Stage 2A / 2B (N1-N2) seminoma
- Nodes < 2 cm with normal markers can be observed for 6 – 8 weeks and re-imaged, as they may be non metastatic
- Don’t treat unless sure of malignancy (increasing size, biopsy, rising markers)
- Traditionally radiated, but now chemo is preferred
Preferred treatment:
3 x BEP
Or 4 x EP (if older or bleomycin contra-indicated)
Radiation is still an alternate treatment
RPLND only in trials currently.
Stage 2C and 3 seminoma (N3 or M1)
Stratify into good risk or intermediate risk (based on extrapulmonary visceral mets).
Good prognosis = 3 x BEP, intermediate prognosis = 4 x BEP
4 x VIP when contraindications to bleomycin (ifosfamide instead of bleomycin).
BEP has proven superior to carboplatin based.
Residual seminoma mass:
- Residual mass of seminoma after chemo should be watched with imaging and markers, not resected, regardless of size
- Ensure no AFP elevation (except chemo induced liver dysfunction) which would suggest NSGCT
- FDG-PET has a high NPV in patients with residual masses after treatment for seminoma
- Wait 2 months after chemo to reduce false positive rates
- Definitely useful in masses > 3 cm, optional if < 3 cm
- If concern for residual malignancy (increasing size, or FDG avidity) – treatment is usually further (salvage) chemotherapy or radiation
- If normal markers/no HCG elevation, consider biopsy before salvage chemo
- Surgery can be considered if more chemo or radiation contra-indicated
- Post chemo surgery for seminoma very difficult with intense fibrosis