This section tells you the treatments that are the standard of care for this type of cancer. “Standard of care” means the best treatments known. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn if it is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Your doctor can help you consider all your treatment options.
In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. For testicular cancer, this team includes a urologist and medical oncologist. A medical oncologist is a doctor who specialises in treating cancer with medication. Sometimes, patients may also see a radiation oncologist. A radiation oncologist a doctor who specialises in giving radiation therapy to treat cancer. Cancer care teams also include a variety of other health care professionals, including physician assistants, oncology nurses, social workers, pharmacists, counsellors, dietitians, and others.
Descriptions of the most common types of treatment used for testicular cancer are listed below, followed by treatment options by the cancer’s stage. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the man’s preferences and overall health. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.
Germ cell tumors are highly sensitive to chemotherapy and are therefore usually curable. However, unlike the other types of germ cell tumors, chemotherapy is not very effective for a teratoma. Because many germ cell tumors are a mixture of teratoma and other types of germ cell tumor, successful treatment often requires both chemotherapy and surgery. Most often, testicular cancer can be successfully treated with surgery, chemotherapy, and/or radiation therapy.
Men with testicular cancer usually have concerns about how their treatment will affect their sexual function, fertility, and quality of life, and each man should discuss these topics with his doctor before treatment begins because there is often more than 1 treatment option available. The final choice of a treatment plan depends on the patient’s specific situation. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment.
Getting care for symptoms and side effects
Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.
Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or radiation therapy. Talk with your doctor about the goals of each treatment in the treatment plan.
Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and palliative care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it can be addressed as quickly as possible.
Surveillance for clinical stage I testicular cancer
After having a radical inguinal orchiectomy, an option for men with clinical stage I seminoma and non-seminoma may be surveillance. With surveillance, the patient is monitored closely and active treatment begins only if the cancer recurs. This option involves regular doctor appointments for physical examinations, blood tests for tumour markers, CT scans, and chest x-rays. This approach requires dedication by the doctor and patient to stick to the surveillance schedule so that any recurrence can be detected at an early stage. It is only considered as an option if the serum tumour markers of AFP and beta-hCG are normal or return to normal after the cancerous testicle is removed.
The main advantage of surveillance is that it avoids any further treatment after orchiectomy − such as chemotherapy, radiation therapy, or additional surgery − for the 80% of men with seminoma and 75% of men with non-seminoma who are not likely to have the disease return after orchiectomy. For an individual patient, the risk of recurrence may be higher or lower based on risk factors determined by the pathologist’s examination of the tumor after the testicle has been removed.
The surveillance schedule for men with non-seminoma involves testing every 1 to 2 months for the first year, every 2 to 3 months in the second year, and less often thereafter. Most visits are to check serum tumor markers. CT scans and chest x-rays are performed less often. The surveillance schedule for men with seminoma is much less intense, with testing performed every 4 months for the first 2 to 3 years and less often thereafter. CT scans, chest x-ray and physical examination performed at each surveillance visit. Patients generally have follow-up screening for at least 10 years after their diagnosis.
Surgery for cancer involves the removal of the tumour and some surrounding healthy tissue during an operation. There are different types of surgery used to treat testicular cancer. Each is described further below.
If a decision is made to perform an orchiectomy, a sample of blood will be collected before surgery to test for levels of serum tumor markers because they are often helpful in planning treatment and follow-up care. For example, increasing or consistently high AFP or beta-hCG after surgery is a sign that the cancer has spread. In this situation, a patient usually needs chemotherapy (see below) even if the metastases cannot be seen on imaging tests.
Radical inguinal orchiectomy
Treatment of testicular cancer usually starts with surgery to remove the testicle with cancer, called radical inguinal orchiectomy. This operation is done through an incision in the groin along the beltline. During the surgery, the entire testicle and most of the spermatic cord are removed. The spermatic cord contains the blood supply to the testicle as well as the channel through which sperm travel from the testicle toward the penis. A man may develop cancer in both testicles either at the same time or at different times. However, this is rare, occurring in about 2% of men with testicular cancer. Then, both testicles need to be removed in a procedure called a bilateral orchiectomy.
Orchiectomy is used to diagnose and treat both early-stage and later-stage seminoma and non-seminoma. For later-stage cancer, a radical inguinal orchiectomy may, occasionally, be delayed until after treatment with chemotherapy is finished.
