At workup after orchiectomy, about 15% to 20% of patients have radiologically involved para-aortic lymph nodes. The number of patients with stage II disease has been too small to mount phase III studies of treatment, and treatment decisions must be determined from reports from single institutions where patients have been treated in a uniform fashion. The most important prognostic factor in stage II seminoma is the bulk of the retroperitoneal tumor. The lymph node size was the only factor that predicted recurrence in 95 patients with stage II seminoma treated with RT at the Princess Margaret Hospital from 1981 to 1999 [36
]. The 5-year relapse-free rate in 79 patients with nodal disease of less than 5 cm (stage IIA-IIB) was 91% (7 of 79 patients) compared with 44% (9 of 16 patients) in patients with bulkier disease (stage IIC). Of these patients, 13 were treated with chemotherapy at relapse, and 9 were free of disease at the last follow-up visit. However, the high failure rate after RT in patients with bulky retroperitoneal disease, that not all patients with recurrence can be salvaged, and the apparently better outcome of similar patients who were treated with chemotherapy at diagnosis mandates primary chemotherapy, instead of RT, for this population. Staging should not be the only parameter used to decide the treatment of retroperitoneal disease in patients with stage II seminoma. The tumor bulk must also be considered. In patients with such bulky disease, chemotherapy, rather than RT, should be used [36
]. The technique of RT for stage II seminoma is similar to that used for stage I disease. The treatment volume includes the gross tumor and the para-aortic and ipsilateral common and external iliac lymph nodes. The radiation dose is typically 25 Gy in 20 daily fractions, plus a boost of an additional 10 Gy to the gross lymphadenopathy [36
]. The use of combination carboplatin and RT in stage IIA-IIB seminoma has been suggested by Gilbert et al. [37
]. They described a series of 62 patients treated with 1 to 2 courses of carboplatin 4 to 6 weeks before RT. Since 1997, 29 patients have been treated with 1 course of carboplatin before RT to the para-aortic nodes alone, and no relapses were observed. This approach is attractive in that it offers the potential of reducing the treatment volume with RT, at the same time improving the results compared with RT alone. However, this approach cannot be accepted as routine practice without additional study, especially because the use of combined modality therapy has been shown to increase the risk of second non-GCT and cardiovascular disease in long-term survivors [38
]. If chemotherapy is recommended as the primary treatment or for relapse after RT, 3 cycles of bleomycin, etoposide, and cisplatin (BEP) or 4 courses of etoposide and cisplatin (EP) should be considered as standard options.