Controversies in the management of testicular seminoma

Tremendous progress has been made in the treatment of testicular seminoma over the past 25 years. The advent of curative cytotoxic chemotherapy, even for patients with advanced metastatic disease, has led to a paradigm shift toward minimizing additional oncologic therapies and their potential side effects. Despite these advances, controversial issues still exist in managing patients with this disease. Patients with stage I disease can now be managed successfully with close surveillance or postoperative radiotherapy (RT). Although deemed safe, considerable debate persists about surveillance including issues of compliance, cost, and secondary effects of routine RT. Aside from RT, patients with stage I disease also can be managed with one- or 2-dose single-agent carboplatin. Although this appears safe and efficacious, an ongoing randomized study is underway to compare its effectiveness with that of RT. Residual mass after chemotherapy for seminoma is not uncommon and therapeutic options include observation, RT, or retroperitoneal lymphadenectomy. Although most agree that patients with small (<3 cm) or ill-defined masses can be observed, debate persists as to the optimal management of patients with well-defined masses greater than 3 cm. For many years, patients with bulky retroperitoneal disease (>5 cm) were treated with up-front radiotherapy and chemotherapy at relapse. The high failure rate outside the treatment field has now changed this paradigm to one of up-front chemotherapy.