| Setting | Treatment |
|---|---|
| STAGE I SEMINOMA seminoma · markers normalised · CT clear | SURVEILLANCE is preferred
cure approaches 99% either way, and surveillance spares the majority who are already cured from any treatment at all · relapse-risk factors: tumour >4 cm, rete testis invasion If not feasible → single-agent carboplatin AUC 7 ×1 (MRC TE19) Para-aortic EBRT 20 Gy — now LEAST favoured
external-beam radiotherapy — second-malignancy + cardiovascular late effects in men who will live decades |
| STAGE I NSGCT — no LVI | SURVEILLANCE
relapse ~15%, and relapse is still curable |
| STAGE I NSGCT — LVI PRESENT LVI on the orchidectomy specimen; relapse risk ~50% | Surveillance remains the preferred option
in a fully-informed patient able to adhere to follow-up — relapse, if it happens, is still curable with full-course chemo Alternative → adjuvant BEP ×1
bleomycin + etoposide + cisplatin — cuts relapse to ~2–3% Or nerve-sparing RPLND |
| METASTATIC — GOOD risk NSGCT: testis/retroperitoneal primary, no non-pulmonary visceral mets, AFP <1000, β-hCG <5000, LDH <1.5× ULN (upper limit of normal) · Seminoma: any primary, normal AFP, no non-pulmonary visceral mets | BEP ×3 Or EP ×4 when bleomycin must be avoided
etoposide + cisplatin — pre-existing lung disease, older age, impaired renal function, or a planned extensive thoracic resection |
| METASTATIC — INTERMEDIATE / POOR risk Intermediate: non-pulm. visceral mets (seminoma) or AFP 1000–10 000 / β-hCG 5000–50 000 / LDH 1.5–10× ULN (NSGCT) · Poor (NSGCT only): mediastinal primary, non-pulm. visceral mets, AFP >10 000, β-hCG >50 000, or LDH >10× ULN — there is no poor-risk seminoma | BEP ×4 Bleomycin contraindicated → VIP ×4
etoposide + ifosfamide + cisplatin ⚠ FULMINANT HIGH-VOLUME CHORIOCARCINOMA IS AN EMERGENCY
massive β-hCG, pulmonary haemorrhage, respiratory failure → start chemotherapy urgently; consider a reduced-intensity first cycle to avoid tumour-lysis / haemorrhage catastrophe, then escalate to full dose |
| RESIDUAL MASS after chemotherapy markers normalised, mass persists | NSGCT → RESECT any residual mass ≥1 cm
post-chemo RPLND ± thoracic resection · findings: necrosis/fibrosis, teratoma (chemo-resistant, grows, can transform — must come out), or viable germ-cell tumour (→ consider further chemo) SEMINOMA → do NOT reflexively operate
masses regress slowly Seminoma, mass >3 cm → FDG-PET at ≥6 weeks
negative → observe; positive → biopsy / resect · PET is unreliable in NSGCT — it cannot exclude teratoma |
| 🔴 RELAPSED / REFRACTORY still curative intent | 🔴 The single most important row in the section — relapse here is NOT palliative Conventional-dose salvage → TIP
paclitaxel + ifosfamide + cisplatin — ~65% long-term remission in favourable-risk relapse · VeIP (vinblastine + ifosfamide + cisplatin) ~25%; or VIP High-dose chemo + autologous stem-cell rescue
carboplatin/etoposide, Indiana regimen — as initial salvage in poor-risk relapse, or after failed conventional salvage · refer to a high-volume germ-cell centre ⚠ Late relapse (>2 yr) is chemo-resistant → SURGERY is the mainstay |
| GROWING TERATOMA SYNDROME mass enlarging WHILE markers normal/falling, on chemo | Complete surgical resection
not progression — chemotherapy will not touch it |
| BRAIN METASTASES | Platinum-based chemotherapy (BEP-type) PLUS radiotherapy and/or surgery
still curative intent, unlike most solid tumours |