What are the treatment options for testicular cancer?

Treatment Options for Testicular Cancer

The primary treatment for testicular cancer is radical inguinal orchiectomy, followed by stage-specific therapy including surveillance, radiation therapy, chemotherapy, or retroperitoneal lymph node dissection, with overall 5-year survival rates exceeding 85% even in advanced disease. 1, 2

Initial Diagnosis and Management

• Diagnosis begins with high-frequency testicular ultrasound to confirm testicular mass, followed by serum tumor markers including alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) prior to orchiectomy 1
• Radical inguinal orchiectomy with division of the spermatic cord at the internal inguinal ring serves as both diagnostic and therapeutic intervention for most patients 1, 3
• Scrotal approach should be avoided due to higher local recurrence rates 1
• Patients should be counseled about risks of hypogonadism and infertility, with sperm banking offered before any treatment 1

Treatment by Histology and Stage

Pure Seminoma

• Stage I:
  • Surveillance is the preferred option (category 1) for patients with pT1 and pT2 disease 1
  • Alternative options include adjuvant carboplatin (1-2 cycles, AUC × 7) or adjuvant radiation therapy (20 Gy in 10 fractions) to para-aortic lymph nodes 1

Non-Seminomatous Germ Cell Tumors (NSGCT)

• Stage I:
  • Risk stratification based on vascular invasion, with low-risk patients undergoing surveillance and high-risk patients receiving adjuvant chemotherapy with BEP × 2 cycles 1
• Advanced Disease:
  • Good prognosis patients: BEP × 3 cycles 1
  • Intermediate or poor prognosis patients: BEP × 4 cycles 1
  • Cisplatin is administered at 20 mg/m² IV daily for 5 days per cycle in combination with other chemotherapeutic agents 4

Special Considerations

• Testis-sparing surgery (TSS) may be considered for highly selected patients with masses <2cm, congenital or acquired solitary testis, or bilateral synchronous tumors 1
• Patients considering TSS should be counseled about higher risk of local recurrence and need for monitoring 1
• For patients with germ cell neoplasia in situ (GCNIS), management options include radiotherapy, surveillance, or orchiectomy 1
• Ifosfamide in combination with cisplatin and either vinblastine or etoposide has shown efficacy in patients who have failed prior chemotherapy regimens 5

Follow-up Protocols

• For patients on surveillance: 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 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 1

Prognosis

• Disease-specific survival for stage I seminoma is 99%, regardless of management strategy 1, 2
• Overall 5-year survival rates are 99% for stage I, 92% for stage II, and 85% for stage III 1, 2
• Even in patients with advanced or metastatic disease, 5-year survival rates exceed 70% with current treatment options 6

Common Pitfalls and Caveats

• Delay in diagnosis can lead to more advanced disease; prompt referral to a urologist is essential when testicular cancer is suspected 2
• Needles or intravenous sets containing aluminum parts should not be used for preparation or administration of cisplatin as aluminum reacts with cisplatin, causing precipitate formation and loss of potency 4
• Treatment decisions should balance oncologic control with survivorship concerns to minimize long-term adverse effects including fertility issues, hypogonadism, cardiovascular disease, and secondary malignancies 2
• Optimal treatment often involves a multidisciplinary team at high-volume, experienced medical centers 2