Side effects of orchiectomy
The removal of 1 testicle typically does not affect a man’s testosterone level if he still has the other testicle, and it is a normal size. If a man’s testosterone level is reduced, symptoms may include depression or other mood changes, fatigue, decreased sex drive, inability to achieve a normal erection, especially in the morning, and hot flashes, as well as loss of muscle and bone mass in the long term. Orchiectomy is unlikely to make a man unable to father a biological child because the remaining testicle will still produce sperm. However, about 25% of men with testicular cancer are infertile even before being diagnosed with cancer. It appears that the cancer itself and/or the reason the cancer developed may cause some men to become infertile. Sperm counts often improve after the testicle with cancer is removed.
If the removal of both testicles is performed, the man will no longer produce sperm or testosterone and will not be able to biologically produce children. If the doctor recommends removing the testicle in a man with 1 testicle, semen is usually analyzed twice before surgery to check if the man’s sperm are fully functioning. If the sperm are functional, then sperm banking is usually recommended, so that he may be able to have children later if he wishes. In addition, for men who have had both testicles removed, testosterone replacement therapy will be needed.
Reconstructive surgery after orchiectomy
Men can decide if they want an artificial or prosthetic testicle implanted in the scrotum. A prosthetic testicle generally has a weight and texture that is somewhat similar to a normal testicle but not exactly the same. Some men find that a prosthetic testicle is uncomfortable and some prefer not to have one. Each man is encouraged to talk with his doctor about whether he wants one and the best timing of this implantation if wanted. Some men prefer to wait until after the active treatment period is over to give this option full consideration.
Retroperitoneal lymph node dissection (RPLND)
This is surgery to remove the retroperitoneal lymph nodes that lie at the back of the abdomen. RPLND may be considered for men with clinical stage I and IIA non-seminoma and men with retroperitoneal masses that remain after finishing chemotherapy (see below) for stage II or III nonseminoma. In men with non-seminoma, any masses larger than 1 cm that remain after chemotherapy are removed if it is possible. For men with pure seminoma, masses smaller than 3 cm are usually left in place and monitored for changes with CT scans.
RPLND is usually performed as an open operation with an incision down the middle of the abdomen. RPLND is a complex surgery requiring experience and skill in order to remove all of the appropriate lymph nodes and to minimize the side effects of the operation. RPLND should only be done by a surgeon who is highly experienced with this operation. Some surgeons perform laparoscopic RPLND, which uses several smaller incisions instead of the 1 large incision, but that approach is still being studied, requires a surgeon skilled in the procedure, and may not be as effective.
RPLND for stage I and IIA non-seminoma. About 25% of patients with clinical stage I non-seminoma who have an RPLND are found to have lymph nodes with cancer. In other words, the surgery shows that they have stage II disease. For men with clinical stage I disease, the risk of recurrence can be lowered with RPLND. In these situations, RPLND is done as a treatment that reduces the risk of recurrence, in addition to being used to stage the cancer. This makes it possible to determine which men are most likely to need chemotherapy after RPLND. Doctors are now able to better determine which stage I tumors are at a higher risk of having spread to the lymph nodes or beyond, based on the results of the pathology tests performed on the tumor in the testicle after it is removed. Decisions about whether to have an RPLND may be based on the patient’s risk factors. Surveillance (see above) for patients with low-risk disease and chemotherapy for patients with high-risk disease may be recommended for some, but RPLND is a reasonable treatment option when a patient can see a urologist with extensive experience with RPLND. If an RPLND is chosen for stage I non-seminoma, it is usually done within 6 weeks after orchiectomy.
If 5 or fewer lymph nodes have cancer and none are larger than 2 cm (pN1), this surgery alone is successful for 80% to 90% of men, while about 10% to 20% of men will have a recurrence. If more lymph nodes have cancer (pN2 or pN3), surgery alone is successful for about 50% of patients, while the other 50% will have a recurrence. The advantage of the RPLND is that it can cure most patients with small lymph node metastases, provide a more accurate assessment of the extent of disease, and avoid the need for frequent CT scans of the abdomen during follow-up care. It also reduces the chance that a man with early-stage (stage I) testicular cancer will need chemotherapy.
Just as RPLND may show cancer in lymph nodes that appeared normal on CT scans for men with clinical stage I non-seminoma, surgery may also show that there is no cancer in lymph nodes that were enlarged on a CT scan, called clinical stage II disease. For men with clinical stage IIA testicular non-seminomas, 20% to 30% will actually have pathological stage I cancer, meaning that the cancer has not spread to any lymph nodes. In these situations, RPLND can help many men avoid unneeded chemotherapy.
