Editing Germ Cell Tumours (section)

===== CSIA and IB Seminoma =====

* '''<span style="color:#ff0000">Options (3):</span>'''
** '''<span style="color:#ff0000">Preferred (1): surveillance</span>'''
** '''<span style="color:#ff0000">Alternatives (2):</span>'''
**# '''<span style="color:#ff0000">Adjuvant primary radiotherapy (20 Gy to the para-aortic region)</span>'''
**# '''<span style="color:#ff0000">Adjuvant primary chemotherapy with single-agent carboplatin (1 cycle)</span>'''
** '''<span style="color:#ff0000">Both 2019 AUA and 2010 CUA guidelines recommend surveillance, adjuvant as an alternative</span>'''
*** '''If adjuvant treatment is chosen'''
**** '''CUA recommends radiotherapy over chemotherapy'''
**** '''EAU recommends against radiotherapy'''
**** '''SWONTECA recommends radiotherapy only if chemotherapy not suitable'''
** Long-term survival rates approaching 100% for each approach
** '''<span style="color:#ff0000">Surveillance for clinical stage I seminoma</span>'''
*** 80-85% of patients with clinical stage I seminoma achieve cure with radical orchiectomy alone
*** Protocol varies by institution, no consensus
**** History and physical examination: every 4-6 months for the first 2 years, and then every 6-12 months in years 3-5.
**** Cross-sectional imaging of the abdomen with or without the pelvis: every 4-6 months for the first 2 years, and then every 6-12 months in years 3-5.
**** Imaging of the chest and serum tumor marker assessment can be obtained as clinically indicated.
***** Compared with NSGCT, surveillance for CS I seminoma is complicated by the limited utility of serum tumor markers to detect relapse
*** '''<span style="color:#ff0000">Risk factors for relapse on surveillance (2):</span>'''
**** '''<span style="color:#ff0000">Tumor size >4 cm</span>'''
**** '''<span style="color:#ff0000">Rete testis invasion</span>'''
*** Patients who relapse on surveillance should be fully restaged and treated based on their TNM-s status.
** '''Adjuvant primary radiotherapy'''
*** Delivered as dog-leg (retroperitoneum and ipsilateral pelvis) vs. para-aortic region
**** Dog-leg
***** Outcomes
****** In-field recurrence after dog-leg radiotherapy occurs in <1%.
******* Most common sites of recurrence are the thorax and left supraclavicular fossa.
******* Virtually all recurrences are cured with first-line chemotherapy.
****** Persistent oligospermia after dog-leg radiotherapy occurs in 8%
***** Advantage
****** Does not require serial follow-up CT imaging after treatment
**** Para-aortic
***** Advantage
****** Smaller field and dose.
***** Disadvantage
****** Requires serial follow-up CT imaging after treatment
**** Dog-leg vs. para-aortic
***** RTC found para-aortic to be non-inferior to dog-leg radiotherapy in CSI seminoma[https://pubmed.ncbi.nlm.nih.gov/21212385/ §]
** '''Adjuvant primary chemotherapy'''
*** Cisplatin is inferior to carboplatin for CSI seminoma
*** Patients require serial follow-up CT imaging