What is the initial treatment for testicular cancer?

Initial Treatment for Testicular Cancer

Radical inguinal orchiectomy is the initial treatment for testicular cancer, serving as both the diagnostic and therapeutic first step for nearly all patients. 1, 2

Pre-Orchiectomy Requirements

Before proceeding to surgery, the following must be completed:

• Obtain serum tumor markers (AFP, β-HCG, and LDH) before any surgical intervention, as these are essential for diagnosis confirmation, risk stratification, and subsequent monitoring 1, 2, 3
• Perform high-frequency scrotal ultrasound to confirm the presence and characteristics of the testicular mass 2
• Offer sperm cryopreservation to all patients before orchiectomy, as subsequent treatments (chemotherapy or radiation) will impair fertility 2, 3
• Counsel patients about risks of hypogonadism and infertility 2

Surgical Approach

• Radical inguinal orchiectomy with division of the spermatic cord at the internal inguinal ring is the standard procedure 2
• Never use a scrotal approach, as this violates lymphatic drainage patterns and significantly increases local recurrence rates 2, 3, 4

Exception: Life-Threatening Metastatic Disease

In patients presenting with extensive, rapidly progressive metastases (particularly lung metastases causing respiratory compromise), there is one critical exception to the orchiectomy-first approach:

• Chemotherapy may be initiated immediately based on clinical presentation and elevated tumor markers alone, without waiting for orchiectomy histology 1, 3
• This applies specifically to patients with life-threatening disease burden where delay could compromise survival 1, 3
• Delayed orchiectomy is then performed after chemotherapy completion, either as a standalone procedure or simultaneously with resection of residual masses 5, 6
• The testis may serve as a sanctuary site during systemic treatment, making eventual orchiectomy mandatory even after chemotherapy 6

Post-Orchiectomy Staging Workup

After orchiectomy, complete the following before determining subsequent treatment:

• Repeat tumor markers at 7 days post-operatively to assess half-life kinetics 2, 3
• CT chest, abdomen, and pelvis for staging 1, 2, 3
• Full blood count, renal function (urea, creatinine, electrolytes), and liver function tests 1
• Brain MRI (or CT if MRI unavailable) if β-HCG >10,000 IU/L or >10 lung metastases present 3
• Bone scan if alkaline phosphatase elevated or bone symptoms present 1, 3

Subsequent Treatment Based on Stage and Histology

Stage I Pure Seminoma (70-75% of cases at diagnosis)

• Surveillance is the preferred option (pT1 and pT2 disease) 2, 7
• 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, 2
• All three approaches achieve similar long-term survival (99% 5-year survival) 2, 7
• Carboplatin or surveillance are preferred over radiotherapy due to long-term risk of second malignancy with radiation 1

Stage I Non-Seminomatous Germ Cell Tumor (NSGCT)

• Risk stratification based on vascular invasion determines management 2
• Low-risk patients: surveillance 2
• High-risk patients: adjuvant chemotherapy with BEP × 2 cycles 2

Stage IIA-B Seminoma

• Dogleg radiotherapy to 30-36 Gy in 15-18 fractions to involved site 1
• Chemotherapy (as for stage IIC) is an active alternative 1

Stage IIC-III or Metastatic Disease

• Cisplatin-based combination chemotherapy (BEP regimen) is the standard treatment 2, 3, 8
• Good prognosis patients: BEP × 3 cycles 2
• Intermediate or poor prognosis patients: BEP × 4 cycles 2
• BEP consists of bleomycin, etoposide (FDA-approved for refractory testicular tumors) 9, and cisplatin 8

Critical Pitfalls to Avoid

• Do not delay chemotherapy in patients with extensive lung metastases waiting for orchiectomy—start treatment based on markers and clinical picture 1, 3
• Never perform scrotal biopsy or scrotal approach surgery for suspected testicular tumors 2, 3, 4
• Always obtain tumor markers before orchiectomy, as they are essential for staging and cannot be accurately interpreted afterward 2, 3, 4
• Do not skip sperm banking counseling, as this is the only opportunity to preserve fertility before treatment 2, 3

Expected Outcomes

With appropriate initial treatment, outcomes are excellent:

• Stage I: 99% 5-year survival 2, 7
• Stage II: 92% 5-year survival 2, 7
• Stage III: 85% 5-year survival 2, 7

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