The main disadvantage of this surgery for stage I non-seminoma is that 70% of patients are cured by removal of the testicle alone. For these men, a RPLND offers no curative benefit, although it does allow the man to avoid the regular CT scans needed with surveillance, as well as, possibly, peace of mind.
Despite the surgery, about 10% of testicular cancers recur even if the lymph nodes were not found to have cancer. If the RPLND finds that the lymph nodes have cancer, then a decision needs to be made whether to give 2 courses of chemotherapy (see below) to decrease the chance of recurrence to about 1%. However, surveillance is also an option, beginning treatment with chemotherapy only if the cancer recurs. This is because this type of cancer has a greater than 95% chance of being cured with 3 cycles of chemotherapy if the recurrence is diagnosed early through regular monitoring.
- RPLND to remove residual tumors after chemotherapy. Removing masses larger than 1 cm that remain after chemotherapy for non-seminomas is believed to be an essential part of treating the disease when it can be safely done. About 35% to 40% of men going through such surgery will have a mass that contains teratoma, and about 10% to 15% will have 1 of the other germ cell cancers. The other 40% to 50% of men will have no cancer or teratoma found and there will only be scarring and/or normal lymph node tissue. Usually, RPLND after chemotherapy is only needed if there are enlarged nodes (greater than 1.0 cm) on scans taken after chemotherapy ends. However, some treatment centers will perform an RPLND after chemotherapy in men who had enlarged retroperitoneal lymph nodes before chemotherapy even if the lymph nodes return to normal size (less than 1 cm) after chemotherapy. For men found to have teratoma, no additional treatment is given after RPLND. For men found to have seminoma, embryonal carcinoma, yolk sac tumor, or choriocarcinoma, 2 additional cycles of chemotherapy are generally recommended after RPLND.
Side effects of RPLND
Some patients may experience temporary side effects from RPLND, such as bowel obstruction (blockage) or infection. This procedure should not affect a man's ability to have an erection, orgasm, or sexual intercourse. However, it may cause infertility because it can damage the nerves that control ejaculation. RPLND performed after chemotherapy is a more complex surgery and is more likely to cause infertility from being unable to ejaculate and other side effects.
Men are encouraged to consider banking sperm before RPLND. There are surgical techniques that are usually successful at sparing the nerves involved with ejaculation. Men should talk about these options with their doctors before surgery.
Other types of surgery to remove cancer remaining after chemotherapy
After chemotherapy (see below), some men may have cancer remaining in lymph nodes outside the retroperitoneum, in the lungs, liver, or other organs. These tumors should also be removed if it is safe to do so. This may involve surgery in more than 1 part of the body. This type of surgery is complex and requires an experienced team of surgeons. If only some of the remaining tumors can be removed, then surgery is not usually performed.
Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specialises in treating cancer with medication.
Chemotherapy for testicular cancer is given directly into a vein so that it enters the bloodstream and reaches cancer cells throughout the body. There are also types of chemotherapy that can be taken by mouth but they are not generally used for testicular cancer.
A chemotherapy regimen (schedule) usually consists of a specific number of cycles of treatment given over a set period of time. A cycle of chemotherapy for testicular cancer typically lasts 3 weeks. And, men with testicular cancer may receive 1 to 4 cycles of treatment, depending on the stage of the cancer. During treatment, a patient may receive 1 drug at a time or combinations of different drugs at the same time.
The following drugs are used for testicular cancer, usually in the combinations listed further below. However, the drugs used for testicular cancer change, and drugs other than those mentioned below may be used. Talk with your doctor about your options for chemotherapy.
The following chemotherapy regimens may be used for testicular cancer.
BEP: bleomycin, etoposide, and cisplatin
Carboplatin (for stage I pure seminoma only)
EP: etoposide and cisplatin
TIP: paclitaxel, ifosfamide, and cisplatin
VeIP: vinblastine, ifosfamide, and cisplatin
VIP: etoposide, ifosfamide, and cisplatin
High-dose carboplatin and etoposide
In general, patients with later-stage disease receive more chemotherapy. The appropriate chemotherapy regimen depends on the stage of the cancer and whether it is a seminoma or a non-seminoma. In addition, how high AFP and beta-hCG levels are helps the doctor determine how much chemotherapy is needed. Chemotherapy regimens for specific stages are discussed further below.
