Testis Cancer
Treatment Options
As stated earlier, the treatment of testicular cancer has evolved into one of the most successful in oncology. With current treatment regimens, testicular cancer can be cured in >90% of patients. Even in cases with Stage IV disease, long term control rates can be achieved in 70-80% of patients (typically, stage IV cancers have very low 5 year survival rates). The treatment of testicular cancer involves a truly multidisciplinary approach. A combination of aggressive surveillance, surgery, chemotherapy, and/or radiation therapy may be employed in the treatment strategy. The primary two factors that are involved in the decision making are the pathology (seminoma versus NSCGT) and the stage of the disease (the extent to which the cancer has spread).
Surveillance or Expectant Management
Surveillance (expectant management) refers to close monitoring of the tumor until there is a need for further therapy (surgery or chemotherapy). This approach is generally recommended for patients who do not have any spread of the cancer outside the testicle and whose cancer does not appear to have aggressive features on the pathology assessment. Additionally, patients without any spread but with some high risk features may be offered surveillance in the proper circumstances and after a full discussion about the risks/benefits.
Although some patients feel that surveillance is "not doing anything," it is quite intensive. Surveillance involves a strict schedule of office visits, blood tests, and CT scans. For patients with higher risk tumors, this schedule may involve assessments every 1-2 months for the first year, every 2 months for the second year, and every 3-4 months for the third year. Before any patient elects for surveillance, he must be willing to commit to the follow up schedule.
Surgery
For patients with tumors that have a high risk of spread to the lymph nodes in the abdomen, the doctor may recommend a surgery to remove these lymph nodes. This surgery is referred to as a retroperitoneal lymph node dissection (RPLND). The surgery may be done through an open incision or by laparoscopic surgery. Open surgery involves a midline incision along the length of the abdomen. Laparoscopic surgery offers the benefits of minimally invasive surgery and is performed through 4 small (1cm) incisions in the midline of the abdomen. The benefits as compared to open surgery include a shorter hospital stay, earlier return to daily activities/work, and a more favorable cosmetic result. The surgery involves the removal of lymph nodes that reside in the posterior portion of the abdomen around the aorta and inferior vena cava. The number of lymph nodes to be removed can vary among individuals and can range from less than 10 to over 50. Along with the removal of the lymph nodes, the remainder of the blood supply to the testicle and spermatic cord is also removed. Once the lymph nodes have been removed, the pathologist can determine if the cancer has spread into the nodes. This in turn will determine if there is a need for additional chemotherapy.
Although RPLND is commonly performed as the initial treatment, some patients require surgery after completing a course of chemotherapy. These patients usually present with advanced disease, undergo chemotherapy, and then have persistently enlarged lymph nodes in the abdomen. Though more technically demanding, the surgery is the same.
Chemotherapy
Patients with NSGCT without definite spread of the cancer outside of the testicle but with some high risk features on the pathology assessment may be offered an abbreviated regimen of chemotherapy as an alternative to surgery (RPLND). This regimen involves two cycles of bleomycin, etoposide, and cis-platinum. There are both risks and benefits to each approach (surgery versus chemotherapy) and requires a full discussion between the doctor and patient.
Patients whose cancer has spread extensively to the lymph nodes and/or other organs (lung, liver, bone, etc) will require chemotherapy as the first line of treatment. Although the urologist continues to be the leader of the team, the chemotherapy is administered by the medical oncology team. The initial regimen involves either bleomycin, etoposide and cis-platinum for 3 cycles or bleomycin and etoposide for 4 cycles. Following the chemotherapy regimen, repeat CT scans are obtained to assess the response of the cancer to the treatment. If there continue to be enlarged lymph nodes on the imaging scans, the doctor will likely recommend surgery to removes these lymph nodes. If, however, there are other organs that continue to show cancer, the doctor will likely recommend additional courses of chemotherapy.
Radiation therapy
Unlike NSGCT, seminomas are extremely sensitive to radiation therapy (along with chemotherapy). Therefore, patients with pure seminoma on the pathology assessment may be recommended to undergo radiation therapy to the lymph nodes in the abdomen. This type of radiation therapy is generally a short course (2-3 weeks) and very well tolerated. If the cancer grows back after radiation, chemotherapy can then be administered with very good results.
*There has been one large study in which patients with low stage seminoma have been given carboplatinum (single drug chemotherapy) with good success rates.
*Short course chemotherapy refers to two cycles of cis-platinum, etoposide, and bleomycin rather than the regular 3 cycles of chemotherapy.
