Version July 2025
AFP: alpha-fetoprotein; BEP: bleomycin, etoposide, cisplatin; beta-hCG: beta-human chorionic gonadotropin; EP: etoposide, cisplatin; LDH: lactate dehydrogenase; NSGCT: nonseminomatous germ cell tumors; ULN: upper limit of normal; VIP: ifosfamide, etoposide, cisplatin.
* Seminomas do not produce AFP. Patients with seminoma and elevated levels of serum AFP (typically >30 ng/mL) are classified and treated as an NSGCT. Some patients with pure seminomas may have elevated levels of beta-hCG, but these elevations are typically modest (<200 IU/L). For those with advanced seminoma, a postorchiectomy beta-hCG level >1000 IU/L indicate that nonseminomatous components are likely present, and a level >5000 IU/L would generally be interpreted as a diagnosis of NSGCT.
¶ For patients with good-risk seminoma and LDH >2.5 times ULN, we treat using an approach similar to those with intermediate-risk seminoma.
Δ For patients with good-risk disease who are not at increased risk for bleomycin-induced pulmonary toxicity, either regimen (EP or BEP) is appropriate. For those at increased for bleomycin-induced lung toxicity (ie, those who are 50 years of age or older, those with compromised kidney or pulmonary function, those who actively smoke, and/or those with prior chest radiation therapy), we prefer EP.
◊ For patients with intermediate- and poor-risk disease who are not at increased risk for bleomycin-induced lung toxicity, we prefer BEP. VIP is an appropriate alternative for patients at high risk for bleomycin-induced pulmonary toxicity (ie, those who are 50 years of age or older, those with compromised kidney or pulmonary function, those who actively smoke, and/or those with prior chest radiation therapy).
