Management of testicular seminoma advanced disease. Report on 14 cases and review of the literature.

INTRODUCTION: About 25% of testicular seminomas present with advanced clinical stage disease. The retroperitoneal lymph nodes are more likely to be involved (20%) than distant organs (5%). Herein we review our experience in the management of 14 patients with clinical stage II pure seminoma of the testis and review the literature concerning this subject. MATERIALS AND METHODS: Between January 1977 and December 2000, of 56 patients with pure seminoma of the testis 14 (25%) were assessed as clinical stage II disease. RT was performed for clinical substage IIA-IIB and chemotherapy in for IIC disease. All patients were closely followed up. RESULTS: Average age was 39.3 years (range 23-47). Mean follow-up was 88.6 months (range 28-232). Clinical stage IIA-IIB was detected in 12 patients (86%) and IIC in 2 (14%). Relapse did not occur in any patient. At the last follow-up evaluation, all patients were alive and disease-free. CONCLUSIONS: Radiation therapy is the standard of care in managing seminoma small bulk retroperitoneal disease including substages IIA and IIB. Overall toxicity of RT is mild and treatment is well tolerated. After RT, about 20% of patients may undergo relapses. Chemotherapy is the choice treatment for advanced seminoma presenting with clinical stage IIC-III disease; recently, it has also been advocated for stage IIB when presenting with multiple small lymph nodes. Carboplatin and cisplatin are the most effective agents with complete response rates of 89-91%. Patients developing progressive disease after first-line chemotherapy undergo combined salvage chemotherapy with cisplatin, ifosfamide and vinblastine with complete response rate of 83%. Patients presenting salvage chemotherapy failure are treated with high-dose chemotherapy associated with autologous bone marrow transplantation. Residual retroperitoneal masses after chemotherapy for advanced seminoma may be assessed by imaging as poorly or well defined. Surveillance is indicated for residual masses smaller than 3 cm as well as for poorly defined masses equal or greater than 3 cm. Well defined masses equal or larger than 3 cm are treated with surgery or RT. Ongoing clinical trials for testicular germ cell metastatic disease are focused on reducing toxicity without compromising efficacy as well as exploring new salvage strategies and improving the prospect of cures and survival rates.