Side effects of chemotherapy
Chemotherapy works very well for testicular cancer but can cause side effects and complications. Most of these side effects usually go away once treatment is finished, but some can show up much later. These are called late effects. Balancing the risks and benefits of chemotherapy is an important issue for men with testicular cancer. However, metastatic testicular cancer (see further below) can generally only be cured with chemotherapy. So, for men with metastatic testicular cancer, the benefits of chemotherapy typically outweigh the risks. On the other hand, men with stage I testicular cancer almost never die of the disease regardless of which treatment they receive, so the risks of chemotherapy may outweigh the benefits for these men.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications.
Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. For testicular cancer, the radiation is generally directed at lymph nodes in the abdomen for men with stage I or II pure seminoma. Sometimes, the radiation treatment area includes lymph nodes on the same side of the pelvis as the testicle where the cancer started.
Radiation therapy for stage I seminoma is now used less often than in the past. Surveillance or, less commonly, carboplatin chemotherapy is usually used instead of radiation therapy as the preferred treatment of stage I seminoma at many treatment centers because of the risk that radiation therapy may cause other cancers and heart disease. However, radiation therapy remains an option for stage I, IIA, and IIB pure seminomas. It is also sometimes used to treat brain metastases from either seminoma or non-seminoma, but testicular cancer rarely spreads to the brain.
Side effects from radiation therapy
Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, loose bowel movements, and peptic ulcers. Medications may be helpful to prevent or reduce nausea and vomiting during radiation therapy. Most side effects go away soon after treatment is finished. Radiation therapy may cause problems with sperm production, but this is less common now with newer radiation techniques that can help men to preserve fertility.
Radiation therapy may increase risk of secondary cancers many years after treatment, as well as cardiovascular disease and gastrointestinal disease. Talk with your doctor about your risk of long-term side effects before starting radiation therapy.
Treatment by stage of the cancer
The treatment choices for testicular cancer depend on whether the cancer is a seminoma or non-seminoma and the stage of the cancer (see Stages above). After a physical examination, staging tests, and the removal of the cancerous testicle, you and your doctor will discuss your treatment options. Treatment options for early stage, later stages, and recurrent seminoma and non-seminoma are described in more detail below.
Clinical stage I non-seminoma testicular cancer
About 25% of patients with clinical stage I non-seminoma have small areas of metastatic cancer that cannot be seen by CT scans when diagnosed. Over time, these areas can grow unless a man receives additional treatment after orchiectomy. The rest are cured when the testicle with cancer is removed. Most recurrences of stage I non-seminoma occur within 9 months after diagnosis and occur in the retroperitoneum. Men with clinical stage I disease have the following options after surgery:
Surveillance. This option involves CT scans of the abdomen and pelvis every 3 to 6 months for the first year, every 4 to 9 months in the second year, and every 6 to 12 months in the third to fifth year. Chest x-rays with physical examinations and tumor marker tests to measure beta-hCG and AFP are done every 1 to 2 months for the first 12 months, every 2 to 3 months in the second year, every 3 to 4 months in the third and fourth years, every 6 months in the fifth year, and then annually. If the cancer recurs, 3 cycles of chemotherapy successfully treats more than 95% of men. RPLND may be used to treat recurrent cancer if it is limited to the retroperitoneal lymph nodes.
RPLND. As described above, this is surgery to remove the retroperitoneal lymph nodes in the back of the abdomen. After an RPLND, the risk of recurrence is less than 10% if no cancer is found in those lymph nodes. Most of these recurrences occur in the lungs or the lymph nodes in the chest and they almost always occur within 2 years after the RPLND.
Chemotherapy. This option involves receiving chemotherapy shortly after the testicle has been removed surgically, called adjuvant chemotherapy. The most commonly used approach has been to give 1 or 2 cycles of BEP chemotherapy that each last 3 weeks. The advantage of this approach is that it lowers the recurrence rate from 25% down to less than 3%. The main disadvantage is that 75% of patients do not need chemotherapy because they have already been cured with the surgical removal of the testicle. Therefore, some doctors recommend against using chemotherapy for clinical stage I non-seminoma, while others may recommend using adjuvant chemotherapy only for men who have a higher risk of recurrence so that fewer men receive unnecessary treatment.
