Contemporary surgical management of testicular seminoma
Review Article

Contemporary surgical management of testicular seminoma

Rachel Passarelli1, John L. Pfail1, Thomas L. Jang2

1Division of Urology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA; 2Division of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA

Contributions: (I) Conception and design: R Passarelli, TL Jang; (II) Administrative support: TL Jang; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: R Passarelli, JL Pfail; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Thomas L. Jang, MD, MPH, FACS. Chief of Urologic Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, Suite 4565, New Brunswick, NJ 08901, USA. Email: jangtl@cinj.rutgers.edu.

Abstract: 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.

Keywords: Testicular seminoma; retroperitoneal lymph node dissection (RPLND); surgical management; urologic oncology

Submitted Feb 18, 2024. Accepted for publication Jun 14, 2024. Published online Aug 02, 2024.

doi: 10.21037/tcr-24-241

Introduction

Background

Testis cancer is the most common solid malignancy in young males aged 15 to 44 years, with approximately 9,760 predicted new diagnoses and 500 deaths estimated in the United States in 2024 (1). Testicular germ cell tumors (GCTs) are divided into two distinct histologic categories with differing managements strategies: seminomas, which encompasses about 60% of all GCTs and non-seminomas, which comprise the remaining 40% (2). Management following radical orchiectomy is dictated by histologic diagnosis, pathologic stage of the primary tumor, and clinical staging of the retroperitoneum and beyond to exclude regional and/or metastatic disease. Testicular cancers are staged according to the American Joint Committee on Cancer (AJCC) staging system, which is derived from the TNMS (tumor, node, metastasis, serum markers) Staging Classification (Tables 1,2) (3). Broadly, tumors that are confined to the testicle are considered AJCC stage I, those with regional lymph node involvement are classified as AJCC stage II, and those with distant metastasis or non-regional lymph node involvement are categorized as AJCC stage III (4). The International Germ Cell Cancer Collaborative Group (IGCCCG) originally devised a classification system in 1997 that incorporates disease extent and serum tumor marker levels post-orchiectomy that classifies patients with GCTs into good-, intermediate- and poor-risk groups (Table 3). This model, which was updated in 2021 to include contemporary patients with metastatic GCTs, provides prognostic information and guides therapy for patients, particularly with advanced disease (5). In general, patients with seminoma are classified as either good-risk or intermediate-risk.

Table 1

TNMS staging criteria for testicular seminoma (3)

Stage Criteria
Clinical T Primary tumor
   cTX Primary tumor cannot be assessed
   cT0 No evidence of primary tumor
   cTis Germ cell neoplasia in situ
   cT4 Tumor invades scrotum with or without vascular/lymphatic invasion
Pathological T Primary tumor
   pTX Primary tumor cannot be assessed
   pT0 No evidence of primary tumor
   pTis Germ cell neoplasia in situ
   pT1 Tumor limited to testis (including rete testis invasion) without lymphovascular invasion
   pT1a Tumor smaller than 3 cm in size
   pT1b Tumor 3 cm or larger in size
   pT2 Tumor limited to testis (including rete testis invasion) with lymphovascular invasion
OR
Tumor invading hilar soft tissue or epididymis or penetrating visceral mesothelial layer, covering the external surface of tunica albuginea with or without lymphovascular invasion
   pT3 Tumor directly invades spermatic cord soft tissue with or without lymphovascular invasion
   pT4 Tumor invades scrotum with or without lymphovascular invasion
Clinical N Regional lymph nodes
   cNX Regional lymph nodes cannot be assessed
   cN0 No regional lymph node metastasis
   cN1 Metastasis with a lymph node mass 2 cm or smaller in greatest dimension
OR
Multiple lymph nodes, none larger than 2 cm in greatest dimension
   cN2 Metastasis with a lymph node mass larger than 2 cm but not larger than 5 cm in greatest dimension
OR
Multiple lymph nodes, any one mass larger than 2 cm but not larger than 5 cm in greatest dimension
   cN3 Metastasis with a lymph node mass larger than 5 cm in greatest dimension
Pathological N Regional lymph nodes
   pNX Regional lymph nodes cannot be assessed
   pN0 No regional lymph node metastasis
   pN1 Metastasis with a lymph node mass 2 cm or smaller in greatest dimension and less than or equal to five nodes positive, none larger than 2 cm in greatest dimension
   pN2 Metastasis with a lymph node mass larger than 2 cm but not larger than 5 cm in greatest dimension; or more than five nodes positive, none larger than 5 cm; or evidence of extra nodal extension of tumor
   pN3 Metastasis with a lymph node mass larger than 5 cm in greatest dimension
M Distant metastasis
   M0 No distant metastases
   M1 Distant metastases
   M1a Non-retroperitoneal nodal or pulmonary metastases
   M1b Non-pulmonary visceral metastases
S Serum markers
   SX Marker studies not available or not performed
   S0 Marker study levels within normal limits
   S1 LDH <1.5 × normal and hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000
   S2 LDH 1.5–10 × normal or hCG (mIU/mL) 5,000–50,000 or AFP (ng/mL) 1,000–10,000
   S3 LDH >10 × normal or hCG (mIU/mL) >50,000 or AFP (ng/mL) >10,000

