Serum HCG is elevated in about 15% of patients with metastatic seminoma. Unlike non-seminoma, serum tumor marker levels are not used to guide treatment.
Stage I Treatment options after orchiectomy are:
Surveillance (preferred), carboplatin x 1, RT (20 Gy)
Stage IS Perform CT chest/abdomen/pelvis
Stage IIA RT (30 Gy) or Chemotherapy (BEP X 3 or EP X 4)
Stage IIB with a LN ≤3cm
Chemotherapy (BEP X 3 or EP X 4) or RT (36 Gy)
Stage IIB Seminoma with a LN >3 cm
BEP X 3 or EP X 4
Stage IIC and III Good Risk
BEP X 3 or EP X 4
Stage III Intermediate Risk (Nonpulmonary Visceral Metastases)
BEP X 4 or VIP X 4
Residual Masses > 3 cm after First-line Chemotherapy
FDG-PET will be done. Patients with PET positive residual masses should undergo surgical resection.
Residual masses that are PET-negative or less than 3 cm can be safely observed after chemotherapy.
Teratoma at Metastatic Sites
This is less common in seminoma compared to non-seminoma but should be considered in patients who fail to respond to chemotherapy.
Stage I Surveillance or RPLND or BEP X 1
RPLND: stage I non-seminoma who had teratoma with malignant transformation at orchiectomy.
We recommend active treatment (RPLND or chemotherapy) to those with lymphovascular invasion and/or embryonal carcinoma predominance.
Stage IS BEP X 3 or EP X 4
Stage IIA with Normal Post-Orchiectomy AFP & HCG RPLND or chemotherapy
Stage IIA S1 BEP X 3 or EP X 4
Stage: IIB BEP X 3 or EP X 4 . RPLND may be done in highly selected patients.
Stage IIB S1 BEP X 3 or EP X 4
IIC, and IIIA BEP X 3 or EP X 4
IIIB and IIIC BEP X 4 or VIP X 4
Post RPLND Management
pN1: surveillance (preferred) or BEP X 2 or EP X 2
pN2: BEP X 2 or EP X 2
pN2: BEP X 3 or EP X 4
pN1-3 pure teratoma: surveillance is preferred.
Post-chemo Residual Masses with Normal Tumor Markers
Resect if ≥ 1 cm and tumor markers are negative.
Next step is going to be per resected pathology:
Teratoma or necrosis: surveillance
Other germ cells: 2 cycles of EP or TIP or VIP or VeIP
Post-chemo Residual Masses with Elevated Tumor Markers
Mildly elevated and normalizing: manage like masses with normal tumor markers.
Elevated but stable: Close surveillance.
Elevated and rising: Second line therapy
Second Line Therapy
If relapse occurs <2 years: consider chemo. Surgery is an option for a single mass.
Conventional chemotherapy regimen: TIP or VeIP
High dose chemo: Carboplatin/ etoposide or P-ICE
Relapse occurs > 2 years: consider surgery, if respectable.