Postsurgical management of stage II seminoma

AFP: alpha-fetoprotein; BEP: bleomycin, etoposide, and cisplatin; beta-hCG: beta human chorionic gonadotropin; CT: computed tomography; EP: etoposide and cisplatin; LDH: lactate dehydrogenase; MRI: magnetic resonance imaging; RPLND: retroperitoneal lymph node dissection; 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 RPLND is an alternative treatment option for patients with nonbulky stage IIB disease (lymph nodes >2 cm and ≤3 cm) who wish to avoid the potential long-term toxicities of chemotherapy or RT and are willing to accept a potentially higher risk of recurrence.

• 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 and retroperitoneal lymph nodes between 1 and 2 cm, the optimal treatment approach is not established. Advantages and disadvantages of each therapy are as follows:

• Both chemotherapy and RT have similar relapse rates and result in excellent disease-free survival.
• 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 chemotherapy and RT (risk of second malignancies with RT; cardiovascular disease, hypertension, hyperlipidemia, metabolic syndrome, neuropathy, tinnitus, and infertility with chemotherapy).
• RPLND is an option for patients who wish to avoid the potential long-term toxicities of chemotherapy or RT and are willing to accept a potentially higher risk of recurrence.