Clinical stage I seminoma testicular cancer
More than 80% of men with clinical stage I seminoma are cured with orchiectomy alone while the remaining 15% to 20% will have a recurrence if given no additional treatment. Most recurrences occur within 12 months after diagnosis and the location of the recurrence is typically in the retroperitoneum. Recurrences of stage I seminoma can almost always be cured with radiation therapy, although a few men will need chemotherapy.
Surveillance. Surveillance is the standard method of managing stage I seminoma. Using a surveillance program, the risk of death from stage I seminoma is less than 1%. Unlike surveillance for non-seminoma, surveillance for seminoma does not require frequent visits to the doctor. While this can vary, a common schedule includes doctor visits every 4 months for the first 2 to 3 years, every 6 months for the next 3 years, and then annually until at least 10 years after the original diagnosis. At each visit, the following tests are performed: a CT scan of the abdomen and pelvis, a chest radiograph, and a physical examination. Blood tests to measure the serum tumor markers beta-hCG and AFP may be done at the same time, but more research is needed to determine if testing serum tumor markers is helpful for these men.
Adjuvant radiation therapy. This is radiation therapy given after surgery. Seminoma is much different from non-seminoma, and early-stage seminoma can be effectively treated with radiation therapy. The chance of recurrence can be decreased to less than 5% with 10 to 15 treatments of radiation therapy to the retroperitoneum. Additional radiation therapy to the pelvis does not reduce the overall risk of recurrence, but it does reduce the risk of a recurrence in the pelvis. Some doctors prefer to treat only the retroperitoneum. Others prefer to include the pelvis to prevent recurrences in that area and eliminate the need for imaging tests of the pelvis to watch for a recurrence.
The disadvantage of radiation therapy for clinical stage I seminoma is that more than 80% of men receive treatment that they do not need because they were cured with the orchiectomy. This is a concern because radiation therapy increases the risk of developing another cancer and heart disease.
Adjuvant chemotherapy. This is chemotherapy after surgery. Chemotherapy for stage I seminoma is a newer and more controversial treatment option than surveillance or radiation therapy. Using carboplatin, studies have shown that the risk of recurrence after orchiectomy can be reduced from 18% to about 2% using 2 doses of carboplatin and to about 5% using 1 dose of carboplatin. Because the use of carboplatin is a newer approach, there is less information on long-term effects after treatment. Therefore, many experts believe that more information is needed before recommending this treatment approach. On the other hand, many other experts have accepted carboplatin as a new treatment option for stage I seminoma, and it is listed as a standard treatment option in most published testicular cancer treatment guidelines. The hope is that carboplatin will cause fewer complications than radiation therapy, but it won’t be known whether this is the case until the health of the men who have received carboplatin has been monitored for a longer period of time. Complications from cancer treatments sometimes do not appear until 10 to 20 years later.
Metastatic testicular cancer
If cancer has spread to another location in the body, it is called metastatic cancer. If this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Also, clinical trials might be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your treatment plan chosen. However, testicular cancer is fast-growing, so it is important to start treatment right away. If a second opinion is wanted, patients should talk with a doctor within 1 or 2 weeks.
Your treatment plan is based on many individual factors, including whether the cancer has spread to the brain. In addition, LDH levels may be monitored for men with metastatic disease to determine the stage and how long chemotherapy is needed.
Initial treatment of metastatic testicular cancer is usually chemotherapy except when immediate treatment of the brain is needed, which is rare. Chemotherapy typically shrinks the size of such tumors in the brain and may remove them entirely over time. If there are any masses remaining after chemotherapy, surgery may be recommended. Radiation therapy to treat the spread of testicular cancer to the brain is controversial. If immediate treatment of a tumor in the brain is needed due to bleeding or swelling or other issues, then removing the mass surgically is usually preferred if it can be done safely, but radiation therapy may be recommended instead of or in addition to surgery depending on the situation. Palliative care will also be important to help relieve symptoms and side effects.
Descriptions of the treatment options for metastatic testicular cancer are described by stage below:
Clinical stage II non-seminoma testicular cancer
Surgery to remove the testicle is done first, followed by additional treatment. The choice of treatment after orchiectomy depends on a patient’s serum tumour marker levels and the size of retroperitoneal lymph nodes. Men with clinical stage II non-seminoma have the following treatment options after surgery:
Chemotherapy. Combination chemotherapy is given after surgery to remove the testicle. Doctors generally recommend using chemotherapy immediately after surgery if serum tumour markers remain high, there are more than 5 enlarged lymph nodes, and/or there are lymph nodes larger than 2 cm. Men are encouraged to consider sperm banking before chemotherapy begins due to the risk of infertility.
