Editing Germ Cell Tumours (section)

===== CS IIA and IIB Seminoma =====

* ≈15-20% of patients with seminoma have CS II disease at diagnosis; 70% of these patients have CS IIA and IIB.
* '''<span style="color:#ff0000">CSIIA:</span>'''
** '''CUA: Dog-leg radiotherapy (25-35 Gy) preferred over first-line chemotherapy (BEP×3 or EP×4)'''
** '''AUA: radiotherapy or chemotherapy'''
* '''<span style="color:#ff0000">CSIIB:</span>'''
** '''CUA: depending on bulk of disease and location of lymph nodes, radiation or chemotherapy [good risk chemotherapy BEP×3 or EP×4] can be used.''' 
*** '''First-line chemotherapy is recommended for bulky (>3 cm) and/or multifocal retroperitoneal metastases'''
** '''AUA:'''
*** '''CSIIB with lymph node ≤3cm: radiotherapy or chemotherapy'''
*** '''CSIIB with lymph node >3cm: chemotherapy'''
* Routine surveillance CT imaging is unnecessary after complete resolution of disease.
*'''<span style="color:#ff00ff">Surgery in Early Metastatic Seminoma (SEMS) Trial</span>'''
**Study design: Phase II trial
**55 patients with pure testicular seminoma after radical orchiectomy with isolated retroperitoneal lymphadenopathy 1-3 cm in greatest dimension. 
***No more than 2 lymph nodes could be enlarged radiographically and lymph nodes needed to be within the ipsilateral RPLND template
***Lymph node enlargement could be synchronous (stage IIA or IIB) or metachronous (stage I with recurrence).
***Open RPLND was performed by certified surgeons who performed ≥8 open RPLND surgeries in the year before site initiation or at least 25 open RPLND surgeries with the past 3 years
**Primary outcome: 2-year relapse-free survival
**Results
***Median follow-up after RPLND: 33 months
***In post-RPLND follow-up, one patient received a single cycle of carboplatin for pN2, all other patients were managed with surveillance
***Pathological nodal stage
****pN0: 16%
****pN1: 22%
****pN2: 56%
****pN3: 5%
***2-year relapse-free survival: 81% (86% cN1 vs. 64% cN2, p=0.04)
***2-year overall survival: 100%
**[https://pubmed.ncbi.nlm.nih.gov/36913642/ Daneshmand, Siamak, et al.] "Surgery in Early Metastatic Seminoma: A Phase II Trial of Retroperitoneal Lymph Node Dissection for Testicular Seminoma With Limited Retroperitoneal Lymphadenopathy." ''Journal of Clinical Oncology'' (2023): JCO-22.