Testicular Cancer

Is your treatment what more than 1,100 Oncologists recommend?

The information provided below is meant to help you understand the role of your  testicular cancer biology treatment decisions, as well as the role of other tools used in determining your ability to receive chemotherapy or targeted therapy (precision medicine).

In 2016, it is estimated that 8,720 new cases of testicular cancer diagnosed in the United States (CA Cancer J Clin 2016; 66(1):7-30). Testicular cancer is curable in 90% of patients. Testicular cancer mostly affects young men in 20-34 year old age group and is more common in Caucasians than in other ethnic groups.

Risk Factors

• Cryptorchidism (failure of the testicle to descend into the scrotum during fetal development) and testicular dysgenesis (congenital maldevelopment of the testis)
• Family history of testicular cancer, which increases the probability of developing testicular cancer by 4-10 fold
• HIV infection, which increases the risk of one subtype of testicular cancer (seminoma)
• Personal history of testicular cancer – 2% of patients with cancer in one testicle will be diagnosed with cancer in the other testicle either at the same time or subsequently
• Klinefelter syndrome is not an important risk factor for testicular cancer, but increases the incidence of germ cell tumors arising in the mediastinum (central part of the chest cavity), but not of germ cell tumors arising in the testicles (treatment is similar)

Treatment

Three different approaches to treating testicular cancer are available. They are:

• Surgery: The primary treatment for testicular cancer is surgical removal of the testicle, or orchiectomy, which is performed via an incision in the groin (not the scrotum)
• Radiation
• Chemotherapy

This website is designed to outline in detail your chemotherapy therapy options and offer you personalized information about the best options to yield optimal survival and quality of life. Multiple factors affect your treatment options including:

• Cancer is recurring (you have had cancer before) or your cancer is a first time diagnosis: The treatment for recurrence is determined by what type of treatment you received for your first diagnosis. Certain chemotherapies can only be given once in your lifetime, so if you have already received one type of chemotherapy with your first cancer, then that chemotherapy will not be recommended for you again.
• The molecular characteristics of the tumor: there are two types of testicular cancer – seminoma and non-seminoma. The latter includes multiple subtypes: teratoma (mature/immature, with malignant transformation), choriocarcinoma, yolk sac (endodermal sinus tumor), embryonal carcinoma, and mixed. The subtypes of testicular cancer are differentiated by their appearance under the microscope. It is important to be aware of which subtype you have, because the treatment is different depending upon the type.
• Cancer stage at the time of the diagnosis.
  • Your treating physician will assess the stage of your disease with imaging studies, including chest x-ray, and CT scan of the abdomen and pelvis. The latter is useful in particular to assess the lymph nodes at the back of the abdomen (retroperitoneal lymph nodes). These lymph nodes are critical in testicular cancer because they are usually the first location to which testicular cancer will spread, and surgical removal of these nodes, also known as retroperitoneal lymph node dissection (RPLND), is sometimes part of the treatment.
  • Testing of the blood for the levels of substances which are often produced by testicular cancer, or tumor markers (human chorionic gonadotropin or HCG, alpha fetoprotein or AFP, and lactate dehydrogenase or LDH) is used to determine prognosis and monitor disease after treatment.
  • Bone scan and MRI of the brain are indicated only if you have symptoms concerning for spread to the bone or brain, respectively.

Testicular Stages

Stage I:

• Stage IA disease is limited to the testicle and epididymis, and no cancer in lymph nodes
• Stage IB disease involves the spermatic cord or scrotum and no cancer in lymph nodes

Stage II:

• Stage IIA (spread to lymph node or nodes but all involved nodes <2cm in size)
• Stage IIB (not meeting criteria for stages IIA and IIC)
• Stage IIC (any involved lymph node >5cm in size)

Stage III: when the disease has spread to other organs, then the disease is classified into good risk, intermediate risk or poor risk group, this would determine the treatment plan and chance for cure.

• Stage IIIA metastasis to lungs or distant lymph nodes (beyond the retroperitoneal area) and tumor marker levels normal or mildly elevated
• Stage IIIB lung or distant lymph node metastases and tumor marker levels are intermediate
• Stage IIIC lung or distant lymph node metastases and tumor marker levels high, or distant metastasis to organs other than lungs or distant lymph nodes

Note that there is no stage IV in testicular cancer.

* You should have sperm banking performed if there is any possibility that you will want to have children in the future. This should ideally be performed before orchiectomy, but definitely before chemotherapy, which can cause permanent infertility. 

Testicular chemotherapy treatment is based on risk assessment. All testicular cancer treatment plans are recommended based on expertise ‘s opinions from multiple national guidelines (NCCN, ASCO, ESMO, ASTRO).

• Good risk: in seminoma, all patients other than those with metastases to organs other than lungs or distant lymph nodes; in nonseminoma, stage I-IIIA disease. (60% non-seminoma AFP<1000, HCG <5000, LDH< 1.5 x normal lab value)
• Intermediate risk: (26% in seminoma, metastases to organs other than lungs or distant lymph nodes; in nonseminoma, stage IIIB disease. seminoma testicular, retroperitoneal, normal AFP; AFP 1K-10K, HCG 5K-50K, LDH <5-10x normal lab value
• Poor risk:  nonseminoma with stage IIIC disease.  Note that there is no poor risk category for seminoma (10-20%) liver metastasis, (14% mediastinal non-seminoma, AFP> 10K, HCG > 50K, LDH> 10x normal lab value)

Chemotherapy works very well for testicular cancer. Common chemotherapy regimens include:

Long Term Side Effects

Since most testicular cancers are cured, the long term late effects from treatment are important to monitor. Most of the chemotherapy side effects will disappear upon completion of therapy. However, some side effects can show up much later.

• Non-seminomatous testicular cancer survivors have 3-5 fold increase in risk of having a heart attack
• Chemotherapy drugs: cisplatin has the potential causing gonadal dysfunction, metabolic syndrome, and high blood pressure. Bleomycin can increase risk of lung toxicity. Cyclophosphamide dose > 29g/ m2 or ifosfamide dose > 60g/m2 can cause infertility
• Radiation can increase the risk for secondary malignancies at least 35 years out (such as sarcoma, melanoma, thyroid cancer, myeloid leukemia, pancreatic cancer, kidney cancer), infertility, ototoxicity, neurotoxicity, pulmonaty toxicity, renal impairment. Testicular radiation dose > 20 Gy can cause Leydig cell dysfunction

Finally, chemotherapy and targeted therapies can result in unpleasant side effects such as hair loss, numbness of fingers or toes, cardiac toxicity, nausea, vomiting, diarrhea, abnormal liver function or low white blood cell count that could cause infection, and fatigue. However, advances in the oncology field have led to numerous supportive measures, such as white blood cell growth support (i.e. Neulasta) or anti-nausea medications (such as Zofran, Emend), that help to control most side effects when used as prescribed.

The best time to use this service (based on more than 1,100 cancer experts) is after you have learned the details of your cancer and treatment plan from your treating physicians, and would like to clarify and confirm that your treatment is the best option for your cancer. This questionnaire is used mainly for drug treatment in medical oncology.