RPLND. As described above, this is surgery to remove the retroperitoneal lymph nodes in the back of the abdomen. This is recommended after orchiectomy when the serum tumor marker levels have returned to normal, none of the lymph nodes is larger than 2 cm, and there are no more than 5 enlarged lymph nodes. Chemotherapy may still be needed after RPLND if a large amount of cancer is found in the removed lymph nodes. Men are encouraged to consider sperm banking before RPLND due to the risk of loss of normal ejaculation after surgery.
Clinical stage II seminoma testicular cancer
Surgery to remove the testicle and lymph nodes with cancer is done first, followed by additional treatment, usually chemotherapy. The main factor in the treatment decision after surgery for a stage II seminoma is the size of the retroperitoneal lymph nodes.
Chemotherapy. Chemotherapy with a combination of drugs is given after surgical removal of the testicle when the lymph nodes are larger than 3 cm or when there are enlarged lymph nodes spread out over a large area in the back of the abdomen. This is the preferred treatment for men with clinical stage IIB and IIC seminoma, as chemotherapy is more likely to get rid of the cancer. Men are encouraged to consider sperm banking before chemotherapy due to the risk of infertility.
Radiation therapy. When lymph nodes are less than 3 cm (stage IIA and early stage IIB), surgery may be followed by radiation therapy to the lymph nodes in the abdomen and pelvis. Alternatively, chemotherapy may be used instead of radiation therapy. Experts disagree about whether radiation therapy or chemotherapy is the preferred option for stage IIA and early stage IIB patients. Both approaches cure 90% or more of patients with this stage. Men are encouraged to consider sperm banking before radiation therapy or chemotherapy due to the risk of infertility.
Stage III non-seminoma testicular cancer
Chemotherapy. Chemotherapy is used for men with non-seminoma that has spread beyond the testicles. The most common regimen given is BEP, which is a combination of bleomycin, etoposide and cisplatin (see chemotherapy, above). The treatments are given as 3-week cycles and patients receive either 3 or 4 cycles of chemotherapy for a total treatment period of 9 to 12 weeks. Each drug is given by IV. Cisplatin and etoposide are given each day on the first 5 days. IV fluid is given before and after the cisplatin to reduce the risk of damaging the kidneys. The treatment takes about 6 hours on these days. Bleomycin is given once each week, typically on the first, eighth, and 15th day of the 21-day cycles. The treatment takes about 30 minutes on the days when only bleomycin is given. Men are encouraged to consider sperm banking before chemotherapy due to the risk of infertility.
The likelihood of chemotherapy successfully treating this cancer depends on the risk group category (see Stages above). More than half of metastatic non-seminoma testicular cancers are classified as good-risk, and more than 90% of these will be successfully treated with 3 cycles of BEP chemotherapy or 4 cycles of chemotherapy using etoposide and cisplatin. An important part of the treatment is surgical removal of any remaining masses after chemotherapy ends. About 25% of metastatic non-seminomas are intermediate-risk disease, and 80% of these are successfully treated with 4 cycles of BEP plus surgical removal of any remaining masses. Finally, about 15% of metastatic non-seminomas are poor-risk disease, and about 50% to 70% of these are cured with 4 cycles of BEP plus surgery to remove of any remaining masses. For patients with intermediate-risk or poor-risk disease who cannot have bleomycin due to side effects, 4 cycles of VIP chemotherapy, each lasting 21 days, has been shown to work just as well as 4 cycles of BEP. VIP consists of etoposide, ifosfamide and cisplatin chemotherapy plus a medication called mesna (Mesnex). Each of the medications is given on the first 5 days of the 21-day cycle.
Surgery after chemotherapy. After chemotherapy is completed, x-rays and CT scans are repeated to see if there are any masses remaining. If masses are seen, then surgery to remove them is usually performed if this is possible. The chance of the surgery curing the cancer is higher if the serum tumor markers are in the normal range when chemotherapy ends. This surgery is difficult and requires an experienced surgeon who regularly performs such operations. Very rarely, if the mass is pressing on the kidney or major blood vessels in the retroperitoneum, then major surgery, such as removal of the kidney and/or blood vessel grafts, may be needed. Often in this situation the nerves that are responsible for ejaculation cannot be spared. It is recommended that men talk about this with their doctors, in addition to banking sperm, before any chemotherapy is given.
