Stage I Seminoma

The initial treatment is radical inguinal orchidectomy. Acceptable therapeutic options following orchidectomy comprise surveillance, radiotherapy, or chemotherapy. A phase-III trial between the Medical Research Council (MRC) and EORTC suggested that adjuvant chemotherapy with one cycle of carboplatin area under curve (AUC) 7 can be recommended as alternative to adjuvant radiotherapy. There were no significant differences in relapse rate, time to relapse and survival after a median of 4-yr follow-up.41,42 Two cycles of carboplatin seem to further reduce the relapse rate to the order of 1–3%, but longer follow-up is essential to confirm the data.42

Stage I non-seminomatous Germ Cell Tumours (NSGCT)

Patients with stage I NSGCT can be offered nerve-sparing retroperitoneal lymph node dissection (RPLND), surveillance, or adjuvant cisplatin-based chemotherapy.42Risk-adapted treatment is currently based on the risk factor vascular invasion. Standard treatment for lowrisk stage 1A NSGCT tumors without evidence of vascular invasion consists of close surveillance after orchidectomy. Adjuvant chemotherapy or nerve-sparing retroperitoneal lymph node dissection (RPLND) remain options for patients not suitable for surveillance. In the case of positive lymph nodes, chemotherapy with two cycles of bleomycin, etoposide, and cisplatin (BEP) should be considered.42 Patients with high-risk stage 1B NSGCT tumors with evidence of vascular invasion (having about 50% risk of relapse) should receive chemotherapy with two cycles of BEP. In several studies involving more than 200 patients, a relapse rate of only 2.7% was reported with very little long-term toxicity. The efficacy and toxicity compared well with the results of surveillance strategies or RPLND in these patients. Two cycles of BEP do not seem to adversely affect fertility or sexual activity. In patients unwilling to undergo chemotherapy, surveillance or nerve-sparing RPLND remain alternative options. In the case of positive lymph nodes, further chemotherapy should be considered.42

Metastatic Germ Cell Tumours

In 1997, the International Germ Cell Cancer Collaborative Group (IGCCCG) defined prognostic factors for metastatic testicular cancer to categorize patients into “good,” “intermediate,” and “poor” prognosis groups (Table 13.4).42,43

Low-Volume Metastatic Disease (Stage II A/B)

Until now, the standard treatment of stage II A/B seminoma has been radiotherapy. An alternative for those with stage IIB seminoma unwilling to undergo radiotherapy is chemotherapy with three cycles BEP or alternatively four cycles etoposide – cisplatin (EP).42 NSGCT stage II A/B without elevated tumor markers can be treated either by RPLND or close surveillance. If the tumor markers are high after orchidectomy, patients require chemotherapy (three or four cycles of BEP), according to IGCCCG “good or intermediate prognosis” NSGCT followed by surgical resection of residual disease. Patients unwilling to undergo primary chemotherapy in the case of metastatic disease may choose for primary RPLND with adjuvant chemotherapy (two cycles BEP).In terms of outcome both treatment options are similar but adverse events and toxicity are different which may influence the patient in selecting the treatment of choice.42

Advanced Metastatic Disease

The treatment for advanced disease is three or four cycles of BEP chemotherapy based on the IGCCCG risk stratification (Table 13.4).42,43 In metastatic NSGCT (³ stage IIC) with a “good prognosis,” the primary treatment of choice is three cycles of BEP or alternatively four cycles of EP. In those with an “intermediate prognosis”, four cycles of BEP are given. For patients with a “poor prognosis”, the standard treatment is four cycles of BEP, or alternatively four cycles of PEI (cisplatin, etoposide, ifosfamide), although this regimen is more toxic.42 High-dose chemotherapy as part of first-line therapy may be considered. However, there is no evidence from randomized trials that it increases survival in patients with poor prognosis. The exact role of high-dose chemotherapy still needs to be identified. Surgical resection of all post-chemother- apy residual disease in NSGCT is indicated in