Contemporary surgical management of testicular seminoma

Testicular cancer is the most commonly diagnosed cancer among young men in the United States. Seminoma comprises a little over half of all testicular germ cell neoplasms. After radial inguinal orchiectomy, management of seminoma is dictated by tumor stage and risk stratification. Dissemination patterns for metastatic testicular cancer are predictable and reproducible, initially metastasizing to the retroperitoneum before disseminating to the lungs or other viscera. Seminomas are exquisitely sensitive to radiation therapy and platinum-based chemotherapy. Approximately 80-85% of men presenting with early stage (clinical stage I) seminoma will not experience a relapse after radical orchiectomy alone. Therefore, surveillance has been supported by the National Comprehensive Cancer Network (NCCN) guidelines as the preferred management strategy. For those at higher risk of relapse, one or two cycles of single-agent carboplatin or radiation therapy are alternative options to reduce the risk of relapse. For patients with early disseminated seminoma (clinical stage IIA and IIB), radiation therapy or chemotherapy with three cycles of bleomycin, etoposide, cisplatin (BEP) or four cycles of etoposide and cisplatin (EP) are well-established options with excellent cure rates. However, these therapies may be associated with significant long-term toxicities. Primary retroperitoneal lymph node dissection (RPLND) in patients with low-volume metastatic seminoma has recently been evaluated for safety and efficacy in prospective clinical trials. Finally, though the role of surgery in patients with advanced seminoma (clinical stage IIC and III) is limited, a subset of patients with a residual mass following chemotherapy >3 cm suggestive of viable germ cell tumor on imaging may benefit from surgical resection. Herein we review the contemporary indications for surgery and outcomes for men with testicular seminoma.