Font Size

Cancer of the Testicle (cont.)

Cancer of the Testicle Treatment

Medical Treatment

The initial treatment for testicular cancer is orchiectomy (surgical removal of the testicle and the attached cord). This is the standard therapy and is recommended for all men with testicular cancer.

Whether you have additional therapy following surgery depends on a number of factors: the tumor type, the location and extent of the cancer (whether it is limited to the scrotum or has spread to the abdominal cavity or other sites), and your urologist's preference on further treatment. You should discuss your urologist's recommendations and the risks and benefits of each before making a decision. You may want to consider getting a second opinion before beginning treatment.

For germ cell tumors, the following options are available for treatment after orchiectomy.

Surveillance: This is sometimes called "watchful waiting" or "observation." What it means is that you receive no further treatment after orchiectomy but must adhere to a very strict schedule of frequent follow-up visits with your urologist. The idea is to catch the earliest hint of residual cancer and then proceed with treatment at that point.

Surveillance protocols vary from urologist to urologist, but a typical protocol would require visits every 1-2 months for the first year, with tumor markers, chest x-ray, and CT scan of the abdomen done at every visit or every other visit.
This goes on indefinitely, gradually (over 5 or more years) tapering the frequency of the visits and tests to once per year (as long as no cancer is detected).
Surveillance is a gamble. You are betting that you have no residual disease but that, if you do, it will be found early. On the other hand, you are avoiding the potentially severe side effects of and lengthy recovery from chemotherapy or radiation therapy.
If you are concerned about being able to stick with the rigorous surveillance schedule, immediate radiation therapy or chemotherapy may be the best choice for you.
Surveillance is not recommended for all men with testicular cancer. Generally, it is reserved for men with stage I disease.
Statistically, men who choose surveillance have just as good a chance of cure as men who proceed with immediate treatment.
The risks and benefits are complex. These should be discussed in great detail with your urologist before making a decision.

Chemotherapy: Combinations of drugs are the standard, whether a cancer is good risk or bad risk. The revolution in treatment of testicular cancer is attributed to the use of these regimens. The drugs are given in cycles consisting of about 5 days of intense treatment followed by a recovery period of 2-3 weeks.

Chemotherapy is strongly recommended for stage III disease.
You will be referred to a cancer specialist (oncologist) for your chemotherapy.
Good-risk tumors are treated with a combination called BEP (bleomycin, etoposide, and cisplatin) for 3 cycles or a combination of etoposide and cisplatin for 4 cycles, since many people cannot tolerate bleomycin.
Bad risk tumors are also treated with BEP, but for 4 cycles. Another option is VIP (etoposide [VP-16], ifosfamide, and cisplatin).
Each cycle lasts 3-4 weeks, although the next cycle may be postponed if you have severe side effects.
In rare cases of very aggressive cancer, high-dose chemotherapy with stem cell transplant is used. This is not offered unless regular chemotherapy has not worked to control the disease.
Side effects may include kidney dysfunction, changes in skin sensation (17-45% of men), hearing changes (30-40%), decreased blood circulation to extremities (25-50%), lung damage, and infertility (50%).

Radiation therapy: Radiation is the targeting of a beam of high-energy radiation directly at the tumor. In testicular cancer, the beam is targeted mainly at the lower abdomen to destroy any residual disease in lymph nodes.

Radiation is usually offered for stage I or stage II disease.
You will be referred to a specialist in radiation therapy (radiation oncologist) for this treatment.
The radiation is given in a series of brief treatments 5 days a week, usually for 3-4 weeks. The repeated treatments help destroy the tumor.
Seminoma is especially responsive to radiation.
The remaining testicle is shielded to prevent damage to healthy tissue.
Side effects include nausea (50%), vomiting (6%), diarrhea, loss of energy, irritation or mild burning of the skin exposed to the radiation beam, impaired fertility, and slightly increased risk of other cancers or leukemia.

Surgery: A second, much more complex surgery is offered to some men. This surgery is designed to get rid of any residual cancer in the retroperitoneal lymph nodes, and is called retroperitoneal lymph node dissection, or RPLND.

This surgery is not offered to all men with testicular cancer. It is usually offered to men with stage I or II nonseminoma who are thought to have residual disease. It is almost never offered to men with seminoma.
The decision to go ahead with RPLND is based on tumor marker levels and findings of CT scan of the abdomen after orchiectomy. Rising or persistently high tumor marker levels or enlarged lymph nodes on the CT scan after orchiectomy strongly suggest residual cancer. Most experts recommend chemotherapy in these cases, not RPLND.
More and more, chemotherapy is being given after orchiectomy in place of RPLND.
In some cases, both RPLND and chemotherapy are recommended.

Summary of treatment by stage

Stage I

Seminoma - Orchiectomy with or without radiation to the retroperitoneum
- There is a 15% chance that tumor will spread to the retroperitoneum.
- Because radiation can destroy this cancer 99% of the time and is generally very well tolerated, radiation therapy is typically recommended.
- For those who choose surveillance, frequent visits (every 1-2 months) and tests are essential.
Nonseminoma - Orchiectomy followed by RPLND or chemotherapy
- Of men who have no evidence of cancer spread on CT scan, 30-50 percent actually do have microscopic spread.
- Treatment options include surgery to remove the lymph nodes in the retroperitoneum (RPLND), chemotherapy, or surveillance.

Stage IIA