What is the treatment approach for testicular tumors?

Treatment Approach for Testicular Tumors

Radical inguinal orchiectomy is the primary treatment for testicular tumors, followed by risk-stratified management based on histology (seminoma vs. nonseminoma) and clinical stage, with surveillance preferred for stage I disease to minimize treatment-related morbidity while maintaining excellent cure rates. 1, 2

Initial Surgical Management

Radical Inguinal Orchiectomy

• Radical inguinal orchiectomy with division of the spermatic cord at the internal inguinal ring is both diagnostic and therapeutic for most patients presenting with a testicular mass 1, 2
• The scrotal approach must be avoided as it is associated with higher local recurrence rates and potential tumor seeding 1, 2
• Surgery should be performed before any other treatment unless life-threatening metastatic disease with clear clinical diagnosis by marker elevation requires immediate chemotherapy 1

Testis-Sparing Surgery (Highly Selected Cases)

• May be considered for masses <2 cm, solitary testis, bilateral synchronous tumors, or contralateral atrophic testis 1, 2
• Requires intraoperative frozen section and should only be performed at highly experienced centers 1
• Patients must be counseled about higher local recurrence risk 2

Pre-Treatment Considerations

• Sperm banking must be discussed and offered before any treatment (surgery, chemotherapy, or radiation) that may compromise fertility 1, 2
• Serum tumor markers (AFP, β-HCG, LDH) must be obtained before orchiectomy and followed until normalization 1

Stage I Pure Seminoma Management

Surveillance is the preferred strategy for stage I seminoma, as disease-specific survival is 99% regardless of management approach, making minimization of treatment toxicity the priority 1, 2

Treatment Options (in order of preference):

1. Surveillance (Category 1, preferred) 1, 2

   • Lowest risk for short and long-term treatment-related morbidity 1
   • Over 80% of patients are cured with orchiectomy alone 1

2. Adjuvant Carboplatin (less preferred alternative) 1, 2

   • 1-2 cycles at AUC × 7 1, 2
   • Results in similar relapse rates to radiotherapy with less protracted treatment-related lethargy and probably fewer treatment-induced malignancies 1

3. Adjuvant Radiation Therapy (less preferred alternative) 1, 2

   • 20 Gy in 10 fractions to para-aortic lymph nodes 1, 2

Risk Factors

• Rete testis infiltration and tumor size ≥4 cm are sometimes used to guide adjuvant treatment decisions, though their predictive value is controversial 1

Stage IIA Seminoma (Lymph Nodes 1-2 cm)

• Treatment options include cisplatin-based chemotherapy or radiotherapy to para-aortic and ipsilateral iliac lymph nodes with 30 Gy in 2 Gy fractions 1
• Recent evidence shows 10.9% relapse rate with radiotherapy versus no relapses after cisplatin-based chemotherapy in small cohorts 1

Stage IIB/IIC and Stage III Seminoma

• Three cycles of BEP (bleomycin, etoposide, cisplatin) represent standard therapy 1, 3
• For good prognosis patients: 3 cycles of BEP or alternatively 4 cycles of EP 1
• For intermediate prognosis patients: 4 cycles of BEP 1, 2
• If contraindications to bleomycin exist (reduced lung capacity, emphysema, heavy smoking): consider 4 cycles of VIP (etoposide, ifosfamide, cisplatin) 1

Non-Seminomatous Germ Cell Tumors (NSGCT)

Stage I NSGCT Risk Stratification

• Low-risk (absence of vascular invasion, ~20% relapse rate): Surveillance preferred 1, 2
• High-risk (presence of vascular invasion, 40-50% relapse rate): Adjuvant chemotherapy with BEP × 2 cycles 1, 2

Metastatic NSGCT

• Treatment according to IGCCCG risk classification 1
• Good-risk disease: BEP × 3 cycles or EP × 4 cycles 1, 2
• Intermediate or poor-risk disease: BEP × 4 cycles 1, 2

Post-Chemotherapy Management for Seminoma

Residual Tumor Assessment

• FDG-PET scan minimum 6 weeks after ending chemotherapy 1
• For lesions >3 cm: FDG-PET is the recommended approach 1
• For lesions <3 cm: FDG-PET may be considered but surveillance is preferred due to lower positive predictive value 1
• Negative PET scan (>90% negative predictive value) warrants follow-up only 1
• Positive PET scan indicates high possibility of residual seminoma; biopsy may be performed before treatment by irradiation or resection 1

Critical Pitfalls to Avoid

• Never perform scrotal biopsy or open surgery through the scrotum—this leads to tumor seeding and altered lymphatic drainage 1, 2
• Do not misclassify testicular masses as epididymitis/orchitis, which delays diagnosis; any persistent testicular abnormality after antibiotics warrants further evaluation 1
• Ensure adequate time elapses for tumor marker normalization (β-HCG half-life: 24-36 hours; AFP: 5-7 days) before staging decisions 1
• Management decisions must be made in a multidisciplinary setting with experienced clinicians in urology, medical oncology, radiation oncology, pathology, and radiology 1
• Patients with elevated AFP should be managed as nonseminoma even if histology shows pure seminoma 1

Special Populations

Elderly Patients

• More susceptible to nephrotoxicity and peripheral neuropathy from cisplatin-based chemotherapy 3
• Careful monitoring of renal function (serum creatinine, BUN, creatinine clearance) required before each treatment cycle 3

Pediatric Patients

• Inferior outcomes occur when post-pubertal males <18 years are treated according to pediatric rather than adult disease guidelines 1
• All pediatric patients receiving cisplatin require audiometric testing at baseline, before each dose, and for several years post-therapy 3

Prognosis

• 5-year survival rates: 99% for stage I, 92% for stage II, and 85% for stage III 2, 4
• Disease-specific survival for stage I seminoma is 99% regardless of management strategy 1, 2