TNMS, tumor, node, metastasis, serum markers; LDH, lactate dehydrogenase; hCG, human chorionic gonadotropin; AFP, alpha-fetoprotein.

Table 2

American Joint Committee on Cancer prognostic stage groups for testicular seminoma (3)

Stage T N M S
Stage 0 pTis N0 M0 S0
Stage I pT1–T4 N0 M0 SX
Stage IA pT1 N0 M0 S0
Stage IB pT2 N0 M0 S0
pT3 N0 M0 S0
pT4 N0 M0 S0
Stage IS Any pT/TX N0 M0 S1–3
Stage II Any pT/TX N1–3 M0 SX
Stage IIA Any pT/TX N1 M0 S0
Any pT/TX N1 M0 S1
Stage IIB Any pT/TX N2 M0 S0
Any pT/TX N2 M0 S1
Stage IIC Any pT/TX N3 M0 S0
Any pT/TX N3 M0 S1
Stage III Any pT/TX Any N M1 SX
Stage IIIA Any pT/TX Any N M1a S0
Any pT/TX Any N M1a S1
Stage IIIB Any pT/TX N1–3 M0 S2
Any pT/TX Any N M1a S2
Stage IIIC Any pT/TX N1–3 M0 S3
Any pT/TX Any N M1a S3
Any pT/TX Any N M1b Any S

Table 3

International Germ Cell Cancer Collaborative Group risk stratification for testicular seminoma (5)

Risk status Nonseminoma Seminoma
Good risk Testicular or retroperitoneal primary tumor Any primary site
AND AND
No nonpulmonary visceral metastases No nonpulmonary visceral metastases
AND AND
Post-orchiectomy markers—all of: Normal AFP
AFP <1,000 ng/mL Any hCG
hCG <5,000 IU/L Any LDH†
LDH <1.5 × upper limit of normal
Intermediate risk Testicular or retroperitoneal primary tumor Any primary site
AND AND
No nonpulmonary visceral metastases Nonpulmonary visceral metastases
AND AND
Post-orchiectomy markers—any of: Normal AFP
AFP 1,000–10,000 ng/mL Any hCG
hCG 5,000–50,000 IU/L Any LDH
LDH 1.5–10 × upper limit of normal
Poor risk Mediastinal primary tumor No patients classified as poor prognosis
OR
Nonpulmonary visceral metastases
OR
Post-orchiectomy markers—any of:
AFP >10,000 ng/mL
hCG >50,000 IU/L
LDH >10 × upper limit of normal

†, patients with good-risk disseminated seminoma with LDH >2.5 × upper limit of normal have a worse prognosis than other good-risk patients. However, there are insufficient data to recommend treating these patients differently based on LDH alone and the risk categorization remains the same (5). AFP, alpha-fetoprotein; hCG, human chorionic gonadotropin; LDH, lactate dehydrogenase.

Rationale and knowledge gap

Patterns for disseminated testicular cancer are predictable and reproducible, initially metastasizing to the retroperitoneum before metastasizing to the lungs or other viscera. As seminomas are exquisitely sensitive to radiation therapy and platinum-based chemotherapy, traditional post-orchiectomy treatment strategies are AJCC-stage and IGCCC-risk dependent, and include surveillance, chemotherapy, radiation, or surgery. Though chemotherapy and radiation therapy are well-established options to reduce relapse rates in early-stage seminoma (clinical stage I) and to treat those with low-volume disseminated disease (clinical stage IIA/IIB), these therapies may be associated with long-term toxicities in this distinctively young population. Therefore, management strategies have focused on survivorship.

