Treatment Options for Testicular Cancer by Type and Stage

These cancers can be cured in nearly all patients. Surgery is done first to remove the testicle and spermatic cord (called a radical inguinal orchiectomy). After surgery, there are often several treatment choices:

Careful observation (surveillance): If the cancer has not spread beyond the testicle, the plan most experts prefer is close monitoring for at least 5 years, if not more. This means getting physical exams and imaging tests (CT scans and sometimes chest x-rays) every 4 to 6 months for the first 3 years, then annually. 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, treatments like radiation or chemo may be used. The cancer will come back in about 15-20% 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 to the para-aortic lymph nodes can be given after surgery to decrease risk of testicular cancer recurrence. These lymph nodes are in the back of the abdomen (belly), around the large blood vessel called the aorta. Because seminoma cells are very sensitive to radiation, low doses can be used. About 10 to 15 treatments are given over 2 to 3 weeks. Post-radiation surveillance involves physical exams every 4 to 6 months for the first 2 years, then annually. Imaging tests may also be done annually.

Chemotherapy: Chemo can be given after surgery to decrease the risk of testicular cancer recurrence. The chemo drug is carboplatin, which is given for 1 or 2 doses. Post-chemo surveillance involves physical exams every 4 to 6 months for the first 2 years, then annually, as well as imaging tests (CT scans and sometimes chest x-rays) annually.

In this stage, one or more tumor marker levels (hCG or LDH) are still high even after radical inguinal orchiectomy (removal of the testicle containing the seminoma). This is very rare, and it can suggest the presence of microscopic disease.

Microscopic disease refers to cancer cells that are present in the body but cannot yet be seen on imaging tests because they are too small. However, the elevated tumor marker levels may be due to other causes, unrelated to cancer. Management of stage IS seminoma involves monitoring for evidence of cancer by checking tumor marker levels and imaging (CT scans). Careful follow-up is important to decide if more treatment, such as chemo, is needed.

Stage IIA testicular cancer indicates that the cancer has spread to nearby lymph nodes and measures 2 cm or less in diameter. Stage IIB testicular cancer indicates that the cancer has spread to nearby lymph nodes and measures 2–5 cm in diameter. These enlarged lymph nodes may need to be reassessed with repeated imaging (CT or MRI) to confirm staging. For stage II testicular cancers, further treatment must be given after a radical inguinal orchiectomy to decrease the risk of disease recurrence. These therapy options include:

Radiation: Radiation to the retroperitoneal lymph nodes can be given after surgery. These are the lymph nodes at the back of the abdomen (belly) area. 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). One known rare but serious side effect of bleomycin is damage to the lungs. Thus, the drug combination of EP is usually preferred for people with a high risk for lung toxicity.

After completion of either radiation or chemotherapy, surveillance for residual or recurring disease will involve routine physical exams and imaging (CT scans and sometimes chest x-rays). Surveillance is done for at least 5 years, if not longer, based on discussions of risks and benefits with your doctor.

Treatment is typically chemotherapy with 4 cycles of EP (etoposide and cisplatin) or 3 or 4 cycles of BEP (bleomycin, etoposide, and cisplatin). Another option might be VIP (etoposide, ifosfamide, and cisplatin) for 4 cycles. Radiation therapy is generally not used for stage IIC seminoma.

These cancers can be cured in nearly all patients. Like treatment for seminomas, surgery is done first to remove the testicle and spermatic cord (called a radical inguinal orchiectomy). After surgery, treatment for stage I disease is different from that of seminomas and depends on whether there are risk factors present for disease recurrence. The presence of risk factors is determined based on findings from the radical inguinal orchiectomy. These risk factors are:

• If cancer cells have entered blood or lymph vessels (lymphovascular invasion)
• If cancer cells have spread to the spermatic cord
• If cancer cells have spread to the scrotum

For stage I non-seminomas without risk factors, careful observation (surveillance) is recommended by most doctors. If the cancer does come back, it's usually within the first year or two, which is why frequent  doctor visits and tests are important during this time. A typical schedule might include physical exams and blood tests every 2 to 3 months along with imaging (CT or MRI) every 4 to 6 months for the first two years. As time goes on and you have no problems, the time between visits and tests gets longer.

For stage I non-seminomas with risk factors, treatment options after surgery include:

• Careful observation (surveillance): The goal is to assess for possible disease recurrence after surgery. A surveillance schedule includes frequent physical exams, blood work to check the tumor markers, and chest x-rays. Visits and tests are done for at least 5 years after surgery and can be extended based on discussions with your doctor.
• Chemotherapy: Chemo is usually 1 cycle of the BEP regimen (bleomycin, etoposide, and cisplatin). This can help reduce the risk that the cancer will come back.
• Retroperitoneal lymph node dissection (RPLND): This is surgery to remove the lymph nodes at the back of the abdomen (belly).

