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 nonseminomatous germ cell tumors 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.
- Nonseminomatous germ cell tumors: 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. Elevated tumor markers which do not return to normal after the orchiectomy indicate this as well.
- 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
- Nonseminomatous germ cell tumor: 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.
Testicular Cancer Surgery (Without Medical Treatment)
Orchiectomy: This operation removes the entire testicle and the attached cord.
- A small incision is made where the leg meets the abdomen (the inguinal region) on the side of the testicle with the tumor.
- The testicle and attached cord are gently moved up out of the scrotum and out of the incision. Only a few stitches are needed.
- Typically, the surgery takes 20-40 minutes. It can be done with a general, spinal, or local anesthetic.
- Absorbable stitches are usually used, and the patient can go home the same day as surgery.
- Many urologists recommend that men bank their semen prior to the surgery, because it can take months to years after therapy to return to full fertility.
- This surgery is recommended for all men with testicular cancer. It is the first and, for some men, the only treatment needed.
- This surgery should not interfere with normal erection, ejaculation, orgasm, or fertility.
Retroperitoneal lymph node dissection: This operation removes the retroperitoneal lymph nodes when they are thought to harbor cancer.
- This is a complex and lengthy surgery that requires a single large incision or several small incisions in the abdomen.
- Most of the abdominal organs have to be moved to get at the retroperitoneal area.
- The operation itself takes several hours and requires general anesthesia.
- Patients will stay in the hospital for about three to five days.
- Besides the usual complications of surgery and general anesthesia, this operation involves the possibility of nerve damage causing retrograde ejaculation. This means that instead of ejaculating in the usual manner, the semen moves backward and ends up in the bladder. This occurs in fewer than 5% of men who have this operation. If there is a large lymph node in the retroperitoneum, rates of retrograde ejaculation increase.
- Another possible complication is intestinal blockage caused by scarring in the abdomen.
Medically Reviewed by a Doctor on 11/20/2017
Steven C Campbell, MD, PhD
Scott H Plantz, MD, FAAEM
Francisco Talavera, PharmD, PhD
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