During surgery, there is about a 40% to 50% chance that only scar tissue will be found, a 35% to 40% chance there will be teratoma, and a 10% to15% chance of some other type of germ cell tumor, such as embryonal carcinoma, seminoma, yolk sac tumor, or choriocarcinoma. If only scar tissue and/or a teratoma is found, then no additional treatment is needed. If cancer is found, 2 more cycles of chemotherapy may be given. The chemotherapy regimen used is typically either EP, TIP, VeIP, or VIP.
- Clinical trials. Patients with poor-risk disease are also encouraged to consider clinical trials as a treatment option.
Metastatic (stage III) seminoma testicular cancer
Chemotherapy. Chemotherapy for metastatic seminoma is the same as for metastatic non-seminoma (see above). About 90% of metastatic seminomas are good-risk disease and are successfully treated with 3 cycles of BEP. Approximately 10% of metastatic seminomas are intermediate-risk disease and are generally treated with 4 cycles of BEP. Men are encouraged to consider sperm banking before chemotherapy due to the risk of infertility.
Surgery after chemotherapy/radiation therapy. It is quite common for a mass to be found on imaging tests after chemotherapy or radiation therapy is finished. There is less than a 10% chance that this mass contains cancer and almost no chance that it contains teratoma. The main treatment options are active surveillance or surgery. Such surgery is often very difficult due to a “scar-like” reaction that makes the mass difficult to remove. This is unique to seminoma. Larger masses are more likely to contain cancer, so some believe surveillance should be used when a mass is smaller than 3 cm and surgery should be used for a mass 3 cm or larger.
A specific type of positron emission tomography (PET) scan, called an FDG-PET scan may be used to learn more about the mass. After the FDG-PET scan is done, the surgeon will operate only if the scan results show evidence of cancer in the remaining mass. A study showed that PET scans are more accurate than CT scans for determining if a remaining mass contains cancer, but it should be used only when the remaining mass is larger than 3 cm. The main benefit of PET scans is avoiding unnecessary surgery to remove masses that are noncancerous. If surgery is recommended but the surgeon determines that the mass cannot be removed, then a biopsy is often performed to try to find out whether the mass is cancerous. If cancer (seminoma) is found, then additional chemotherapy, referred to as second-line chemotherapy, is given.
If active surveillance is recommended and the mass grows, second-line chemotherapy is the preferred treatment. Surgery can be considered if the mass remains after the chemotherapy. If an RPLND is performed, men should consider sperm banking before surgery because of the risk of infertility.
For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.
Remission and the chance of recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.
A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
Regular follow-up examinations to check for signs that the cancer may be returning are extremely important. If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). Testicular cancer does not often return as a local recurrence because the entire testicle is removed. A rising beta-hCG or AFP may be a sign that the cancer has returned and more treatment is needed. Men who have had a testicular cancer recurrence are encouraged to see a doctor who is an expert in treating recurrent testicular cancer.
When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the treatments described above such as surgery, chemotherapy, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.
For recurrent testicular cancer, treatment usually includes chemotherapy and surgery. If the cancer was stage I and returns during active surveillance, then the most common treatment is chemotherapy with 3 or 4 cycles of BEP or 4 cycles of EP depending on the stage of the cancer. If the cancer is only in the retroperitoneal lymph nodes and is a pure seminoma, then radiation therapy is the usual treatment. If the cancer is only in the retroperitoneal lymph nodes and is a non-seminoma, RPLND only may be considered instead of chemotherapy.
The standard treatment for recurrent testicular cancer that has previously been treated with chemotherapy is 4 cycles of additional chemotherapy. The standard chemotherapy regimens include VeIP and TIP. Sometimes, high-dose chemotherapy with stem cell transplantation may be used but it is not known if high-dose chemotherapy works better than standard-dose chemotherapy. If chemotherapy is given, any remaining masses are managed the same way that they are after initial chemotherapy (see above). A recurrence more than 2 years after treatment should be removed surgically if possible. Chemotherapy may or may not be recommended after surgery.
A man with recurrent testicular cancer is encouraged to talk with doctors who have experience in treating recurrent testicular cancers before choosing a treatment approach.
People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. >