Adjuvant Therapy
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Known as adjuvant therapy, post-surgical treatment depends partly on whether the cancer has spread beyond the testicle. It can also depend on what type the tumor is. Testicular tumors are either pure seminoma, nonseminomatous, or some combination of the two types. Seminomas -- cancers that occur when germ cells, the cells that divide to produce sperm cells, become cancerous at a very early stage in their development -- are the most common type of testicular tumor, accounting for 50 percent of cases. In most cases of early stages of seminoma, a three-week course of daily external beam radiation treatments is given to the lymph node regions in the abdomen and pelvis.
The rest are different types of nonseminomatous tumors and mixtures of tumor types. Twenty to 25 percent are embryonal carcinomas, which can arise in more mature germ cells. Another 25 to 30 percent are teratoma carcinomas, which contain different kinds of tissue, often types not normally found in the testes. These other types of tissue are present because the malignant germ cells begin to "differentiate" or develop into various types of body tissue -- for example cartilage, nerve, or muscle -- which normally does not happen until after the mature sperm cell combines with a woman's egg cell. As they develop, these prematurely differentiated cells can sometimes become malignant. About one percent of testicular cancers are choriocarcinomas, a particularly malignant type of germ cell tumor that shares some characteristics with placenta, the blood-filtering tissue that normally forms in the uteruses of pregnant women.
Testicular cancers tend to spread through the spermatic cord, the tube that carries sperm away from the testicle, and through associated blood and lymph vessels to the nearby lymph glands, called the retroperitoneal lymph nodes. When the disease spreads beyond the lymph nodes, it's most likely to arise in the lungs or the liver.
Occasionally in patients with nonseminomatous tumors, or in patients in whom there is no sign that disease has spread beyond the testicle, doctors will recommend surveillance after surgery, waiting to see if there is a relapse before starting any further treatment. This approach is followed because, when the main tumor is removed early, testicular cancer has a high cure rate even if there is a relapse, meaning that there may be no clear advantage to treatment if there is no evidence the disease has spread. Given the slight risk of leukemia that results from the use of some chemotherapies, Memorial Sloan-Kettering doctors usually avoid chemotherapy for testicular cancer patients unless there is evidence that the disease has spread. When doctors do use chemotherapy for testicular cancer, they will usually administer cisplatin and etoposide, two drugs that do a very good job of controlling the disease with minimal side effects.
The Management of Low-Volume Seminoma -- I, IIA
In the United States, radiation therapy remains the treatment of choice for patients with clinical Stage I and IIa seminoma. Although the clinical data for adjuvant radiation therapy used to treat clinical Stage I seminoma suggest that almost all patients are cured, the concern for long-term side effects from irradiation has resulted in the emergence of surveillance protocols for patients with clinical Stage I seminoma. Surveillance protocols require careful, long-term follow-up, and seminoma patients are disadvantaged because disease markers, known as serum tumor markers, are frequently not elevated until late in the disease progression. Approximately 15 to 20 percent of patients will relapse on surveillance, with the majority occurring during the first two years, although relapses have occurred beyond five years.
The Management of Low-Volume Nonseminomatous Germ Cell Tumors -- I, IIA
Following radical orchiectomy, many patients with clinical stage I nonseminomatous germ cell tumors (NSGCT) are cured. However approximately 20 percent to 30 percent of patients are what's known as under-staged by CT scan, meaning they will either relapse systemically or in the retroperitoneum (the area of the abdomen behind all the abdominal organs). Treatment options for patients with clinical stage I NSGCT include surveillance or primary retroperitoneal lymph node dissection (RPLND). Primary RPLND is both a diagnostic and therapeutic procedure, in which lymph nodes from the retroperitoneum are removed for biopsy or, if cancer is found, treatment. Approximately 30 percent of patients with clinical stage I NSGCT and 60 percent of patients with clinical stage IIa NSGCT will be found to have retroperitoneal metastases at the time of RPLND and the majority of these patients are cured with RPLND. Patients with what's known as bulky metastatic disease during RPLND are usually treated with chemotherapy following surgery to prevent disease recurrence. With this approach, approximately 98 percent of patients will remain free of disease.
The Management of Advanced Germ Cell Tumors --IS, IIB, IIC, III
Patients with advanced germ cell tumors (IIB - III) and those with persistently elevated tumor markers following radical orchiectomy (IS) are initially treated with platinum-based chemotherapy according to the International Germ Cell Cancer Collaborative Group risk stratification. Following completion of chemotherapy, the majority of patients with metastatic nonseminoma should undergo a RPLND. Following chemotherapy, approximately 40 percent of patients undergoing RPLND will have teratoma in their retroperitoneum, and an additional 10 to 15 percent will have a germ cell tumor. Following RPLND, the vast majority of patients with fibrosis and teratoma will be cured of their disease, although life-long follow-up is necessary.
For the majority of patients with metastatic seminoma, close surveillance is performed following chemotherapy.
Treatment and Fertility
Although potency is not usually impaired by testicular cancer treatment, the ability to produce viable sperm (fertility) can be destroyed by chemotherapy and radiation treatments. For this reason, Memorial Sloan-Kettering doctors recommend that patients whose treatment regimen will carry the risk of sterility store sperm before treatment starts. This sperm will be frozen and could possibly be used later to conceive a child, which might otherwise be impossible. Artificial or prosthetic testicles are sometimes used.
