCCN 2006 Seminoma Stages IA, IB, and IS Early stage seminoma is a radiosensitive tumor. Patients with disease in stages IA, IB, and IS are treated with radiation (20-30 Gy) to the infradiaphragmatic area including para-aortic lymph nodes. Prophylaxis to the mediastinum is not given, since relapse rarely occurs at this site. Surveillance has been studied as an alternative to radiation therapy for stage I seminoma in instances in which radiation might have excessive morbidity, or in selected T1 or T2 cases (category 2B) in patients who are committed to long-term follow-up. Annual pelvic CT is recommended for 3 years for patients who underwent para-aortic RT. Either strategy after orchiectomy has shown almost 100% cure rate for patients with stage I testicular seminoma. Between 15% and 20% of seminoma patients relapse during surveillance if they do not receive adjuvant radiation therapy after orchiectomy. The median time to relapse is approximately 12 months, but relapses do occur more than 5 years following orchiectomy. Since the morbidity of radiation in this setting is low, surveillance for stage I seminoma is generally not recommended in the United States, except for patients at higher risk for morbidity from radiation therapy. Stage IIA and IIB Stage IIA is defined as disease measuring less than 2 cm in diameter on CT scan and stage IIB as disease measuring 2 to 5 cm in maximum diameter. For patients with stage IIA or IIB disease, 35 to 40 Gy is administered to the infradiaphragmatic area including para-aortic and ipsilateral iliac lymph nodes. As in the management of stage I, prophylactic mediastinal radiation therapy is not indicated. If a horseshoe kidney is present, then radiation therapy is not administered, and the patient is treated with good-risk systemic chemotherapy (described below).Advanced Seminoma Stage IIC is defined as retroperitoneal disease greater than 5 cm in maximum transverse diameter. Standard chemotherapy for good risk germ cell tumors is used to treat patients with stage IIC seminoma. After chemotherapy, if the CT scan is normal without radiographic evidence of residual disease, then the patient should be observed only. A PET scan is preferred for patients after chemotherapy in whom residual disease is determined on CT scan. Patients with negative PET scan results should be observed. Three options are exist for patients with positive PET scan results: 1) surgical biopsy; 2) biopsy and salvage therapy; and 3) radiation therapy (category 2B). For patients who cannot receive a PET scan, post-chemotherapy management is based on CT scan findings. Controversy exists regarding optimal management when the residual mass is greater than 3 cm, as approximately 25% of these patients have a viable seminoma or previously unrecognized nonseminoma. The options include: 1) surgery, with resection of the residual mass or multiple biopsies; 2) radiation therapy (category 2B); and 3) observation. If surgery is selected, the procedure consists of resection of the residual mass or multiple biopsies. A full bilateral or modified retroperitoneal lymph node dissection (RPLND) is not performed because of its technical difficulty in seminoma patients, owing to extensive fibrosis, which may be associated with severe morbidity. If the residual mass is 3 cm or less, patients should be observed. For patients with progressive disease on CT scan salvage therapy is recommended. Patients with stage III disease or seminoma arising from an extragonadal site, such as the mediastinum, are treated with standard chemotherapy regimens according to risk status. All stage III seminoma tumors are defined as good risk with the exception of stage IIIC (nonpulmonary visceral metastasis), which is defined as intermediate risk. Approximately 90% of patients with advanced seminoma are cured with cisplatin-containing chemotherapy. |