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Chemotherapy is used when the disease has spread beyond the regional lymph nodes, especially when it has gone above the diaphragm into the mediastinal or supraclavicular nodes. The exception is for undifferentiated or trophoblastic teratoma which is treated irrespective of the stage of the disease. Chemotherapy is used for all cases of metastatic disease in both seminoma and teratoma.
treatment of testicular cancer
The initial management in majority of testicular cancer includes an orchidectomy in continuity with the spermatic cord (1)
- preoperative investigations should include assay of alfa fetoprotein AFP, HCG, and LDH, bilateral testicular ultrasound, and a chest x-ray
- where possible an inguinal orchidectomy should be performed
- a testicular prosthesis should be offered to all patients.
- when appropriate, sperm storage should be offered to men who may require chemotherapy or radiotherapy (2)
Patients in whom the diagnosis is not in doubt (high tumour markers and the presence of a testicular mass) may be referred for immediate chaemotherapy (2)
Management of contralateral testis
- diagnosis of carcinoma in situ (CIS)
- patients with a testicular cancer who are 30 years old or less and have a small (<12 ml) contralateral testis should be considered for biopsy of the contralateral testis to diagnose CIS. If CIS is identified subsequent management should be in a specialist centre
- management of carcinoma in situ
- Patients with biopsy-proven CIS of the contralateral testis should have the options of surveillance, prophylactic orchidectomy and adjuvant radiotherapy discussed with them. Where radiotherapy is given, a dose of 20 Gy in 10 fractions over two weeks is adequate to eradicate CIS and testosterone replacement may not be necessary.
Management of stage 1 disease:
- seminoma
- patients with stage I seminoma should have the advantages and disadvantages of the various post-orchidectomy management options discussed with them, including surveillance, single-dose adjuvant carboplatin and adjuvant radiotherapy
- in patients with stage I seminoma who are to receive adjuvant 'dog-leg' or para-aortic strip radiotherapy, a dose of 20 Gy in ten fractions over two weeks be prescribed to the International Commission on Radiation Units (ICRU) reference point
- the potential risk of second malignant neoplasms should be outlined to patients where adjuvant radiotherapy is being considered
- orchiectomy alone will cure most patients with clinical stage I seminoma. About 10-20% of patients will experience disease relapse (3)
- stage I Non-seminomatous germ cell tumours (NSGCT) and mixed seminoma/NSGCT
- is cured with orchiectomy alone in 50-80% of patients (3)
- management strategies for clinical stage I non-seminoma include active surveillance, one cycle of BEP (bleomycin, etoposide, platinum), or primary RPLND (retroperitoneal lymph node dissection) (3)
Management of metastic disease - seminoma
- in stage IIA seminoma both chemotherapy and radiotherapy treatment options should be considered and discussed with the patient
- the optimal treatment for an individual patient will depend on clinical judgement and patient preference
- for patients with stage IIC and IID seminoma, chemotherapy is the recommended initial treatment
- Patients with stage III and IV seminoma should be treated with cisplatin-based chemotherapy
- in patients with stage III and IV seminoma carboplatin should only be used as an alternative to cisplatin in exceptional circumstances
Management of metastic disease - NSGCT
- good prognosis disease
- patients with good prognosis metastatic non-seminomatous germ cell tumour should receive three cycles of BEP chemotherapy in either a 3-day or 5-day schedule
- patients with good prognosis metastatic non-seminomatous germ cell tumour and in whom bleomycin is contraindicated should receive four cycles of EP chemotherapy (with 500 mg/m2 etoposide and 100 mg/m2 cisplatin per cycle)
- intermediate/poor prognosis disease
- outwith the trial setting standard initial chemotherapy for patients with intermediate and poor-risk germ cell tumours is four courses of 5-day BEP
Notes:
- SIGN guideline suggest that following confirmation of a germ cell tumour, all patients should be referred to a specialist centre for the management of testicular tumours (2)
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