December 03, 2007

Testicular Cancer - Treatment Options

Stage I seminomas are usually treated with surgical removal of the testicle and spermatic cord (radical inguinal orchiectomy) followed by radiation aimed at regional lymph nodes (inguinal and retroperitoneal lymph nodes). Because seminoma cells are very sensitive to radiation, moderate doses can be used, usually around 10 to 15 treatments. More than 95% of stage I seminomas can be cured this way.

The doctor may recommend radiation therapy even if CT scan results do not show that the cancer has spread to the nodes. This is because in approximately 20% of cases of testicular cancer of this type, cancerous cells have spread but were not detected during imaging studies. Radiation therapy is usually successful in destroying these hidden (occult) metastases.

Another approach to treating men with stage I seminomas is currently being evaluated. Instead of treating regional lymph nodes with radiation right after surgery, patients are followed closely with blood tests and regularly scheduled imaging studies for several years. If these tests do not find any spread beyond the testicle, no additional treatment is given. If spread is detected later, radiation or chemotherapy can still be used effectively. This approach is about as effective as immediate radiation therapy, particularly if the original testicular cancer was not larger than 6 cm (about 2 ½ inches) and if there is no evidence that the cancer has spread into lymphatic vessels or blood vessels.

A third approach that has proved as effective as radiation is to 1 or 2 courses of chemotherapy with the drug carboplatin.

One way doctors make a decision on whether or not to treat is based on the size of the tumor and whether it invades nearby blood vessels. If the tumor is larger than 4 centimeters (1.5 inches) or invades blood vessels, they will recommend treatment with either radiation or chemotherapy.

Stage I nonseminoma germ cell cancers are also highly curable (98%), but the standard approach is different from treatment of seminomas. As with seminomas, the initial treatment is radical inguinal orchiectomy. Then there are 3 options:

Retroperitoneal lymph node dissection. This has the advantage of a high cure rate and the disadvantages of major surgery with its complications and the possibility of the loss of ejaculation.

Careful observation with frequent (usually monthly) doctor visits and tests for several years. This has the advantage of no surgery or chemotherapy side effects. Its disadvantage is that the cancer can return and without careful watching can grow so large that it may not be curable. So far, this has not happened in men who saw their doctor for follow-ups as scheduled. About 80% of relapses occur in the first 12 months, and most of the rest in the next 12 months.

Immediate treatment with 2 cycles of chemotherapy. This option, used mainly for stage IB, also has a high cure rate but has the disadvantage of the side effects of chemotherapy (mostly the short-term effects, since 2 courses do not usually cause any long-term effects). Most doctors do not recommend this option because of the possible (but unlikely) long-term side effects of chemotherapy. If the tumor is stage IS, then full dose chemotherapy is recommended (i.e., if the testicle and its tumor have been removed but abnormal blood levels of tumor markers, such as HCG or AFP, persist without a rapid decline after surgery).
Doctors have learned that certain features of the tumor mean that the cancer might come back. These depend on the blood test results and the appearance of the cancer cells under the microscope. If these signs are present, doctors are less likely to recommend observation only.

Stage II Germ Cell Cancers

Stage II seminomas are classified as either "nonbulky" or "bulky," which refers to the size of the retroperitoneal lymph nodes. Nonbulky tumors are treated with radical inguinal orchiectomy followed by radiation to the regional (retroperitoneal) lymph nodes. Bulky tumors are treated with radical inguinal orchiectomy, followed by combination chemotherapy that includes 3 cycles of cisplatin, etoposide, and bleomycin. Usually higher doses of radiation are given for nonbulky stage II seminoma than for stage I seminoma. Radiotherapy is not used for bulky stage II seminoma. Chemotherapy is the best treatment for patients with this stage of seminoma.

At one time, lymph nodes in the center of the chest were treated with radiation, but this is no longer recommended.

