For patients with stage 1 seminoma, and this accounts for approximately three quarters of all men with testicular seminoma presenting in the UK, approximately 20% will harbour microscopic disease in the abdominal lymph nodes. This microscopic seminoma is highly sensitive to low doses of conventional radiotherapy sand it has been standard practice to treat such stage 1 seminoma patients with radiotherapy bringing their first time cure rate up to 95%.
Watch and wait policies have substituted this proactive therapy policy, but have in general been eschewed because of the large amount of follow up scanning necessary.
Recently, it has been observed that the extreme chemosensitivity to platinum based chemotherapy could be used to substitute radiotherapy and trials are underway examining the use of short course chemotherapy versus the usual radiotherapy in these stage 1 cases.
In early stage 2 seminoma, radiotherapy may still be curative but when the bulk of disease increases (Stage 2B-C) primary chemotherapy always supersedes with or without radiotherapy (or occasionally surgery) to any residual abdominal node masses.
Radiotherapy is less useful for the teratoma lineage tumours and the policy for stage 1 teratoma patients is watchful waiting with serial serum marker tests (HCG and AFP) and CT scanning regularly.
Approximately 20% of patients who are stage 1 at presentation subsequently relapse and, so long as the relapse is picked up early , their longevity/cure chance is not prejudiced by the watchful waiting policy.
It should also be noted that any pre-operative high serum level of markers should return to normal if the patient is to be regarded as true stage 1 and a watch policy employed. Having said this, there are trials taking place concerning the use of short course chemotherapy in perceived bad risk stage 1 teratoma patients (largely based on vascular invasion on the microscopic exam of the resected testis).
For stage 2 disease and all other higher risk groupings, full courses of chemotherapy are advised.
The drug cis-platinum seems to be especially toxic to cancers harbouring the p12 isochrome and the current policy is to give combination chemotherapy using two other drugs viz. bleomycin and etoposide to accompany cis-platinum. The success of this triplet of chemotherapy drugs has been one of the success stories of the modern oncology era. A minimum of three courses are delivered and maximum of six. The chemotherapy is quite toxic and lethargy, depilation of hair and nausea are the main three complaints.
The response to chemotherapy is monitored by serial assessment of serum markers (HCG and AFP) and by serial scanning. Even after curative doses of chemotherapy have been delivered, a residual mass may remain in the region of the abdominal lymph nodes; a PET (positron emission tomogram) will predict whether this still contains viable tumour cells, as this scans for metabolically active lesions. However, many doctors prefer to surgically remove any residual masses even though they are most likely comprised of inert cells.
Following completion of the chemotherapy programme, the patient must be assiduously watched for three years. If relapse of any testicular tumour occurs it is likely to be in the first three years, although the literature does contain instances of later relapses.