Objective

In this review, we discuss the contemporary stage- and risk-dependent management for patients with testicular seminomas and outline indications to consider surgery in men with metastatic seminoma.

Management of early-stage seminoma (clinical stage I)

The management of stage I seminoma has evolved over time. Acceptable treatment options following orchiectomy currently include surveillance, adjuvant radiotherapy, or adjuvant single-agent carboplatin chemotherapy. According to the American Urological Association (AUA) and the National Comprehensive Cancer Network (NCCN) clinical practice guidelines on Testicular Cancer, surveillance is the preferred management approach after radical orchiectomy (3,6).

Surveillance presents the best option for patients to avoid treatment-related morbidity from chemotherapy or radiation and confers an 80% to 85% relapse-free rate after orchiectomy alone. For the 15% to 20% of patients who relapse on initial surveillance, cancer-specific survival after subsequent treatment is similar to those treated with up-front chemotherapy or radiation (7,8).

The factor most associated with increased risk of relapse in patients with stage I seminoma is increased size of the primary tumor. Though there is a size-dependent increase in risk of relapse, a cutoff of 3 cm was arbitrarily chosen to subcategorize stage I seminomas given the wide variation of size reported in the literature (4,9,10). Rete testis invasion is another factor that has been associated with risk of relapse in stage I seminoma in some studies, though its prognostic significance has not been universally corroborated (11). As a result, the NCCN guidelines do not advise risk-adapted management of men with stage I seminoma but instead, strongly recommend surveillance (3). The absence of both factors portend a low risk of recurrence, approximately 6% (12).

The 5-year relapse-free survival rates for patients who receive 1 or 2 cycles of adjuvant single-agent carboplatin is about 95% and 97%, respectively (10,12,13). Though platinum-based chemotherapy is associated with increased risk of secondary malignancies and cardiac toxicity, the intermediate- and long-term risks from single-agent carboplatin are not yet known (14).

Radiation therapy confers excellent oncologic outcomes for stage I seminoma patients. In a large randomized phase III trial comparing carboplatin to radiation therapy for men with stage I seminoma, 4-year relapse rates between chemotherapy versus radiation were similar (97.7% versus 96.7%, respectively) (13). However, the risk of secondary malignancies in patients receiving radiotherapy for stage I seminoma is well documented and the low overall risk of relapse without adjuvant treatment in these patients needs to be considered and weighed against the potential long-term toxicities of radiotherapy (15).

Management of early disseminated seminoma (clinical stage IIA and IIB)

Men with stage II seminoma comprise roughly 15% to 20% of seminoma patients and for patients with low-volume stage II disease (IIA/IIB), radiation therapy or primary chemotherapy [3 cycles of bleomycin, etoposide, cisplatin (BEP) or 4 cycles of etoposide, cisplatin (EP)] have traditionally been the mainstay of treatment (3).

Historically, radiotherapy was the backbone of treatment for patients with low-volume retroperitoneal disease. In a seminal prospective multicenter trial, Classen and co-investigators followed 87 patients with stage II seminoma (66 stage IIA and 21 stage IIB) after radiotherapy and found that at a median follow-up of 70 months, relapse-free survival was 95% and 89% in the IIA and IIB cohorts, respectively. All relapses were managed with salvage platinum-based chemotherapy successfully, leading to disease-specific survivals approaching 100% (16).

Primary induction chemotherapy has been shown to be similarly effective. Garcia-del-Muro et al. prospectively evaluated 72 patients, 18 with stage IIA and 54 with stage IIB disease, to assess response to platinum-based chemotherapy regimens. After a median follow-up of 71.5 months, the 5-year progression-free survival (PFS) rates for men with stage IIA or IIB disease were 100% and 87%, respectively. Five-year PFS and overall survival (OS) rates for the entire cohort were 90% and 95%, respectively (17).

