Testicular Cancer

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Treating Testicular Cancer TOPICS

Treatment options for testicular cancer, by type and stage

Treatment for testicular cancer is based mainly on the type and stage of the cancer. Among the germ cell tumors, pure seminomas are treated one way, and all other cancers (all types of non-seminomas and mixed germ cell tumors) are treated another way.

Stage 0 germ cell tumors

In this stage, the tumor in the testicle is carcinoma in situ (CIS), the cancer has not spread outside the testicle, and the levels of tumor markers (like HCG and AFP) are not elevated.

If this stage is diagnosed after surgery to remove the testicle, no other treatment is needed.

If the CIS is found after a testicular biopsy (such as for fertility problems), the doctor may recommend that it not be treated right away. Instead, the patient may be watched closely with repeat physical exams, ultrasound of the testicle, and blood tests of tumor marker levels. Treatment may not be needed as long as there are no signs that the CIS is growing or turning into an invasive cancer. If CIS is treated, it is with surgery (to remove the testicle) or with radiation therapy to the testicle.

If tumor marker levels are high, the cancer is not really stage 0 – even when only CIS is found in the testicle and there are no signs of cancer spread. These cases are treated like stage IS cancers.

Stage I germ cell tumors

Stage I seminomas: These cancers can be cured in nearly all patients. They are first treated by surgically removing the testicle and spermatic cord (radical inguinal orchiectomy). After surgery, there are several treatment choices:

  • Careful observation (surveillance): If the cancer has not spread beyond the testicle, often the preferred option is to be watched closely by your doctor for up to 10 years with treatments like radiation or chemo only if cancer spread is found. This means getting physical exams and blood tests every 3 to 6 months for the first year, and less often after that. Imaging tests (CT scans and sometimes chest x-rays) are often done every 3 months for 6 months, and then less often after that. If these tests do not find any signs that cancer has spread beyond the testicle, no other treatment is needed. In about 15% to 20% of patients the cancer will come back as spread to lymph nodes or other organs, but if it does, radiation or chemo can still usually cure the cancer.
  • Doctors are less likely to advise surveillance if the tumor invades blood or lymph vessels in the spermatic cord or if it has reached the scrotum. In these cases, either radiation or chemo is likely to be a better option.

  • Radiation therapy: Radiation aimed at para-aortic lymph nodes (in the back of the abdomen, around the large blood vessel called the aorta) is another option. Because seminoma cells are very sensitive to radiation, low doses can be used, usually about 10 to 15 treatments (given over 2 to 3 weeks).
  • The doctor may recommend this because in about 1 in 5 patients with stage I seminoma, cancer cells have spread outside the testicle but cannot be seen on imaging tests like CT scans. Radiation therapy can usually destroy these hidden (occult) metastases.

  • Chemotherapy: An option that works as well as radiation is to give 1 or 2 cycles of chemotherapy (chemo) with the drug carboplatin after surgery.

Stage IS seminomas: In this stage, the level of one or more tumor markers is still high after the testicle containing the seminoma is removed. This is very rare, but it is often treated with radiation.

Stage I non-seminomas: Nearly all of these cancers can be cured, but the standard treatment is different from that of seminomas. As with seminomas, the initial treatment is surgery to remove the testicle and tumor (radical inguinal orchiectomy). Then the treatment choices depend on the stage.

For stage IA (T1) there are 2 choices:

  • Careful observation (surveillance): Surveillance might let you avoid the possible side effects of surgery, but it requires a lot of doctor visits and tests. Doctor visits and lab tests are done every 2 months for the first year, with CT scans every 4 to 6 months. Over time, the time between visits and tests gets longer. If the cancer does come back, it is usually within the first year or two. Relapses are generally treated with chemo. Even though more patients will have a relapse with surveillance than with lymph node dissection, the cure rates are similar because the relapses are usually found early enough to be cured.
  • Retroperitoneal lymph node dissection (RPLND): Removal of lymph nodes at the back of the abdomen has the advantage of a high cure rate but the disadvantages of major surgery, with its possible complications, including losing the ability to ejaculate normally. After RPLND, if cancer is found in the nodes, chemo may be recommended.

For stage IB (T2, T3, or T4) there are up to 3 options:

  • Retroperitoneal lymph node dissection (removal of lymph nodes at the back of the abdomen). If cancer is found in the lymph nodes, chemo is often recommended.
  • Chemotherapy with the BEP regimen (bleomycin, etoposide, and cisplatin) for 2 cycles. This has a high cure rate, but it can have side effects (which are mostly short-term). Chemo is used more often in Europe than in the United States.
  • Careful observation (surveillance): This requires frequent doctor visits and tests for several years. This may be an option for some patients with T2 tumors.

Stage IS non-seminoma: If the tumor marker levels (like AFP or HCG) are still high even after the testicle/tumor is removed but no tumor is seen on a CT scan, chemo is recommended, with either 3 cycles of BEP or 4 cycles of EP (etoposide and cisplatin).

Stage II germ cell tumors

Stage IIA seminomas: After surgery to remove the testicle (radical inguinal orchiectomy), the preferred treatment is radiation to the retroperitoneal lymph nodes. Usually stage II seminomas are given higher doses of radiation than stage I seminomas. The other option is chemo, with either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin).

