Systemic Therapy

Chemotherapy may play a role in the treatment of any stage of seminoma.

Stage I Disease

A single cycle of carboplatin has been shown to have excellent results as adjuvant treatment for stage I seminoma. This has been confirmed in the TE19 trial (Oliver et al). Longer term follow up shows a different pattern of relapse in patients treated with this regimen compared to radiotherapy, with more relapses occurring in para-aortic nodes (compared to pelvic and mediastinal recurrences in the radiotherapy group).
The dose is calculated by the Area Under the Curve (AUC) method, with a target AUC of 7 mg/ml/min. This calculation involves measuring the patient's glomerular filtration rate (GFR).
This regime has become the standard of care in Norway and Sweden.

Continuing study - There is concern about the patterns of relapse with carboplatin relative to radiotherapy. Some centres suggest two doses of AUC7 carboplatin; others have advocated chemotherapy followed by radiotherapy (or vice versa). There is no evidence for either of these treatments in the literature at this stage.

Follow up for adjuvant chemotherapy includes:

  • Clinical follow up with serum markers every 3 months for 2 years, 4 monthly for year 3 and 6 monthly for years 4-5
  • Chest x-ray at 6 months, 12 months and then yearly for 5 years
  • CT abdomen (not pelvis) at 1 year, 2 years and 5 years
  • Discharge after 5 years follow up

If relapse occurs then the regime for Stage IIA/IIB disease is used.

Stage IIA/IIB disease

Radiotherapy is typically recommended for Stage IIA disease, and there is debate as to the ideal treatment for stage IIB (radiation vs chemotherapy). The chemotherapy regime used for these patients is either:

  • Cis/Carboplatin + Etoposide + Bleomycin (3 cycles) - 'PEB' or 'BEP'
  • Cis/Carboplatin + Etoposide (4 cycles) - 'PE' or 'EP'

The choice of regimen depends on the expected patient tolerance of bleomycin.
If relapse occurs after chemotherapy, then salvage chemotherapy or local radiotherapy may be used.
If chemotherapy is used, follow up is similar to higher stage disease:

  • Clinical follow up every 2 months for 1 year, 4 monthly for 1 year and then 6 monthly for 3 years
  • Chest x-ray every 4 months for 2 years, then yearly for 3 years
  • CT should be performed until complete response has been achieved, or as frequently as determined by the multidisciplinary team.
  • Discharge after 5 years follow up

Stage IIC, IIIA - IIIC disease

Chemotherapy forms the primary treatment after orchidectomy for more advanced disease.

  • For patients without stage M1b disease (disease localised to non-regional nodes or pulmonary metastases) then treatment with 3 cycles of BEP is the standard recommendation (or 4 cycles PE if bleomycin is contraindicated)
  • For patients with widespread disease (M1b) then 4 cycles BEP or 4 cycles PEI (cisplatin/etoposide/ifosfamide) if bleomycin is contraindicated provides good control

Patients should be followed up after treatment with a CT Chest/Abdomen/Pelvis

  • If there is residual mass/es with size/s of under 3 cm then surveillance is appropriate
  • If masses are larger than 3 cm then PET scan is indicated
    • If the PET is positive then surgical biopsy / excision should be considered