While radiotherapy and chemotherapy have excellent cure rates, they may both be associated with significant long-term toxicities. Multiple studies highlight cardiac toxicity in patients who received radiotherapy, chemotherapy, or a combination. Haugnes and colleagues assessed cardiovascular disease in patients who received chemotherapy, radiation or a combination of chemotherapy and radiation when compared to surgery alone. In their cohort of 990 patients, the risk of atherosclerotic disease was 2.3-, 2.6-, and 4.8-fold higher for radiotherapy, chemotherapy, or combination therapy, respectively, when compared to patients managed with surgery alone. Furthermore, patients treated with BEP alone were shown to have a 5.7 higher risk of cardiovascular disease compared to surgery only patients, and a 3.1-fold higher risk of myocardial infarction compared to controls from the general population (18). Secondary malignancy in the prior radiation field as well as secondary leukemia are also risks in this patient population (19,20). Given these concerns of long-term toxicities in this young population where long-term survival is an expectation, treatment strategies have focused on minimizing morbidity.

Primary retroperitoneal lymph node dissection (RPLND) has been proposed as an alternate treatment option for patients with low-volume metastatic seminoma given its well-established efficacy, safety, and few long-term complications in the treatment of men with nonseminomatous GCTs (NSGCTs). Similar to NSGCTs, dissemination patterns for testicular seminoma are very predictable, reliably metastasizing via the lymphatic system to the retroperitoneum before systemic metastasis to the lung, non-regional lymph nodes or other viscera. In men with low-volume clinical stage II NSGCT, RPLND is curative in a substantial proportion of patients, with relapses successfully salvaged by chemotherapy in most instances, resulting in OS rates nearing 100%. Primary RPLND in this setting provides the most accurate staging and can direct the need and consideration for additional adjuvant therapies. Additionally, the incidence of short-term complications after primary RPLND is relatively low, and RPLND is associated with very few long-term complications when compared to chemotherapy or radiation (21,22). The main long-term complication after RPLND is ejaculatory dysfunction (23). However, with contemporary nerve-sparing techniques and performance of RPLND at high-volume centers, immediate morbidity associated with surgery is low and antegrade ejaculation can be preserved in approximately 90% of patients (24,25). Though the data is emerging, RPLND may offer similar efficacy for men with low-volume metastatic seminoma similar to men with low-volume metastatic NSGCT.

A retrospective study in 1997 by Warszawski and Schmucking evaluated 63 patients with clinical stage I or II seminoma who underwent RPLND (26). At a median follow-up of 79 months, they found that RPLND provided relatively similar disease control compared to radiation therapy with respect to in-field, retroperitoneal recurrences. However, relapse rates after RPLND in this setting increased with larger nodal burden, with relapse rates of 4.1% in clinical stage I disease compared to relapse rates of 58.3% for clinical stage IIC disease (26).

Other retrospective studies report encouraging oncologic efficacy for RPLND as primary treatment for low-volume metastatic seminoma. Mezvrishvili and Managadze evaluated 14 patients with pure seminoma (10 high-risk stage I and 4 with stage IIA disease) who underwent primary RPLND. At a mean follow-up of 56 months, all patients were disease free with preservation of antegrade ejaculation (27). Hu and colleagues reported on 4 patients who underwent primary RPLND (3 for IIA seminoma and 1 for IIB seminoma) with no evidence of disease recurrence or complications at 25-month follow-up and maintenance of antegrade ejaculation (28).

