What are the treatment options for testicular cancer?

Treatment Options for Testicular Cancer

Radical inguinal orchiectomy is the primary treatment for all patients with testicular cancer, followed by risk-stratified management based on histology (seminoma vs. nonseminoma) and clinical stage, with surveillance being the preferred option for most stage I disease. 1, 2

Initial Treatment: Radical Inguinal Orchiectomy

• All patients require radical inguinal orchiectomy with division of the spermatic cord at the internal inguinal ring as both diagnostic and therapeutic intervention 2
• A scrotal approach must be avoided due to higher local recurrence rates 2
• Sperm banking should be offered before any treatment due to risks of infertility and hypogonadism 2
• Serum tumor markers (AFP, hCG, LDH) must be obtained before orchiectomy to support diagnosis and guide subsequent management 2

Stage I Seminoma Treatment Algorithm

Surveillance is the strongly preferred option for stage I seminoma (pT1 and pT2 disease), as over 80% of patients are cured with orchiectomy alone and disease-specific survival approaches 100% regardless of management strategy 1, 2

Alternative options include:

• Adjuvant carboplatin (1-2 cycles, AUC × 7) for patients who prefer reduced relapse risk 2
• Adjuvant radiation therapy (20 Gy in 10 fractions) to para-aortic lymph nodes 2
• Both alternatives reduce relapse rates but expose patients to treatment-related morbidity when most would never relapse 1

Surveillance Protocol for Stage I Seminoma:

• History, physical examination, and cross-sectional imaging of abdomen ± pelvis every 4-6 months for years 1-2 1
• Then every 6-12 months for years 3-5 1
• Routine chest imaging and tumor markers only as clinically indicated, since most relapses are detected on abdominal-pelvic imaging 1

Stage I Nonseminomatous Germ Cell Tumor (NSGCT) Treatment Algorithm

Risk stratification based on lymphovascular invasion determines management:

Low-Risk NSGCT (No Lymphovascular Invasion):

• Surveillance is preferred 2
• Physical examination and tumor markers (AFP, hCG ± LDH) every 2-3 months in year 1, every 2-4 months in year 2, every 4-6 months in year 3, and every 6-12 months for years 4-5 1
• Chest x-ray and abdominal ± pelvic imaging every 3-6 months in year 1, every 4-12 months in year 2, once in year 3, and once in year 4 or 5 1

High-Risk NSGCT (Lymphovascular Invasion Present):

• Adjuvant chemotherapy with BEP × 2 cycles 2
• Shorter imaging intervals recommended due to higher relapse risk 1

Alternative: Primary Retroperitoneal Lymph Node Dissection (RPLND)

• Referral to experienced surgeon at high-volume center is recommended 1
• Full bilateral template dissection required for suspicious lymph nodes or somatic-type malignancy 1
• Modified template dissection may be performed for clinically negative nodes 1
• Nerve-sparing should be offered to preserve ejaculatory function without compromising lymph node dissection quality 1

Advanced/Metastatic Disease Treatment

Management decisions must be based on imaging within 4 weeks and tumor markers within 10 days, with treatment determined by IGCCCG risk group 1

Good-Risk Disease:

• BEP × 3 cycles (bleomycin, etoposide, cisplatin) OR EP × 4 cycles (etoposide, cisplatin) 1, 2
• Over 90% cure rate with standard chemotherapy 3

Intermediate or Poor-Risk Disease:

• BEP × 4 cycles 1, 2
• Approximately 80% overall cure rate with modern chemotherapy 3

Salvage Chemotherapy:

• For patients not cured with initial BEP, salvage chemotherapy with tandem transplant of high-dose chemotherapy with peripheral stem cell rescue cures approximately 50% 3

Stage II Disease

Stage IIA/IIB Seminoma:

• Chemotherapy or radiation therapy options based on nodal size 1

Stage IIA/IIB NSGCT:

• Either primary RPLND or chemotherapy based on extent of nodal involvement 1

Special Considerations

Testis-sparing surgery may be considered for highly selected patients with masses <2 cm, solitary testis (congenital or acquired), or bilateral synchronous tumors, though patients must be counseled about higher local recurrence risk 2

Critical Management Principles

• All management decisions should be made in a multidisciplinary setting involving experienced clinicians in urology, medical oncology, radiation oncology, pathology, and radiology 1
• Expert pathology review should be considered when treatment decisions will be impacted 1
• For equivocal imaging findings with normal tumor markers, repeat imaging in 6-8 weeks may clarify disease extent and avoid overtreatment 1
• Adequate time must elapse for tumor markers to normalize post-orchiectomy (hCG half-life: 24-36 hours; AFP: 5-7 days) before making treatment decisions 1

Common Pitfalls to Avoid

• Never treat post-pubertal males <18 years according to pediatric protocols, as this results in inferior outcomes; use adult disease guidelines 1
• Avoid scrotal orchiectomy approach due to altered lymphatic drainage and higher recurrence 2
• Do not obtain PET scan for staging, as it is not recommended 1
• Ensure TNM-s category assignment to guide management decisions 1

Prognosis

Five-year survival rates are excellent: 99% for stage I, 92% for stage II, and 85% for stage III disease 2, 4