What to Do When First-Line Chemotherapy Fails in Metastatic Seminoma (Stage IIC or Higher)

Clinical scenario

This protocol applies to patients with seminoma germ cell tumour presenting with metastatic disease at stage IIC or higher, classified in the IGCCCG good prognosis group. The defining features are any primary site, no nonpulmonary visceral metastases, normal AFP, and any hCG or LDH.

Previous treatment — goals not achieved

First-line therapy with BEP × 3 (cisplatin, etoposide, bleomycin) — or EP × 4 (etoposide, cisplatin) when bleomycin was contraindicated — did not achieve the required endpoints: normalization of serum tumour markers (hCG, LDH) and complete or partial radiological response on cross-sectional imaging.

This protocol defines the salvage step taken after that failure.

Salvage approach — partial overview

The next step involves salvage chemotherapy using a cisplatin- and ifosfamide-based three-agent regimen administered over four cycles. The specific combination selected depends on clinical judgement; multiple regimen options exist within this class.

Treatment goals are normalization of serum tumour markers and complete or partial radiological response. The full structured regimen and decision criteria are available in the complete protocol.

Instant Access to Structured Evidence-Based Regimens

References

All of the following criteria: Any primary site, No nonpulmonary visceral metastases, Normal AFP, Any hCG, Any LDH.
Treat seminoma stage IIC and higher, with primary chemotherapy according to IGCCCG classification (BEP x 3 in good-prognosis and BEP x 4 in intermediate prognosis).
The regimens of choice are four cycles of a three-agent regimen including cisplatin and ifosfamide plus a third drug: etoposide (VIP), paclitaxel (TIP), or potentially gemcitabine (GIP).

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