The role of primary RPLND for patients with low-volume metastatic seminoma has been clarified recently through data from several prospective clinical trials. The SEMS (Surgery in Early Metastatic Seminoma) Trial is a multi-institutional phase 2 clinical trial that assessed 55 patients from 12 institutions with low volume (<3 cm) metastatic seminoma who received open primary RPLND as treatment. Two-year recurrence-free survival (RFS) of 81% and OS of 100% was observed at a median follow-up 33 months. Only 4 patients (7%) experienced long-term complications, which included incisional hernia or anejaculation. Men who recurred in this trial were successfully treated with additional surgery or chemotherapy (29). The PRIMETEST trial is a phase 2 single-arm, single-center trial evaluating the oncologic efficacy and safety of primary RPLND (open or robotic) for patients with seminoma and unilateral retroperitoneal lymph node metastasis (<5 cm). A total of 33 patients with low volume (<5 cm) disease undergoing primary RPLND or RPLND for recurrence after surveillance or after one dose of carboplatin therapy were included. Though the primary end point of PFS after 36 months was not met,a PFS of 70% after a median follow-up of 32 months was observed. All recurrences were effectively treated with systemic therapy (30). Finally, the COTRIMS (Cologne Trial of Retroperitoneal Lymphadenectomy In Metastatic Seminoma) trial is a prospective, single-arm, clinical phase 2 trial including clinical stage IIA/B seminoma patients evaluating RFS and OS as well as complications after open or robotic RPLND. Thirty patients underwent primary RPLND for stage IIA (n=19) or IIB (n=11) seminoma. At 20-month follow-up, RFS was 90%, with 13% (4 patients) experiencing a Clavien 3a or higher complication (31).

Although inclusion criteria such as extent of disease (size and number of lymph nodes), surgical approach (open or robotic) and template of node dissection varied among these trials, the data collectively demonstrate that primary RPLND can be performed safely, effectively, and with minimal morbidity in patients with low-volume metastatic seminoma. Furthermore, the low percentage of patients who relapse after primary RPLND can be successfully salvaged with chemotherapy or additional surgery. Primary RPLND should be considered as another viable treatment option for patients with low-volume metastatic disease (stage IIA seminoma and select patients with stage IIB seminoma).

Management of advanced-stage seminoma (clinical stage IIC and III)

Patients with advanced-stage seminoma (stage IIC or stage III) are categorized as either good- or intermediate-risk according to IGCCCG risk stratification. For patients with good-risk disease, 3 cycles of BEP or 4 cycles of EP are appropriate primary induction chemotherapy regimens. Patients with intermediate-risk disease should receive 4 cycles of BEP or 4 cycles of cisplatin, etoposide, ifosfamide (VIP) in patients who cannot tolerate bleomycin. There is currently minimal to no role for upfront primary surgery in men with advanced-stage seminoma (3,32).

Following induction chemotherapy for large volume metastatic seminoma, all patients should undergo serum tumor marker measurements and computed tomography (CT) imaging of the chest, abdomen, and pelvis to assess for residual masses. Residual mass can be detected in at least 40% of patients, however, with surveillance alone 50% will spontaneously resolve in the following year (33). Surveillance should be considered post chemotherapy for patients with no residual mass or a residual mass less than or equal to 3 cm and serum tumor marker normalization. For patients with a residual mass greater than 3 cm, a fludeoxyglucose (FDG)-positron emission tomography (PET) scan should be performed at least 6 to 8 weeks after the last cycle of chemotherapy was completed. A cutoff of 3 cm was determined based on data showing that in patients with masses <3 cm, viable tumor was present in 3%, compared to 27% in masses >3 cm (34).

Historically FDG-PET scans were the imaging of choice for post chemotherapy monitoring as a result of the SEMPET trial, which demonstrated an 80% sensitivity, 100% specificity, 100% positive predictive value (PPV) and 96% negative predictive value (NPV) with increasing sensitivity in post chemotherapy residual masses >3 cm (35). However, more recent studies have found FDG-PET imaging to have a low PPV for vital tumor in residual masses post chemotherapy in those with metastatic seminoma, with PPVs ranging from 23% to 67%, despite a high sensitivity and NPV (36,37).

The management for residual masses deemed concerning on imaging for viable tumor is either surgical treatment with RPLND, if feasible, or salvage chemotherapy. Typically, 90% of residual masses in this setting are histologically necrosis with only 10% composed of viable GCT. Post chemotherapy RPLND in the seminoma population is technically challenging secondary to chemotherapy-induced desmoplasia that results in an operating field with intense fibrosis and altered tissue planes, which can result in incomplete resection or microscopic disease at the resection margin (38). Complete resections in this setting are reported in only up to 75% of patients (33,39,40). Of patients undergoing post chemotherapy RPLND, 38% have been shown to require adjunctive procedures such as nephrectomy, inferior vena cava resection, arterial grafts, small bowel resections and hepatic resections with post operative complications reaching as high as 25% (38). Prognosis for these patients is unfavorable even after surgical resection. A retrospective single institution database review suggested 5-year cancer-specific survival in this patient population was only 54% with a mean post RPNLD time to death of only 6.8 months. Only 25% of patients remained recurrence free, of which 44% required additional chemotherapy (41). Salvage chemotherapy is the alternative treatment to patients who do not undergo post chemotherapy RPLND. In patients receiving second-line vinblastine, ifosfamide, cisplatin (VeIP), 83% achieved complete remission with 40% subsequently relapsing and only 54% surviving long term (42). As the prognosis is guarded in all patients with persistent disease following chemotherapy regardless of subsequent treatment pathway, patient-specific factors are important considerations and a multidisciplinary approach is critical to reaching a consensus on a therapeutic plan.

