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 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), the doctor may recommend that it not be treated right away. Instead, it 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 typically surgery (to remove the testicle) or radiation therapy to the testicle.

If 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, the treatment used is for stage IS cancers. (See below.)

Seminomas

Stage I seminomas

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 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, treatments like radiation or chemo may be used. 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 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.

Chemotherapy: An option that works as well as radiation is 1 or 2 cycles of chemo 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 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), one treatment option is radiation to the retroperitoneal lymph nodes. These are the lymph nodes at the back of the 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). The doctor will then watch closely (every 3 to 6 months) for any 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 typically the preferred treatment. It is usually 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 the lymph nodes aren't enlarged from cancer spread.

Stage IIC seminomas

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.

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. A typical schedule might include visits 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 the abdomen (belly) removed has the advantage of a high initial 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, the doctor may suggest 1 cycle of the BEP regimen (bleomycin, etoposide, and cisplatin). This helps reduce the 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 the 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, the doctor may recommend 1 cycle of the BEP regimen (bleomycin, etoposide, and cisplatin). This can help reduce the risk that the cancer will come back. If cancer was found in the lymph nodes after surgery, 2 to 4 cycles of BEP or EP (etoposide and cisplatin) may be given, depending 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 for some T2 tumors that haven't reached 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 typically recommended. This may be either 3 cycles of BEP (bleomycin, etoposide, and cisplatin) or 4 cycles of EP (etoposide and cisplatin).

Stage II non-seminomas

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.

Stage IIA non-seminomas

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: This would include either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin). Surgery might be done after this if there are signs there might still be cancer present.

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

Stage IIB non-seminomas

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

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 may then be done to take out all enlarged nodes if the tumor marker return to 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. Chemo may then be given after surgery.

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

Stage III seminomas and non-seminomas

Even though stage III cancers 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. Depending on the risk group the cancer falls into, this might be with:

• EP (etoposide and cisplatin) for 4 cycles
• BEP (bleomycin, etoposide, and cisplatin) for 3 or 4 cycles
• VIP (etoposide, ifosfamide, and cisplatin) for 4 cycles

If there's a high suspicion that the cancer might be a testicular choriocarcinoma, chemo may be started without a biopsy or surgery to remove the testicle.

If the cancer has spread to the brain, surgery (if there are only 1 or 2 tumors in the brain), radiation therapy aimed at the brain, or both may also be used. 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 scans and tumor marker levels are normal, no further treatment may be needed.

Sometimes a few tumors might be left after treatment. 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. The doctor might recommend high-dose chemo followed by a stem cell transplant. Enrolling in a clinical trial of a newer chemo regimen might be another good option.

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.