So I assume this isn't adjuvant therapy if this is stage IIA/B seminoma. If it is a 2-2.5 cm node and marker negative, our current approach is to repeat the CT in 6 weeks and if it is growing, initiate BEP X 3 as an outpatient. In the interim, I would emphasize very heavily the SAR-CoV-2 precautions that all patients and all people should be taking.
Drs. @Craig R. Nichols and @Nadine Housri have worked with GCT experts to create practical recommendations during this pandemic. You can read these here.
Briefly, these patients should be still be treated with timely curative intent. Treatment decisions will need to be individualized for each patient and chemo may need to be postponed until symptoms have regressed. Full recommendations from Drs. Nichols, Housri et al. pertaining to your question listed below:
In patients without SARS-CoV-2 and COVID-19, BEP x 3 in IGCCC good risk is preferred unless there is an ironclad contra-indication to bleomycin. In patients with concurrent good risk disease and COVID-19, there are no data and the majority of our group would recommend that proceeding with standard BEP or if you are uncomfortable with that, VIP X 3. It also must be remembered that patients with good risk disease can often have chemotherapy initiation be safely delayed to allow a week or two for viral clearance and resolution of symptoms.
A minority of our group in North America and Europe favored a more cautious posture regarding bleomycin in good risk GCT patients and is as follows:
If SARS-CoV-2 is found in patients planning to start chemotherapy for good prognosis metastatic disease, we recommend that initiation of treatment may be postponed until symptoms are in regression. The patients should be closely monitored during this time with e.g. weekly checkups, weekly measurement of tumor markers and biweekly imaging until initiation of treatment. It is important for patients not to have their prognosis worsen by moving from good prognosis to intermediate prognosis. Treatment should be given without bleomycin to reduce the risk of pulmonary toxicity and we recommend VIP x 4 in intermediate and poor prognosis patients. In good prognosis patients we recommend EP x 4 or VIP x 3. Treatment should be given with hematopoietic growth factors.
If SARS-CoV-2 is found in patients already initiated chemotherapy for metastatic disease there is little evidence as to what is the correct treatment. In asymptomatic patients treatment may be continued as planned with very close follow-up. Bleomycin should be omitted for the remainder of the treatment. Treatment should be given with hematopoietic growth factors. Patients with symptoms in this situation should be discussed on an individual basis with a high volume center/collaborative group.
Delays in surgical management should be kept to a minimum if possible. Outpatient procedures such as diagnostic biopsies or excision should not be delayed if possible. Judicious delays in post-chemotherapy surgery may be considered on a region by region basis and patient risk of delay. Expert high-volume centers should develop strategies for surge capacity if required.
Curative-intent salvage chemotherapy and surgery should proceed as possible as appropriate to the regional medical environment. Regions or nations should develop short term strategies for consolidating these important technologies and experience to high volume centers e.g. high dose chemotherapy complex salvage surgery. Insurers should break down network and payment barriers in the short term to facilitate distributed expert management.
Palliative, non-curative approaches should seek to minimize contact with inpatient or outpatient services and include oral chemotherapy management, non-chemotherapy management and single dose radiation for bone metastases.