Discussion

Overall, we provide a comprehensive review of stage and risk dependent management of testicular seminoma with attention to considerations for surgical intervention. We include both a discussion of all the currently available prospective clinical trial data in this space, as well as the relevant and best available quality retrospective data on this topic. A limitation is that the prospective trial data presented included different inclusion criteria, surgical templates (bilateral template versus modified template), and surgical approach (open versus robotic). Additionally, secondary to the relative rarity of the disease, the retrospective data presented in this review included fairly small samples without comparative arms.

Conclusions

Men with low-volume metastatic testicular seminoma have historically been treated with primary induction chemotherapy or radiation therapy. Because of the long-term toxicities related to these traditional therapies, primary RPLND has been proposed for well selected patients with low-volume metastatic seminoma and its efficacy and safety have been confirmed in several prospective clinical trials (SEMS, COTRIMS, PRIMETEST). Finally, though the role of surgical resection of a residual mass post-chemotherapy in men with advanced-stage seminoma is limited, a subset of men with viable tumor suggested on imaging may benefit from resection if technically feasible.

Acknowledgments

Funding: The work from the Cancer Institute of New Jersey was supported by a grant from the National Cancer Institute (No. P30CA072720).

Footnote

Peer Review File: Available at https://tcr.amegroups.com/article/view/10.21037/tcr-24-241/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-24-241/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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References

