Postsurgical management of stage II seminoma

Stage II seminoma is a highly curable disease. The postsurgical management of stage II seminoma requires multidisciplinary input from medical oncology and radiation oncology. Listed treatments are preferred options, although alternative agents that are not listed may also be effective. Clinical trials are encouraged if available. For further details and evidence, refer to UpToDate content on treatment of stage II seminoma. For the management of more advanced testicular tumors, refer to UpToDate content on initial risk-stratified management of advanced testicular germ cell tumors.

AFP: alpha-fetoprotein; LDH: lactate dehydrogenase; beta-hCG: beta human chorionic gonadotropin; CT: computed tomography; MRI: magnetic resonance imaging; BEP: bleomycin, etoposide, and cisplatin; EP: etoposide and cisplatin; RT: radiation therapy (to regional lymph nodes).

* Patients with stage II seminoma and a mild elevation of either LDH or beta-hCG alone do not meet criteria for S1 disease and are typically treated using a similar approach to those with S0 disease. Such patients may also be evaluated for alternative causes of the isolated tumor marker (eg, tissue injury for LDH; hypogonadal states, tumor lysis, antibody interference with assay, marijuana use, other cancers for beta-hCG). Refer to UpToDate content on serum tumor markers in testicular germ cell tumors.

¶ RT is an appropriate alternative for nonbulky stage IIB disease (lymph nodes >2 cm and ≤3 cm).

Δ Lymph nodes that measure at least 1 cm in greatest dimension can potentially have disease involvement. However, some nodes may be enlarged due to nonmalignant causes (15 to 30%). Surveillance imaging can help determine the etiology of the lymph nodes (benign versus malignant) and guide treatment.

Lymph nodes that decrease to less than 1 cm in size are likely benign. Such patients are reclassified and treated as stage I seminoma.
Patients whose lymph nodes increase in size on repeat imaging can be confidently treated for stage II seminoma (eg, chemotherapy or RT).
Patients whose lymph nodes remain stable in size can continue surveillance with imaging every six to eight weeks.

◊ For stage IIA seminoma, both chemotherapy and RT have similar relapse rates and result in excellent disease-free survival. The optimal treatment approach is not established. Advantages and disadvantages of each therapy are as follows.

Patients with larger (closer to 2 cm) or more numerous lymph nodes (especially those distributed over a large area of the retroperitoneum) may derive greater benefit from chemotherapy.
RT is associated with less acute toxicities, has a shorter treatment duration than chemotherapy, and may be preferred by some for convenience, especially those with smaller lymph nodes.
Long-term toxicities differ between the treatments (risk of second malignancies with RT; cardiovascular disease, hypertension, hyperlipidemia, metabolic syndrome, neuropathy, tinnitus, and infertility with chemotherapy).

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Postsurgical management of stage II seminoma