Radical inguinal orchiectomy
Standard initial treatment is radical inguinal orchiectomy.
Clamp and divide the spermatic cord at the internal ring and remove:
- Testis
- Epididymis
- Cord structures
Do not perform routine transscrotal biopsy or scrotal orchiectomy because this alters lymphatic drainage and contaminates the scrotum.
Offer sperm banking before chemotherapy or radiotherapy where future fertility is important.
Stage I seminoma
After orchiectomy, surveillance is preferred for most compliant patients.
Adjuvant options include:
Carboplatin AUC 7 IV for one cycle
in selected patients.
Routine adjuvant radiotherapy is used much less often because of long term second malignancy and cardiovascular concerns.
Stage I nonseminoma
Risk is strongly influenced by lymphovascular invasion.
Options are:
- Surveillance
- One cycle BEP
A high risk stage I patient can be offered one cycle BEP or surveillance after counselling.
BEP regimen
A standard 5 day BEP cycle uses approximately:
Bleomycin 30 units IV on days 1, 8 and 15
Etoposide 100 mg/m² IV days 1 to 5
Cisplatin 20 mg/m² IV days 1 to 5
Cycle repeats every 21 days.
Good prognosis metastatic nonseminoma is generally treated with:
BEP × 3 cycles
while intermediate or poor prognosis disease generally requires:
BEP × 4 cycles.
When bleomycin is contraindicated, use an established alternative such as EP or VIP according to tumour category.
Residual mass
After chemotherapy for nonseminoma:
Resect residual retroperitoneal masses greater than approximately 1 cm when markers have normalised or are normalising because residual tissue may contain:
- Teratoma
- Viable cancer
- Necrosis.
Residual seminoma is managed differently, often using functional imaging for larger persistent masses rather than automatically resecting every residual lesion.