  1. Siegel RL, Giaquinto AN, Jemal A. Cancer statistics, 2024. CA Cancer J Clin 2024;74:12-49. [Crossref] [PubMed]
  2. Rajpert-De Meyts E, McGlynn KA, Okamoto K, et al. Testicular germ cell tumours. Lancet 2016;387:1762-74. [Crossref] [PubMed]
  3. NCCN. Testicular Cancer (Version 1.2023). 2023; Available online: https://www.nccn.org/professionals/physician_gls/pdf/testicular.pdf
  4. Amin MB, Greene FL, Edge SB, et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging. CA Cancer J Clin 2017;67:93-9.
  5. Beyer J, Collette L, Sauvé N, et al. Survival and New Prognosticators in Metastatic Seminoma: Results From the IGCCCG-Update Consortium. J Clin Oncol 2021;39:1553-62. [Crossref] [PubMed]
  6. Stephenson A, Bass EB, Bixler BR, et al. Diagnosis and Treatment of Early-Stage Testicular Cancer: AUA Guideline Amendment 2023. J Urol 2024;211:20-5. [Crossref] [PubMed]
  7. Kollmannsberger C, Tyldesley S, Moore C, et al. Evolution in management of testicular seminoma: population-based outcomes with selective utilization of active therapies. Ann Oncol 2011;22:808-14. [Crossref] [PubMed]
  8. Tandstad T, Smaaland R, Solberg A, et al. Management of seminomatous testicular cancer: a binational prospective population-based study from the Swedish norwegian testicular cancer study group. J Clin Oncol 2011;29:719-25. [Crossref] [PubMed]
  9. Warde P, Specht L, Horwich A, et al. Prognostic factors for relapse in stage I seminoma managed by surveillance: a pooled analysis. J Clin Oncol 2002;20:4448-52. [Crossref] [PubMed]
  10. Aparicio J, Maroto P, del Muro XG, et al. Risk-adapted treatment in clinical stage I testicular seminoma: the third Spanish Germ Cell Cancer Group study. J Clin Oncol 2011;29:4677-81. [Crossref] [PubMed]
  11. Zengerling F, Kunath F, Jensen K, et al. Prognostic factors for tumor recurrence in patients with clinical stage I seminoma undergoing surveillance-A systematic review. Urol Oncol 2018;36:448-58. [Crossref] [PubMed]
  12. Aparicio J, Germà JR, García del Muro X, et al. Risk-adapted management for patients with clinical stage I seminoma: the Second Spanish Germ Cell Cancer Cooperative Group study. J Clin Oncol 2005;23:8717-23. [Crossref] [PubMed]
  13. Oliver RT, Mead GM, Rustin GJ, et al. Randomized trial of carboplatin versus radiotherapy for stage I seminoma: mature results on relapse and contralateral testis cancer rates in MRC TE19/EORTC 30982 study (ISRCTN27163214). J Clin Oncol 2011;29:957-62. [Crossref] [PubMed]
  14. van den Belt-Dusebout AW, de Wit R, Gietema JA, et al. Treatment-specific risks of second malignancies and cardiovascular disease in 5-year survivors of testicular cancer. J Clin Oncol 2007;25:4370-8. [Crossref] [PubMed]
  15. Horwich A, Fossa SD, Huddart R, et al. Second cancer risk and mortality in men treated with radiotherapy for stage I seminoma. Br J Cancer 2014;110:256-63. [Crossref] [PubMed]
  16. Classen J, Schmidberger H, Meisner C, et al. Radiotherapy for stages IIA/B testicular seminoma: final report of a prospective multicenter clinical trial. J Clin Oncol 2003;21:1101-6. [Crossref] [PubMed]
  17. Garcia-del-Muro X, Maroto P, Gumà J, et al. Chemotherapy as an alternative to radiotherapy in the treatment of stage IIA and IIB testicular seminoma: a Spanish Germ Cell Cancer Group Study. J Clin Oncol 2008;26:5416-21. [Crossref] [PubMed]
  18. Haugnes HS, Wethal T, Aass N, et al. Cardiovascular risk factors and morbidity in long-term survivors of testicular cancer: a 20-year follow-up study. J Clin Oncol 2010;28:4649-57. [Crossref] [PubMed]
  19. Hallemeier CL, Pisansky TM, Davis BJ, et al. Long-term outcomes of radiotherapy for stage II testicular seminoma--the Mayo Clinic experience. Urol Oncol 2013;31:1832-8. [Crossref] [PubMed]
  20. Kollmannsberger C, Beyer J, Droz JP, et al. Secondary leukemia following high cumulative doses of etoposide in patients treated for advanced germ cell tumors. J Clin Oncol 1998;16:3386-91. [Crossref] [PubMed]
  21. Subramanian VS, Nguyen CT, Stephenson AJ, et al. Complications of open primary and post-chemotherapy retroperitoneal lymph node dissection for testicular cancer. Urol Oncol 2010;28:504-9. [Crossref] [PubMed]
  22. Cahill E, Chua KJ, Doppalapudi SK, et al. Contemporary analysis of complications after retroperitoneal lymph node dissection: Data from the National Surgical Quality Improvement Program 2006-2018. J Clin Oncol 2023;41:416. [Crossref]
