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 different stages of germ cell tumors, pure seminomas tend to be treated one way, and non-seminomas and mixed germ cell tumors are treated another way.

Carcinoma in situ (stage 0) testicular tumors

In this stage, the cancer has not spread outside the testicle, and your tumor marker levels (like HCG and AFP) are not elevated.

If CIS is diagnosed after surgery removes the testicle, no other treatment is needed. If CIS is found after a testicular biopsy (such as for fertility problems), your doctor may recommend that it not be treated right away. Instead, you 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's surgery (to remove the testicle) or radiation therapy to the testicle.

If your tumor marker levels are high, the cancer isn't really stage 0 – even when only CIS is found in the testicle and there are no signs of cancer spread. In this case, you'll get the treatment used for stage IS cancers. (See below.)

Seminomas

Stage I seminomas

These cancers can be cured in nearly all patients. You first have surgery to remove the testicle and spermatic cord (called a radical inguinal orchiectomy). After surgery, you have many treatment choices:

Careful observation (surveillance): If the cancer has not spread beyond the testicle, the plan most experts prefer is that you be watched closely by your doctor for up to 10 years. 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 done every 3 months for 6 months, and then once or twice a year. If these tests do not find any signs that cancer has spread beyond the testicle, no other treatment is needed. If the cancer has spread, you may get treatments like radiation or chemo. The cancer will come back in about 15% to 20% of patients, most often as spread to lymph nodes , but if it does, radiation or chemo can still usually cure the cancer.

Radiation therapy: Radiation aimed at para-aortic lymph nodes is another option. These nodes are in the back of your abdomen (belly), around the large blood vessel called the aorta. Because seminoma cells are very sensitive to radiation, low doses can be used and you'll get about 10 to 15 treatments over 2 to 3 weeks.

Chemotherapy: An option that works as well as radiation is 1 or 2 cycles of chemotherapy with the drug carboplatin after surgery. Many experts prefer chemo over radiation because it seems to be easier to tolerate.

Stage IS seminomas

In this stage, one or more of your tumor marker levels is still high after the testicle containing the seminoma has been removed. This is very rare, and it can be treated with chemo.

Stage IIA seminomas

Radiation: After surgery to remove the testicle (radical inguinal orchiectomy), the preferred treatment is radiation to the retroperitoneal lymph nodes. These are the lymph nodes at the back of your abdomen (belly). Usually stage II seminomas are given higher doses of radiation than stage I seminomas.

Chemotherapy: Another option is chemo, with either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin). You doctor will watch you closely (every 3 to 6 months) to look for signs that the cancer has come back.

Stage IIB seminomas

These seminomas have spread to cause larger lymph nodes or have spread to many different lymph nodes.

Chemotherapy: This is the preferred treatment. You can get either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin).

Radiation: This may be an option instead of chemo if your lymph nodes aren't enlarged from cancer spread.

Stage IIC seminomas

You will get chemotherapy with 4 cycles of EP or 3 or 4 cycles of BEP. Radiation therapy is generally not used for stage IIC seminoma.

Non-seminomas

Stage I non-seminomas

Nearly all of these cancers can be cured, but the treatment is different from that of seminomas. As with seminomas, the initial treatment is surgery to remove the testicle and tumor (called radical inguinal orchiectomy ). The other treatment choices will depend on the stage.

Choices for stage IA (T1)

  • Careful observation (surveillance): Surveillance is preferred by most experts, but it requires a lot of doctor visits and tests. You'll start at every 2 months for the first year, with CT scans every 4 to 6 months; then every 3 months for the second year, with scans every 6 to 12 months. As time goes on and you have no problems, the time between visits and tests gets longer. If the cancer does come back (relapse), it's 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 much the same because the relapses are usually found early.
  • Retroperitoneal lymph node dissection (RPLND): Having the lymph nodes at the back of your abdomen (belly) removed 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.
  • Chemotherapy: Instead of surgery, your doctor may suggest you get 1 cycle of the BEP regimen (bleomycin, etoposide, and cisplatin). This helps reduce your risk of relapse.

Choices for stage IB (T2, T3, or T4)

  • Retroperitoneal lymph node dissection (RPLND): This is surgery to remove the lymph nodes at the back of your abdomen (belly). If cancer is found in the lymph nodes, chemo is often recommended depending on the number of nodes with cancer in them. (See below.)
  • Chemotherapy: Instead of surgery, your doctor may recommend 1 cycle of the BEP regimen (bleomycin, etoposide, and cisplatin). This can help reduce your risk that the cancer will come back. If cancer was found in your lymph nodes after surgery, you may get 2 to 4 cycles of BEP or EP (etoposide, and cisplatin). It depends on how many nodes had cancer in them. This has a high cure rate, but it can have side effects (which are mostly short-term).
  • Careful observation (surveillance): This requires frequent doctor visits and tests for several years. This may be an option if you have a T2 tumor that didn't reach blood vessels.

