Cancer of the Testicle (cont.)
Surgery and Treatment by Stage
Surgery: A second more complex surgery is offered to some men. This surgery is designed to remove any residual cancer in the retroperitoneal lymph nodes and is called a 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 a high risk of cancer in the retroperitoneum. It is also commonly recommended following chemotherapy if abnormally enlarged lymph nodes are present in the retroperitoneum. 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.
- In some cases, both RPLND and chemotherapy are recommended.
Summary of treatment by stage
- Seminoma: Orchiectomy with or without radiation to the retroperitoneum
- There is a 15% chance that tumor will spread to the retroperitoneum.
- Because radiation can eliminate this cancer 99% of the time and is generally very well tolerated, radiation therapy is typically recommended.
- Single dosage of chemotherapy (carboplatin [Paraplatin]) may be an effective alternative treatment but is not commonly recommended in the United States.
- For those who choose surveillance, frequent visits (every one to two 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% do have microscopic spread. This risk can be predicted by a pathologic evaluation of the testicular tumor and depends on the presence of embryonal carcinoma or invasion of the cancer into the lymphatic/blood vessels.
- Treatment options include surgery to remove the lymph nodes in the retroperitoneum (RPLND), chemotherapy, or surveillance.
- Seminoma: Orchiectomy followed by radiation therapy, although chemotherapy is also effective
- Nonseminoma: Chemotherapy or RPLND
- Seminoma: Either radiation or chemotherapy
- Nonseminoma: Either chemotherapy or RPLND
Stage IIC, III
- Seminoma: Chemotherapy followed by post-chemotherapy RPLND, if needed
- Nonseminoma: Chemotherapy followed by post-chemotherapy RPLND, if needed
Most non-germ cell testicular tumors usually require no further treatment after orchiectomy. If there is a high-risk of metastases or if metastases are present, further surgery is often recommended.
Steven C Campbell, MD, PhD
Scott H Plantz, MD, FAAEM
Francisco Talavera, PharmD, PhD
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