Treatment: Seminoma: Stage I

Seminoma is the least malignant subtype of testicular germ cell cancer and has the least risk of metastasis at presentation. Until recently because of the high cure of metastasis by radiation use of radiation as prophylaxis for stage one disease has been standard of care. Since the advent of platinum based chemotherapy and observations of excess late second cancers and cardiac deaths there has been a major evolution in treatment which is reviewed in this chapter. The first phase involved exploration of reduced doses of radiation and single agent chemotherapy as alternative adjuvant strategies. Clinical trials confirmed the safety in the short term of reducing radiation dose but even at the lower doses of radiation, a single dose of carboplatin demonstrated significant less acute toxicity and in medium term follow-up demonstrated 78% reduction of contralateral germ cell cancer and was not associated with increased pelvic lymphnode metastasis. Further phase two studies using risk adapted strategies demonstrated the feasibility of excluding 65% of patients needing to have chemotherapy. The data from the patients undergoing surveillance has demonstrated that the excess cardiovascular risk in late follow up of patients after radiation may in fact be partially due to testicular atrophy, a common concomitant of testicular germ cell cancer. On the basis of these results, combined trials of testis conservation to conserve germinal and endocrine function combined with single agent carboplatin has emerged as the next challenge for the future trials.