Stage IS non-seminoma

If your tumor marker levels (like AFP or HCG) are still high even after the cancer has been removed, but the CT scan doesn't show a tumor, chemo is recommended. You may get either 3 cycles of BEP (bleomycin, etoposide, and cisplatin) or 4 cycles of EP (etoposide and cisplatin).

Stage II non-seminomas

You will first have surgery to remove the testicle and spermatic cord (called a radical inguinal orchiectomy). After surgery, your treatment choices depend on details about the cancer.

Stage IIA non-seminomas

Treatment depends on your tumor marker levels after surgery and the extent of spread to the retroperitoneal lymph nodes. These are the lymph nodes at the back of your abdomen (belly).

If your tumor marker levels are normal, you have 2 main options:

  • Retroperitoneal lymph node dissection (RPLND): Surgery will be done to remove the lymph nodes at the back of your abdomen. If the lymph nodes that were removed contain cancer, you may get 2 cycles of the chemo drugs listed below. If there's no cancer in the nodes, your doctor will watch you closely for signs that the cancer has come back.
  • Chemotherapy: If cancer was found in many lymph nodes, you'll get either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin). Your next treatment may be surgery to take out all enlarged nodes if your tumor marker levels are normal.

If your tumor markers are still higher than normal you'll get chemo as listed above.

Stage IIB non-seminomas

Your treatment depends on your tumor marker levels after surgery and the extent of spread to the lymph nodes at the back of your the abdomen (belly). These are called the retroperitoneal lymph nodes.

If your tumor marker levels are normal, your options are:

  • Chemotherapy: You'll get either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin) may be used. Your next treatment may be surgery to take out all enlarged nodes if your tumor marker levels are normal.
  • Retroperitoneal lymph node dissection (RPLND): In few select cases, where the cancer has spread only to these lymph nodes, surgery may be done to take them out. You may get chemo as listed above after surgery.

If your tumor markers are still higher than normal you'll get chemo as listed above.

Stage III seminomas and non-seminomas

Even though stage III 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 4 cycles of EP (etoposide and cisplatin) or 3 or 4 cycles of BEP (bleomycin, etoposide, and cisplatin).

You may get 4 cycles of BEP if you have an intermediate or poor risk non-seminoma. (This depends on the spread to distant areas and tumor marker levels.) If you have medical reasons that make treatment with bleomycin unsafe, then you may be get VIP (vinblastine, ifosfamide, and cisplatin) instead.

If the cancer is seminoma that has spread to your bones, liver, or brain, it's intermediate risk and you'll get VIP (etoposide, mesna, ifosfamide, and cisplatin).

If you have very high levels of the tumor marker HCG, distant spread of cancer is seen on scans, and there's a high suspicion that you might have a testicular choriocarcinoma, chemo may be started without a biopsy or surgery to remove the testicle.

If the cancer has spread to your brain, you will get 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's left. If you have normal scans and normal tumor marker levels, you'll be watched carefully and may not need 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:

  • A stage III seminoma that's still there after chemo or doesn’t “light up” on a PET scan, will be watched with CT scans to see if it grows. If it does, more treatment is needed. If the tumors do light up on a PET scan, they could be cancer, and treatment is needed. Treatment may be surgery (such as a retroperitoneal lymph node dissection) or chemo (using a different combination of drugs).
  • A stage III non-seminoma tumor that remains after treatment is usually removed surgically, which may result in a cure. If cancer is found in the tumors removed, you might need more chemo, maybe with different drugs. After this, surgery might be done to take out any tumors that remain.

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

Recurrent testicular cancer

If the cancer goes away with treatment and then comes back, it's 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 different chemo, 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. Clinical trials of newer treatments may also be good options.

Sertoli cell and Leydig cell tumors

Typically, radical inguinal orchiectomy is the treatment for Sertoli cell and Leydig cell tumors. Radiation therapy and chemo generally don't work for 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.

More treatment information for testicular cancer

For more details on treatment options – including some that may not be addressed here – the National Comprehensive Cancer Network (NCCN) and the National Cancer Institute (NCI) are good sources of information.

The NCCN is made up of experts from many of the nation’s leading cancer centers. It develops cancer treatment guidelines for doctors to use when treating patients. They're available on the NCCN website (www.nccn.org).

The NCI provides treatment information by phone (1-800-4-CANCER) and on its website ( www.cancer.gov). More detailed information intended for use by cancer care professionals is also available on www.cancer.gov.

The American Cancer Society medical and editorial content team
Our team is made up of doctors and master's-prepared nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

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Last Medical Review: May 17, 2018 Last Revised: May 17, 2018

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