How is testicular cancer treated at each stage?
Nearly all testicular cancers start in the germ cells (the cells that become sperm or eggs). The main types of testicular germ cell tumors are seminomas and non-seminomas. Non-seminomas tend to grow and spread faster than seminomas. Seminomas are more sensitive to radiation, and both kinds are very sensitive to chemotherapy. If a testicular tumor has both seminoma and non-seminoma cells, it is treated as a non-seminoma.
The three main kinds of treatment for testicular cancer are:
- Surgical treatment: This treatment can include removing the testicle (orchiectomy) and removing associated lymph nodes (lymph-node dissection). Usually, orchiectomy is performed for both seminoma and non-seminoma testicular cancers, whereas lymph node removal is used mostly for non-seminomas. Surgery may also be performed in certain situations to remove tumors from the lungs or liver if they have not disappeared following chemotherapy.
- Radiation therapy: This treatment uses high-dose X-rays to kill cancer cells. Radiation might be used after surgery for patients with seminomas to prevent the tumor from returning. Usually, radiation is limited to the treatment of seminomas.
- Chemotherapy: This treatment uses drugs such as cisplatin, bleomycin, and etoposide to kill cancer cells. Chemotherapy has improved the survival rate for people with both seminomas and non-seminomas.
Treatment by stage for testicular cancer
In Stage I, the treatment is usually surgery to remove the testicle. For stage I seminomas, the standard treatment is observation, one or two doses of carboplatin chemotherapy (given 21days apart if giving two doses), or radiation to the lymph nodes in the abdomen. For non-seminomas, management consists of observation, chemotherapy with one cycle of bleomycin, etoposide, and cisplatin, or surgery to remove lymph nodes in the back of the abdomen (the surgery is referred to as a retroperitoneal lymph node dissection).
In Stage II, seminoma tumors are divided into bulky and non-bulky disease. Bulky disease is generally defined as tumors greater than 5 centimeters. For non-bulky disease, the treatment of stage II seminomas includes surgery to remove the testicle, followed by either radiation to the lymph nodes or chemotherapy using nine weeks (three 21-day cycles) of bleomycin, etoposide, and cisplatin, or 12 weeks (four 21-day cycles) of etoposide and cisplatin. In cases of bulky disease, the treatment involves surgery to remove the testicle, followed by chemotherapy using nine weeks (three 21-day cycles) of bleomycin, etoposide, and cisplatin, or 12 weeks (four 21-day cycles) of etoposide and cisplatin without bleomycin.
The treatment of Stage II non-seminomas is similarly divided into bulky and non-bulky disease, but the cutoff is lower at 2 centimeters. For non-bulky disease with normal AFP and BHCG blood test results, treatment is usually surgery to remove the testicle followed by either retroperitoneal lymph node dissection to remove the lymph nodes in the back of the abdomen (the retroperitoneum) or else chemotherapy using nine weeks (three 21-day cycles) of bleomycin, etoposide, and cisplatin, or 12 weeks (four 21-day cycles) of etoposide and cisplatin. If a lymph node dissection is performed and cancer is found in the lymph nodes that are removed, then six weeks of chemotherapy using cisplatin and etoposide (either with or without bleomycin) is often recommended. For bulky disease (greater than 2cm) and also for non-bulky disease if blood tests show abnormally high levels of AFP or BHCG, surgery is performed to remove the testicle, followed by chemotherapy (the same chemotherapy as defined above for seminoma). After chemotherapy, surgery should be performed to remove the lymph nodes in the back of the abdomen if there are any remaining enlarged nodes.
In Stage III, the treatment is surgery to remove the testicle followed by multi-drug chemotherapy. Treatment is the same for Stage III seminomas and non-seminomas, except that after chemotherapy, surgery is often performed to remove any residual tumors in non-seminomas. In seminomas, residual tumors usually do not require any additional treatment. Chemotherapy typically consists of nine weeks of bleomycin, etoposide, and cisplatin, or 12 weeks of etoposide plus cisplatin for patients with favorable risk factors and 12 weeks of bleomycin, etoposide, and cisplatin for patients with unfavorable risk factors. Unfavorable risk factors include highly elevated tumor markers in the blood and tumors in organs other than the lungs, such as the liver, bones or brain.
If the cancer is a recurrence of a previous testicular cancer, the treatment usually consists of chemotherapy using combinations of different medicines, such as ifosfamide, cisplatin, etoposide, vinblastine, or paclitaxel. This treatment sometimes is followed by an autologous bone marrow or peripheral stem-cell transplant. Recurrences occurring more than two years after initial treatment are usually treated with a combination of surgery and chemotherapy.