Initial Management
Management of any testicular mass with suspected malignancy is straightforward:
- Serum AFP / β-hCG / LDH
- CT Chest/Abdomen/Pelvis
- Unilateral orchidectomy with a high ligation of the spermatic cord
- Histopathological examination of the orchidectomy specimen
Pathology will demonstrate a seminoma, non-seminomatous germ cell tumour or a mixed germ cell tumour. For treatment of the latter, see the non-seminomatous germ cell tumour topic.
Spermatocytic seminoma is a special subtype that occurs in older men. Orchidectomy is almost universally curative.
Further management of classical and anaplastic seminoma is dependent on the stage of disease:
- Stage IA/IB -> Organ confined disease
- Stage IS -> Persistent elevated tumour markers after orchidectomy
- Stage II -> Nodal disease
- Stage III -> Metastatic disease
Organ Confined Disease (T1-4 N0 M0)
If there is no evidence of nodal involvement, other factors must be considered:
- Spermatocystic seminoma is a disease of elderly men. If present, management is purely observational as surgical resection is curative
- For motivated patients with no risk factors (tumour size < 6 cm, lymphovascular invasion) then observation is a possibility
- For patients with one or more risk factors, or who would have difficulty with the number of investigations involved in observation, further adjuvant therapy is indicated.
There are two evidence based treatments used for adjuvant therapy in Stage IA/B seminoma:
- Radiotherapy involves external beam radiation to para-aortic nodes
- 20 Gy in 10 fractions has been shown to be have equal efficacy to higher doses and is the most commonly used dose
- Systemic Therapy involves administration of a single cycle of carboplatin
Both treatments show similar outcomes in terms of overall survival and disease free survival, although the patterns of relapse are slightly different. Chemotherapy patients are more likely to recur in the para-aortic nodes, whereas radiotherapy patients usually have recurrences in other nodal groups or in the lungs.
Older radiotherapy techniques utilised a 'dog leg' field which also included ipsilateral pelvic nodes; there was improved control of disease in the pelvic nodes at the expense of increased toxicity.
Persistent Elevation of Markers after Orchidectomy for T1-4 N0 disease
This is perhaps more common in non-seminomatous germ cell tumours as tumour markers are uncommonly elevated in seminoma and usually fall after resection has occurred. Cytotoxic systemic therapy is the usual course of action.
Stage IIA/IIB disease (TAny N1-2)
These patients have visible disease in the para-aortic nodes on CT imaging, with no masses over 5 cm in size. Both chemotherapy and radiotherapy have been evaluated for treatment of these patients:
- Radiotherapy fields typically encompass the para-aortic and ipsilateral pelvic nodes. This can be done using volume based planning or with a field based 'dog leg' plan that extends from T11, covers the para-aortic and para-caval nodes as well as the ipsilateral renal hilum, then extending inferiorly and laterally to cover the ipsilateral iliac nodes. Doses may be higher than those used for Stage IA/B disease due to the increased disease burden - 30 - 36 Gy is not uncommon.
- There is debate about appropriate fields. The para-aortic nodes may be treated alone, or with a dog-leg technique, or with an 'inverted Y' that covers both sides of the pelvis
- Chemotherapy involves 4 cycles of cisplatin and etoposide, with bleomycin added for large volume disease. When disease responds poorly, dose escalation can be performed with addition of bleomycin and ifosfamide.
If residual masses remain then they can be observed if not suspicious; alternatively retroperitoneal lymph node dissection can be used to remove any remaining disease.
Stage IIC and IIIA-C disease
Patients with large retroperitoneal nodes (over 5 cm) show a higher rate of recurrence following para-aortic radiotherapy (approaching 50%) and systemic therapy is more commonly used. Patients with other metastases are also treated more effectively with systemic treatment.
- Cisplatin forms the basis of chemotherapy for advanced seminoma
A residual mass is not uncommon after systemic treatment. For small (< 3 cm) dense masses, observation is a possibility. For larger or more abnormal appearing masses, surgical biopsy is indicated. If residual malignant cells are seen then salvage therapy with vinblastine, ifosfamide and cisplatin is prescribed. If no malignant cells are identified then further observation is undertaken.
