Seminoma: Stage II
Patients with Stage II testicular seminoma have a curable cancer that involves the testis and the retroperitoneal lymph nodes. Retroperitoneal lymph node involvement is further characterized by the number of nodes involved and the size of involved nodes. Patients with Stage II seminoma are often divided into “bulky” and “non-bulky” for treatment planning.
The primary treatment of Stage II seminoma is surgical removal of the cancer by orchiectomy followed by adjuvant therapy to reduce the risk of cancer recurrence.
The following is a general overview of treatment for Stage II seminoma. Cancer treatment may consist of surgery, radiation, chemotherapy, targeted therapy, or a combination of these treatment techniques. Combining two or more of these treatment techniques–called multi-modality care–has become an important approach for increasing a patient’s chance of cure and prolonging survival.
In some cases, participation in a clinical trial utilizing new, innovative therapies may provide the most promising treatment. Treatments that may be available through clinical trials are discussed in the section titled Strategies to Improve Treatment.
Circumstances unique to each patient’s situation influence which treatment or treatments are utilized. The potential benefits of multi-modality care, participation in a clinical trial, or standard treatment must be carefully balanced with the potential risks. The information on this Web site is intended to help educate patients about their treatment options and to facilitate a mutual or shared decision-making process with their treating cancer physician.
It is important to understand that some patients with Stage II seminoma already have small amounts of cancer that have spread into the lymph nodes and cannot be detected with any of the currently available tests. Undetectable areas of cancer that remain after surgery are referred to as micrometastases. The presence of micrometastases causes cancer recurrence following treatment with surgery alone. An effective treatment is needed to cleanse the body of micrometastases in order to improve a patient’s duration of survival and potential for cure.
The delivery of cancer treatment following local treatment with surgery is referred to as “adjuvant” therapy and may include chemotherapy or radiation therapy. Following orchiectomy, 15-50% of patients will experience cancer recurrence if they are not treated with adjuvant therapy. By administering chemotherapy or radiation therapy to the retroperitoneal and inguinal lymph nodes after surgery, the chance of cancer recurrence can almost be completely eliminated. The choice of receiving radiation therapy or chemotherapy is influenced by side effects, convenience and whether the cancer is bulky.
Patients with non-bulky disease have cancers involving the lymph nodes that are less than 5 centimeters (2 inches) in greatest dimension measured on a computed tomography (CT) scan. The standard treatment for non-bulky cancers consists of radiation to the retroperitoneal lymph nodes following surgical orchiectomy. This results in a cure rate of more than 90%. One of the controversies in management of Stage II seminoma is how much surveillance is necessary in patients who have received radiation therapy since the recurrence rate is so low.
Patients with bulky disease have cancers involving the lymph nodes that are greater than 5 centimeters (2 inches) in greatest dimension when measured on a CT scan. Standard therapy for bulky disease utilizes a Platinol® (cisplatin)-based combination chemotherapy regimen or radiation therapy to the abdominal and pelvic lymph nodes following surgical orchiectomy. In the past, patients with bulky disease were treated with radiation therapy and orchiectomy; however, one frequent cause of treatment failure in patients with bulky disease receiving radiation therapy was cancer recurrences outside the field of radiation. Because cancers recurred outside the radiation field, doctors began using chemotherapy, which is a systemic treatment capable of killing cancer cells throughout the body.
In a clinical study comparing 19 patients treated with chemotherapy to 16 patients treated with radiation therapy, the results indicated that none of the patients treated with chemotherapy experienced cancer recurrences, whereas 9 of the 16 patients treated with radiation therapy experienced recurrences.1 Chemotherapy without radiation may be the better treatment alternative for patients with bulky disease. Standard chemotherapy based on carefully controlled clinical studies consists of 3 cycles of bleomycin, etoposide and Platinol (BEP) or 4 cycles of etoposide and Platinol (EP).2
After completion of therapy, a residual mass in the location of the original cancer is often detected by CT, magnetic resonance imaging (MRI), or positron emission tomography (PET) scans. A residual mass may represent scar formation or inadequately treated cancer, and is best evaluated by PET scan at least 6 weeks after completing chemotherapy. If the PET scan is negative, routine follow up is indicated. If the PET scan is positive, there may be residual cancer and a biopsy is considered useful in order to determine the most appropriate course of action.2
Strategies to Improve Treatment
The progress that has been made in the treatment of testicular cancer has resulted from improved development of chemotherapy and radiation treatments in patients with more advanced stages of cancer and participation in clinical trials. Future progress in the treatment of testicular cancer will result from continued participation in appropriate clinical trials.
Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed. For more information, go to Managing Side Effects.
Adjuvant Therapy: Clinical trials are attempting to define the optimal role of chemotherapy and radiation therapy for patients with Stage II disease. Researchers are also attempting to decrease the short and long-term side effects of chemotherapy without decreasing survival.
1 Warde P, Gospodarowicz M, Panzarella T et al. Management of stage II seminoma. Journal of Clinical Oncology. 1998;16:290-294.
2 National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology.™ Testicular Cancer. V.2.2008. © National Comprehensive Cancer Network, Inc. 2008. NCCN and NATIONAL COMPREHENSIVE CANCER NETWORK are registered trademarks of National Comprehensive Cancer Network, Inc.