Stage II nonseminoma germ cell tumors are also divided into "nonbulky" and "bulky." For nonbulky disease, radical inguinal orchiectomy is followed by retroperitoneal lymph node removal. About one fourth of these men will not have cancer in their lymph nodes even though their CT scan suggested they might. For the other three fourths who do have cancer in their lymph nodes, there are 2 options after surgery:

Observation. As for stage I testicular cancer, monthly visits are required with frequent testing. This is usually recommended for men who had cancer in fewer than 5 lymph nodes and whose lymph nodes were small (less than 1 inch).

Chemotherapy. For men with more cancer-involved lymph nodes or larger ones, or for those who want to avoid the intense observation period, chemotherapy is given. This usually consists of 2 courses of chemotherapy, most often with the drugs cisplatin and etoposide.

Men with bulky disease in their lymph nodes should, of course, have the testicular tumor removed surgically. For these men, the next step is not more surgery, but chemotherapy. Several regimens are used, but the most common contain etoposide, bleomycin, and cisplatin. These are given as 3 or 4 courses. Following this, a repeat CT scan is done to see if the retroperitoneal lymph nodes are still enlarged. If they are, a retroperitoneal lymph node dissection is performed. This surgery is a little more difficult for men who have had chemotherapy than for those who have not.

Finally, if the tumor markers are high after orchiectomy, chemotherapy is probably the first treatment and then surgery of the lymph nodes will be considered, depending on the results of CT and PET scans.

Stage III Germ Cell Cancers

Stage III seminomas are treated with orchiectomy followed by chemotherapy with a combination of drugs. The main regimens are the same as those used for stage II testicular cancers (usually etoposide, cisplatin, and bleomycin). This approach produces a cure in over 70% of cases.

Those who are not cured might consider enrolling in clinical trials of other chemotherapy agents (for more information, see Clinical Trials in this section). Patients whose cancer has metastasized to the brain usually receive chemotherapy plus radiation therapy aimed at the brain, although surgery for the brain tumor is another option.

Stage III nonseminomas usually receive the same treatment with chemotherapy and have similar survival rates as seminomas. Once chemotherapy is complete, the doctor looks for any cancer that remains. Sometimes a few tumors remain. These are most often in the lung or in the retroperitoneal lymph nodes. Removing these surgically may result in a cure.

If the tumor markers are very high then the usual chemotherapy programs may not be successful and a clinical trial of more aggressive therapy may be the best choice.

Recurrent Germ Cell Cancer

Treatment of recurrent germ cell cancer depends on the initial stage and treatment. Cancer that comes back in the retroperitoneal lymph nodes after orchiectomy alone was performed for early stage tumors can be treated by surgery if the recurrence is small. Depending on the results of the surgery, chemotherapy may be recommended.

If the recurring cancer in the retroperitoneal lymph nodes is extensive or if the cancer has returned elsewhere, then chemotherapy is recommended. This may be followed by surgery.

If a man’s cancer recurs after chemotherapy or if his treatment is no longer working, then he will be treated with different drugs, typically, ifosfamide, cisplatin, and either etoposide or vinblastine.

The treatment of recurrent disease with standard-dose chemotherapy has not been as effective as doctors would like. Therefore, many men whose disease comes back after chemotherapy receive high-dose chemotherapy followed by autologous blood stem cell transplantation. For men with recurrent disease, this may be a better option, rather than standard chemotherapy. (See Stem Cell Transplantation in this section for more information.)

In general, it is probably safest to seek a second opinion from a center of excellence, with extensive experience in the treatment of relapsed testicular cancer, before starting other treatments after chemotherapy is no longer working.

Sertoli Cell and Leydig Cell Tumors

Radical inguinal orchiectomy is usually recommended for Sertoli cell and Leydig cell tumors. Radiation therapy and chemotherapy are generally not effective in these rare types of testicle tumor. If metastasis beyond the testicle is suspected, retroperitoneal lymph nodes may be surgically removed

Adapted from: American Cancer Society, inc.