Skip to content
Home » Oncology » Oncology – Testis » Stage 1 seminoma – management

Stage 1 seminoma – management

Stage 1 seminoma:

Pathological risk factors for occult metastatic disease in stage 1 seminoma:

  • Tumour size (> 4 cm)
  • Rete testis invasion

Absence of both of these factors = 6 % risk of relapse.

Overall risk of relapse after orchidectomy = 15 – 20 %

 

Options:

  1. Surveillance
  2. Chemotherapy – one cycle of carboplatin
  3. Radiation therapy

 

Surveillance

  • Most recurrences occur in the retroperitoneal lymph nodes in the first 2 years
  • Only 6 % risk of relapse if < 4 cm and no rete testis tumour invasion
  • Cancer specific survival 99 % even including relapse in well surveilled patients

 

Chemo – carboplatin

  • Dose of 7 mg/mL/min AUC (single dose)
  • Risk of relapse reduced to 3 – 4 % after chemo
  • Non inferior to radiation in a trial
  • Relapses occur later cf. surveillance
  • Most patients who relapse after adjuvant carboplatin can be managed with standard platinum based chemo
  • Toxicity – nausea, vomiting, myelosuppression. Long term effects unclear.

 

Radiation

  • Typically “dogleg” – para-aortic nodes + ipsilateral pelvic nodes
  • Total dose 20 – 24 Gy (20 Gy non inferior to 30 in trial)
  • Acute GI upset 60 %, chronic GI symptoms 5 %
  • Long term risk of secondary malignancy has made XRT an unattractive option
  • Higher rates of cardiac disease in long term
  • Toxicity data based on older regimens with wider fields, may not be applicable

 

EAU guidelines:

  • Offer surveillance as preferred option if resources available and patient compliant
  • Do not perform adjuvant treatment in patients with no risk factors (size/rete testis)
  • Do not routinely perform adjuvant radiotherapy – reserve for patients unsuitable for surveillance or chemo

ANZUP guidelines on surveillance:

  • CT chest at baseline – not routinely needed after that
  • bHCG and AFP for surveillance – LDH doesn’t add value
  • Consider testis cancer specific CT protocol – diaphragm to ischium
  • Value of follow up beyond 5 years uncertain – at a minimum need GP follow up of cardiovascular risk and testosterone, some advocate for CT at 10 years
  • ANZUP has a testicular cancer surveillance “individual patient schedule” which can be customised for use