Selecting initial therapy. Seminoma and nonseminoma.

About 80% of seminoma presents as low-stage disease. If clinical studies are negative, the usual initial therapy is "prophylactic" radiotherapy to the retroperitoneal zone. If clinical Stage II disease is evident, radiotherapy versus primary chemotherapy is being studied. Primary chemotherapy is treatment of choice for clinical Stage III disease. Postchemotherapy radiographic lesions are safe to follow without surgical extirpation as they are usually necrotic. Surveillance for clinical Stage I disease is another option. For nonseminoma, clinical Stage I disease has been managed with staging RPLND. But 70% of such cases will have negative nodes. Hence, primary surveillance studies are under way, with chemotherapy reserved for those who relapse clinically (estimated 95% survival). Sadly, surveillance has not been effective when applied on an ad hoc basis at the community level. Problems are compliance, delayed detection of relapse, nonreporting of failures. Clinical Stage II disease is managed with RPLND. Adjuvant, limited postoperative chemotherapy is an option versus no postoperative chemotherapy followed by full chemotherapy for those who relapse as Stage III disease later. Another option under study for Stage II disease is primary chemotherapy with RPLND surgery reserved for those who achieve only a partial remission.