What are the treatment options for testicular cancer?

Treatment Options for Testicular Cancer

Radical inguinal orchiectomy is the primary treatment for most patients with testicular cancer, followed by stage-specific management including surveillance, chemotherapy, radiation therapy, or retroperitoneal lymph node dissection based on histology and risk factors. 1, 2

Initial Diagnosis and Management

• High-frequency testicular ultrasound should be performed to confirm the presence of a testicular mass and determine if it is intratesticular or extratesticular 1
• Serum tumor markers including alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) must be obtained before orchiectomy as they support diagnosis and may indicate germ cell tumor histology 1
• Patients should be counseled about risks of hypogonadism and infertility, with sperm banking offered before any treatment 1
• Radical inguinal orchiectomy with division of the spermatic cord at the internal inguinal ring is both diagnostic and therapeutic for most patients 1, 2
• A scrotal approach should be avoided as it is associated with higher local recurrence rates 1

Treatment by Histology and Stage

Pure Seminoma

Stage I (IA and IB)

• Surveillance is the preferred option (category 1) for patients with pT1 and pT2 disease 1
• Alternative options if surveillance is not applicable:
  • Adjuvant carboplatin (1-2 cycles, AUC × 7) - category 1 recommendation 1
  • Adjuvant radiation therapy (20 Gy in 10 fractions) to para-aortic lymph nodes - category 1 recommendation 1

Stage II and III

• Chemotherapy regimens according to risk status:
  • Good prognosis: BEP (bleomycin, etoposide, cisplatin) × 3 cycles 1
  • Intermediate prognosis: BEP × 4 cycles 1
• Residual masses post-chemotherapy should be surgically resected when possible 1

Non-Seminomatous Germ Cell Tumors (NSGCT)

Stage I

• Risk stratification based on vascular invasion:
  • Low risk (no vascular invasion): Surveillance protocol 1
  • High risk (with vascular invasion): Adjuvant chemotherapy with BEP × 2 cycles 1
  • Alternative for patients who cannot receive chemotherapy: Nerve-sparing retroperitoneal lymph node dissection (RPLND) 1

Stages II-IV

• Treatment based on International Germ Cell Consensus Classification risk groups:
  • Good prognosis: BEP × 3 cycles 1
  • Intermediate or poor prognosis: BEP × 4 cycles 1
• Cisplatin dosing for testicular cancer: 20 mg/m² IV daily for 5 days per cycle 3

Special Considerations

Testis-Sparing Surgery (TSS)

• May be offered to highly selected patients with:
  • Masses <2cm with equivocal ultrasound/physical exam findings and negative tumor markers, or
  • Congenital, acquired, or functionally solitary testis, or
  • Bilateral synchronous tumors 1
• Patients considering TSS should be counseled about higher risk of local recurrence and need for monitoring 1

Germ Cell Neoplasia In Situ (GCNIS)

• Management options include:
  • Radiotherapy to the affected testis (18-20 Gy in 10 fractions)
  • Surveillance (if future fertility is desired)
  • Orchiectomy 1

Follow-up Protocols

Surveillance Protocol

• Clinical review, chest X-ray, and tumor markers monthly for 1 year, every 2 months for 2nd year, every 4 months for 3rd year, then every 6 months to 5 years
• CT scans after 3,6,9,12, and 24 months 1

Post-chemotherapy Follow-up

• Clinical review, chest X-ray, and tumor markers every 2 months for 1 year, every 3 months for 2nd year, then every 6 months to 5 years, and then annually
• CT scans only as clinically indicated 1

Prognosis

• Disease-specific survival for stage I seminoma is 99%, regardless of management strategy 1
• Overall 5-year survival rates:
  • Stage I: 99%
  • Stage II: 92%
  • Stage III: 85% 4

Common Pitfalls and Caveats

• An elevated AFP level indicates nonseminoma, and patients should be managed accordingly, even if histology shows pure seminoma 1
• Tumor size >4cm and rete testis invasion are not reliable predictors of relapse in stage I pure seminoma 1
• For patients with borderline elevated tumor markers post-orchiectomy (within 3× upper limit of normal), a rising trend should be confirmed before management decisions as false positives may occur 1
• Patients with multiple lung metastases or extensive disease may require urgent chemotherapy even before histological confirmation 1