Stage IIB seminomas: These seminomas have spread to larger lymph nodes or to several different lymph nodes. After surgery to remove the testicle (radical inguinal orchiectomy), chemo is the preferred treatment. Either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin) may be used. Radiation may be an option instead of chemo for patients who don’t have lymph nodes enlarged from cancer spread.

Stage IIC seminomas: These cancers are treated with radical inguinal orchiectomy, followed by chemo with 4 cycles of EP or 3 or 4 cycles of BEP. Radiation therapy is generally not used for stage IIC seminoma.

Stage II non-seminomas: After radical inguinal orchiectomy to remove the testicle with the tumor, treatment depends on the remaining levels of tumor markers in the blood and the extent of spread to retroperitoneal lymph nodes. There are 2 main options:

  • Retroperitoneal lymph node dissection (RPLND): The lymph nodes at the back of the abdomen are removed. This is more often an option for stage IIA disease. If the lymph nodes removed contain cancer, further treatment with chemo may be needed.
  • Chemotherapy: For many stage II cancers, the preferred treatment is chemo instead of RPLND. Either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin) may be used.
  • After chemo, a CT scan is repeated to see if the lymph nodes are still enlarged. If they are, they are usually removed by RPLND.

Stage III germ cell tumors

Even though stage III germ cell tumors have spread by the time they are found, most of them can still be cured.

Both stage III seminomas and non-seminomas are treated with radical inguinal orchiectomy followed by chemo with either EP (etoposide and cisplatin) for 4 cycles or BEP (bleomycin, etoposide, and cisplatin) for 3 to 4 cycles. 4 cycles of BEP are needed for patients with poor prognosis non-seminomas (usually because they have spread to distant areas other than the lungs or because of very high tumor marker levels). If the patient has medical reasons that make treatment with bleomycin unsafe, then he may be treated with VIP (vinblastine, ifosfamide, and cisplatin).

In cases where very high levels of the tumor marker HCG is found in a man, distant spread of cancer is seen on scans, and there is a high suspicion that he may have a testicular choriocarcinoma, chemo may be started without a biopsy or initial removal of a testicle.

If the cancer has spread to the brain, it will be treated with either surgery (if there are only 1 or 2 tumors in the brain), radiation therapy aimed at the brain, or both. If the tumors in the brain are not bleeding or causing symptoms, some doctors may choose to start the chemo first.

Once chemo is complete, the doctor looks for any cancer that is left. Patients with normal scans and normal tumor marker levels are usually watched carefully after this and may need no further treatment.

Sometimes a few tumors are left. These are most often in the lung or in the retroperitoneal lymph nodes. Further treatment at this point depends on the type of cancer.

Seminomas: Small tumors that are still there after chemo or don’t “light up” on a PET scan, are often watched with CT scans to see if they grow. If they do, further treatment is needed. If the tumors do light up on a PET scan, they could be cancers, and treatment is needed. Treatment may be surgery (such as a retroperitoneal lymph node dissection) or chemo (using a different combination of drugs).

Non-seminomas: Remaining tumors are usually removed surgically, which may result in a cure. If cancer is found in the tumors removed, further chemo (usually for 2 cycles, often with different drugs) might be needed. Another option might be to start by giving further chemo with different drugs. Surgery might be used after this if any tumors remain.

If the cancer is resistant to chemo or has spread to many organs, the usual doses of chemo may not always be enough. Sometimes the doctor might recommend high-dose chemo followed by a stem cell transplant. Patients might also want to consider enrolling in a clinical trial of newer chemo regimens.

Recurrent germ cell tumors

If the cancer goes away with treatment and then comes back, it is said to have recurred or relapsed. If this happens, it’s usually within the first 2 years after treatment. In general, if the cancer recurs, it’s probably best to get a second opinion from a center with extensive experience in treating relapsed testicular cancer before starting treatment.

Treatment of recurrent germ cell tumors depends on the initial treatment and where the cancer recurs. Cancer that comes back in the retroperitoneal lymph nodes can be treated by surgery to remove the nodes (RPLND) if the recurrence is small and if the only surgical treatment given before was orchiectomy. Depending on the results of the surgery, chemo may be recommended as well.

If it looks as if cancer has recurred in a lot of the retroperitoneal lymph nodes or if the cancer has returned elsewhere, chemo is usually recommended. This may be followed by surgery.

If a man’s cancer recurs after chemo or if treatment is no longer working, he will be treated with a different chemo regimen, which typically includes ifosfamide, cisplatin, and either etoposide, paclitaxel, or vinblastine.

The treatment of testicular cancer that has come back after chemo is not always as effective as doctors would like, so some doctors may advise high-dose chemo followed by a stem cell transplant. This may be a better option for some men with recurrent disease, rather than standard chemo. (See the section “High-dose chemotherapy and stem cell transplant for testicular cancer” for more information.) Clinical trials of newer treatments can also be considered.

Sertoli cell and Leydig cell tumors

Typically, radical inguinal orchiectomy is the treatment for Sertoli cell and Leydig cell tumors. Radiation therapy and chemo are generally not effective in these rare types of testicular tumors. If the doctor suspects the tumor has spread beyond the testicle, the retroperitoneal lymph nodes may be surgically removed.

Last Medical Review: 01/20/2015
Last Revised: 02/13/2015