  23. Beck SD, Bey AL, Bihrle R, et al. Ejaculatory status and fertility rates after primary retroperitoneal lymph node dissection. J Urol 2010;184:2078-80. [Crossref] [PubMed]
  24. Donohue JP, Thornhill JA, Foster RS, et al. Clinical stage B non-seminomatous germ cell testis cancer: the Indiana University experience (1965-1989) using routine primary retroperitoneal lymph node dissection. Eur J Cancer 1995;31A:1599-604. [Crossref] [PubMed]
  25. Nonomura N, Nishimura K, Takaha N, et al. Nerve-sparing retroperitoneal lymph node dissection for advanced testicular cancer after chemotherapy. Int J Urol 2002;9:539-44. [Crossref] [PubMed]
  26. Warszawski N, Schmücking M. Relapses in early-stage testicular seminoma: radiation therapy versus retroperitoneal lymphadenectomy. Scand J Urol Nephrol 1997;31:355-9. [Crossref] [PubMed]
  27. Mezvrishvili Z, Managadze L. Retroperitoneal lymph node dissection for high-risk stage I and stage IIA seminoma. Int Urol Nephrol 2006;38:615-9. [Crossref] [PubMed]
  28. Hu B, Shah S, Shojaei S, et al. Retroperitoneal Lymph Node Dissection as First-Line Treatment of Node-Positive Seminoma. Clin Genitourin Cancer 2015;13:e265-9. [Crossref] [PubMed]
  29. Daneshmand S, Cary C, Masterson T, et al. Surgery in Early Metastatic Seminoma: A Phase II Trial of Retroperitoneal Lymph Node Dissection for Testicular Seminoma With Limited Retroperitoneal Lymphadenopathy. J Clin Oncol 2023;41:3009-18. [Crossref] [PubMed]
  30. Hiester A, Che Y, Lusch A, et al. Phase 2 Single-arm Trial of Primary Retroperitoneal Lymph Node Dissection in Patients with Seminomatous Testicular Germ Cell Tumors with Clinical Stage IIA/B (PRIMETEST). Eur Urol 2023;84:25-31. [Crossref] [PubMed]
  31. Heidenreich A, Paffenholz P, Hartmann F, et al. Retroperitoneal Lymph Node Dissection in Clinical Stage IIA/B Metastatic Seminoma: Results of the COlogne Trial of Retroperitoneal Lymphadenectomy In Metastatic Seminoma (COTRIMS). Eur Urol Oncol 2024;7:122-7. [Crossref] [PubMed]
  32. Albers P, Albrecht W, Algaba F, et al. EAU guidelines on testicular cancer: 2011 update. Eur Urol 2011;60:304-19. [Crossref] [PubMed]
  33. Ravi R, Ong J, Oliver RT, et al. The management of residual masses after chemotherapy in metastatic seminoma. BJU Int 1999;83:649-53. [Crossref] [PubMed]
  34. Puc HS, Heelan R, Mazumdar M, et al. Management of residual mass in advanced seminoma: results and recommendations from the Memorial Sloan-Kettering Cancer Center. J Clin Oncol 1996;14:454-60. [Crossref] [PubMed]
  35. De Santis M, Becherer A, Bokemeyer C, et al. 2-18fluoro-deoxy-D-glucose positron emission tomography is a reliable predictor for viable tumor in postchemotherapy seminoma: an update of the prospective multicentric SEMPET trial. J Clin Oncol 2004;22:1034-9. [Crossref] [PubMed]
  36. Cathomas R, Klingbiel D, Bernard B, et al. Questioning the Value of Fluorodeoxyglucose Positron Emission Tomography for Residual Lesions After Chemotherapy for Metastatic Seminoma: Results of an International Global Germ Cell Cancer Group Registry. J Clin Oncol 2018; Epub ahead of print. [Crossref] [PubMed]
  37. Lewis DA, Tann M, Kesler K, et al. Positron emission tomography scans in postchemotherapy seminoma patients with residual masses: a retrospective review from Indiana University Hospital. J Clin Oncol 2006;24:e54-5. [Crossref] [PubMed]
  38. Mosharafa AA, Foster RS, Leibovich BC, et al. Is post-chemotherapy resection of seminomatous elements associated with higher acute morbidity? J Urol 2003;169:2126-8. [Crossref] [PubMed]
  39. Flechon A, Bompas E, Biron P, et al. Management of post-chemotherapy residual masses in advanced seminoma. J Urol 2002;168:1975-9. [Crossref] [PubMed]
  40. Herr HW, Sheinfeld J, Puc HS, et al. Surgery for a post-chemotherapy residual mass in seminoma. J Urol 1997;157:860-2. [Crossref] [PubMed]
  41. Rice KR, Beck SD, Bihrle R, et al. Survival analysis of pure seminoma at post-chemotherapy retroperitoneal lymph node dissection. J Urol 2014;192:1397-402. [Crossref] [PubMed]
  42. Miller KD, Loehrer PJ, Gonin R, et al. Salvage chemotherapy with vinblastine, ifosfamide, and cisplatin in recurrent seminoma. J Clin Oncol 1997;15:1427-31. [Crossref] [PubMed]
Cite this article as: Passarelli R, Pfail JL, Jang TL. Contemporary surgical management of testicular seminoma. Transl Cancer Res 2024;13(11):6463-6472. doi: 10.21037/tcr-24-241

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