Treatment - Testicular Cancer

Treatment (After Orchiectomy)

• Seminoma. The majority of seminomas are confined to the testis and are very sensitive to external beam radiation therapy. Adjuvant low-dose (1500 cGy) radiation to the retroperitoneum and ipsilateral pelvis is recommended for patients with stage I seminoma given that approximately 15 percent of patients on surveillance will relapse. In the era of platinum-based chemotherapy, prophylactic mediastinal radiotherapy is no longer recommended. The 5-year actuarial cure rates approach 97 percent in low stage disease. Patients may elect to forego radiotherapy and choose surveillance with the understanding that up to 17 percent will relapse within 5 years. These patients should be committed to intense monthly follow-up and may be salvaged in up to 80 percent of cases by platinum based chemotherapy. Proponents in favor of adjuvant radiotherapy argue that some patients who elect surveillance may never be salvaged given the bulk of disease at presentation. Some debate exists with regard to treatment for intermediate stage disease, whereas most agree that chemotherapy should be employed in bulky or advanced disease (stage IIb and III). Although anaplastic seminoma usually presents at a higher stage than classic seminoma, it carries the same prognosis stage for stage and should be treated as such. The use of RPLND in the treatment of postchemotherapy residual disease is controversial.
• Nonseminomatous germ cell tumors
  • Stage L Clinical stage 1 NSGCT are best treated with a retroperitoneal lymph node dissection (RPLND). This can be performed by a transabdominal or thoracoabdominal approach. Only 10 percent of patients treated this way will relapse, and virtually all recurrences will occur in the chest, which is easily monitored and treated. The cure rate for this approach is roughly 99 percent.
  • Early stage 2 disease can be treated with surgery. Advanced stage 2 and 3 disease is best treated by chemotherapy first, followed by a postchemotherapy RPLND for suspected residual disease. Postchemotherapy tumor histology may show only necrotic tumor (40 percent), mature teratoma (40 percent), or residual carcinoma (20 percent).
    • If a patient decides against surgery and undergoes intensive surveillance after orchiectomy, relapse will occur in 30 percent of cases (chest and retroperitoneum) as late as 4 years post-orchiectomy.
    • Due to noncompliance with surveillance and the potential for presentation with bulky metastatic disease, the cure rate with platinum-based chemotherapy is approximately 95 percent. Given the inherent risks of RPLND, the International Germ Cell Cancer Collaborative Group developed a prognostic factor-based staging system to assess risk of recurrence. Patients in the good prognosis group (AFP less than (I000 ng/mL, hCG less than 5,000 mIu/L and LDH less than 1.5 X normal) may be better candidates for surveillance, given that a minority of these patients will relapse in the retroperitoneum, thus saving the morbidity of RPLND. This issue, however, remains controversial. The major long-term complication of RPLND is disruption of ejaculatory function as a result of damage to the sympathetic nerve fibers to the pelvis.
    • Decreased morbidity has been obtained by mapping the metastatic deposits of NSGCT and developing surgical templates specific for the involved testicle. Lymphatics draining the right testicle drain primarily to retroperitoneal nodes in the interaortocaval region. In addition, metastatic disease from right-sided tumors may cross over to the left side. For this reason, a modified right-sided template RPLND should include a complete dissection above the level of the inferior mesenteric artery (IMA) up to the renal vessels, laterally up to both ureters, and caudally (below the (IMA) down to the aortic bifurcation on the ipsilateral side. Left-sided tumors, however, primarily metastasize to the para-aortic lymph nodes and rarely cross over to the right side. A modified left-sided RPLND is the mirror image of a modified right-sided template, except that the right-sided border only extends near the right margin of the inferior vena cava, and not the ureter. Using a nerve-sparing technique, ejaculation is preserved in 75 to 90 percent of patients with little potential compromise of surgical cure.
• Chemotherapy
  • Platinum based chemotherapy remains the foundation of therapy for this condition.
  • The combination of Bleomycin, Etoposide, and Platinum [BEP] is commonly applied in the appropriate patients. Most patients will receive 3 courses of therapy and be reevaluated.
  • Salvage therapy is usually the combination of Vinblastine, Ifosfomide, and Cistatinum [VIP].
  • High dose chemotherapy and autologous bone marrow transplantation is an option in high risk and relapsing patients.
  • Prognostic classification system. A validated model which that allows comparison of outcomes in different clinical trials. This allows one to modify chemotherapy for patient based on risk [Table 1].

Table 1. Prognostic Classification System for Testicular Cancer