Controversies in the management of stage I seminoma.

Current controversies in the treatment of stage I seminoma center on the relative roles of surveillance, adjuvant radiotherapy (RT), and adjuvant single-agent chemotherapy. Surveillance has been studied in over 800 patients, 17.1% of whom have relapsed. There is no evidence that surveillance compromises survival in properly selected, compliant patients. The economic benefit of treating only those patients who relapse is offset by the cost of screening diagnostic studies and salvage therapy, and by issues of patient anxiety and compliance. Other methods of reducing the toxicity of RT include reductions in RT dose and volume. A randomized trial has shown that omission of the pelvic field produces relapse-free survival equivalent to that achieved with pelvic plus para-aortic RT. A similar study is currently evaluating a reduction in RT dose from 30 to 20 Gy. Early results from nonrandomized studies of one or two cycles of single-agent chemotherapy demonstrate efficacy comparable to RT in the adjuvant treatment of stage I seminoma. A randomized trial is underway to determine the equivalence of adjuvant carboplatin (Paraplatin) and RT. Long-term follow-up from these studies will provide information not only on the relative efficacy of these alternative strategies but also on the late effects of therapy, including infertility and second malignancy.