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, this can suggest the presence of microscopic disease. Microscopic disease refers to cancer cells that are present in the body but cannot yet be seen on imaging tests because they are too small. In this situation, chemo is typically recommended. This may be either 3 cycles of BEP (bleomycin, etoposide, and cisplatin) or 4 cycles of EP (etoposide and cisplatin).

Surgery is done first to remove the testicle and spermatic cord (called a radical inguinal orchiectomy). After surgery, treatment choices depend on the details of the cancer.

• Chemotherapy: Chemotherapy is a standard option for anyone with stage II testicular cancer. A combination of drugs is usually given after surgery to remove the testicle. Chemotherapy is the most common treatment for stage IIB and IIC disease and for people with stage IIA disease whose serum tumor markers remain elevated after orchiectomy. For people with stage IIA disease and normal serum tumor markers, chemotherapy or RPLND may be recommended.
• Retroperitoneal lymph node dissection (RPLND): This is surgery to remove the retroperitoneal lymph nodes in the back of the abdomen. This is a standard treatment option after orchiectomy when the serum tumor marker levels have returned to normal, none of the lymph nodes are larger than 2 cm, and there are no more than 5 enlarged lymph nodes. Chemotherapy may be recommended after RPLND if a large amount of cancer is found in the removed lymph nodes.

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

If tumor marker levels are normal, there are 2 main options:

• Retroperitoneal lymph node dissection (RPLND): This is surgery to remove the lymph nodes at the back of the abdomen. If the lymph nodes that were removed contain cancer, chemo (typically for 2 cycles) might be given. If there's no cancer in the nodes, the doctor will watch closely for signs that the cancer has come back.
• Chemotherapy: Either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin) may be used. Surgery might be done after this if there are signs there might still be cancer present (i.e., enlarged lymph nodes).
• Radiation therapy: When lymph nodes are less than 3 cm, surgery may be followed by radiation therapy to the lymph nodes in the abdomen and pelvis. Sometimes, chemotherapy may be used instead of radiation therapy. Experts disagree about whether radiation therapy or chemotherapy is the preferred option for patients with stage IIA and early stage IIB – as both approaches cure 90% or more of patients. One advantage of radiation therapy is that it does not increase the risk of developing serious infections, while chemotherapy does. Both chemotherapy and radiation therapy are associated with an increased risk of second cancers and certain other health problems in the future.

If tumor markers are still higher than normal after the initial surgery, treatment is typically with chemo as listed above (EP or BEP).

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

If tumor marker levels are normal, the options are:

• Chemotherapy: Either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin) may be used. Surgery might be done after this if there are signs there might still be cancer present (i.e., enlarged lymph nodes).

• Retroperitoneal lymph node dissection (RPLND): In a few select cases, where the cancer has spread only to certain lymph nodes, surgery may be done to take them out. Chemo may then be given after surgery.
• Radiation therapy: When lymph nodes are less than 3 cm, surgery may be followed by radiation therapy to the lymph nodes in the abdomen and pelvis. Sometimes, chemotherapy may be used instead of radiation therapy. Experts disagree about whether radiation therapy or chemotherapy is the preferred option for patients with stage IIA and early stage IIB – as both approaches cure 90% or more of patients. One advantage of radiation therapy is that it does not increase the risk of developing serious infections, while chemotherapy does. Both chemotherapy and radiation therapy are associated with an increased risk of second cancers and certain other health problems in the future.

If tumor markers are still higher than normal after the initial surgery, treatment is typically with chemo as listed above (EP or BEP).

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). It is quite common for a mass to be found on imaging tests after chemotherapy or radiation therapy is finished. There is less than a 10% chance that this mass contains cancer and very little chance that it contains a teratoma. The main treatment options are active surveillance or surgery. Such surgery is often very difficult due to a “scar-like” reaction that makes the mass difficult to remove. This is unique to seminoma. Many oncologists recommend surveillance of remaining masses in people with seminomas. Because larger masses are more likely to be cancerous, some doctors recommend surveillance when a mass is smaller than 3 cm and surgery when a mass is 3 cm or larger.

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, x-rays and CT scans are done again to see if there are any remaining masses. If there are masses, they are removed with surgery if possible. The chance of the surgery curing the cancer is higher if serum tumor marker levels are normal after chemotherapy. This surgery is difficult and requires an experienced surgeon who regularly performs such operations. Very rarely, if the mass is pressing on the kidney or major blood vessels in the retroperitoneum, the kidney and/or a portion of the blood vessels may need to be removed. Often, in this situation the nerves that are responsible for ejaculation cannot be saved.

During surgery, there is about a 35-50% chance that only scar tissue will be found, a 35-50% chance there will be a teratoma, and a 10-15% chance of some other type of germ cell tumor, such as embryonal carcinoma, seminoma, yolk sac tumor, or choriocarcinoma. If only scar tissue and/or a teratoma is found, then no additional treatment is needed. If cancer is found, 2 more cycles of chemotherapy may be given. The chemotherapy regimen used is typically either EP, TIP, VeIP, or VIP.