Testicular cancer is a disease in which cells in one or both testicles become abnormal and begin to grow uncontrollably. These cancerous cells will eventually form a growth, or tumor, that can spread to other parts of the body. Testicular cancer is typically curable, especially if found early. The three main treatment options are surgery, chemotherapy, and/or radiation therapy.
The testicles are part of the male reproductive system. They are located under the penis in a sac-like pouch called the scrotum. They are also referred to as testes or gonads. The testicles produce sperm and testosterone, a hormone which plays a role in the development of the reproductive organs and other male characteristics.
Most cancers of the testicle develop in the sperm-producing cells known as germ cells, and these cancers are referred to as germ cell tumors. Germ cell tumors most commonly start in the testicles but can also develop in other parts of the body, such as the retroperitoneum (the back of the abdomen in front of the spine), the mediastinum (the central portion of the chest between the lungs), the lower spine, and very rarely the pineal gland (a small gland in the brain). There are two types of germ cell tumors that occur in the testicles: seminoma and non-seminoma. Generally, seminoma is relatively slow growing, while non-seminoma tends to grow and metastasize (spread) more quickly.
Teratoma is a unique type of non-seminoma. Unlike the other types of germ cell tumor, it is not very sensitive to chemotherapy. The primary treatment for teratoma is to remove it by surgery. Although teratoma is less likely to spread, it needs to be treated (for example, removed by surgery) because it can transform into a much more dangerous cancer if left in place.
This section provides information only on germ cell tumors (seminoma and non-seminoma) of the testicles. Other, less common types of testicular tumors include Leydig cell tumor, Sertoli cell tumor, and carcinomas of the rete testis. These can often be successfully treated by surgically removing the affected tissue; however, if they metastasize, they are more difficult to treat. Other types of cancer, such as lymphoma and leukemia, occasionally spread to the testicles. For more information about cancer that started in another part of the body and spread to the testicles, please see Cancer.Net's Cancer Type information.
Statistics
In 2008, an estimated 8,090 men in the United States new will be diagnosed with testicular cancer. It is estimated that 380 deaths from this disease will occur this year. The deaths are from cancers that have spread to other parts of the body and could not be effectively treated by chemotherapy, radiation therapy, and/or surgery.
The five-year relative survival rate (percentage of patients who survive at least five years after the cancer is detected, excluding those who die from other diseases) of patients with with testicular cancer is 95%. Testicular cancer may be more difficult to treat if it has spread to the liver, bones, or brain, but even in those cases, men can often be cured.
Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a man how long he will live with testicular cancer. Because the survival statistics are measured in five-year (or sometimes one-year) intervals, they may not represent advances made in the treatment or diagnosis of this cancer.
Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2008.
A risk factor is anything that increases a person's chance of developing cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health-care choices.
Although the cause of testicular cancer is not known, the following factors can raise a man's risk of developing testicular cancer:
Age. Testicular cancer is most commonly found in men between 20 and 45, but it can occur in men of any age.
Family history. A man who has a relative who has had testicular cancer is at increased risk of developing testicular cancer, particularly if the relative is the man's brother.
Personal history. Men who have had cancer in one testicle are at increased risk for developing cancer in the other testicle.
Race. Although men of any race can have testicular cancer, white men are more likely than men of other races to be diagnosed with testicular cancer.
Cryptorchidism (undescended testicle). Men with this condition, in which one or both testicles do not descend into the scrotum before birth as they normally should, have an increased risk of developing testicular cancer. This risk may be lowered if surgery is performed to correct the condition before the boy reaches puberty. Some doctors have recommended that cryptorchidism be corrected when a boy is very young, between six and 15 months, in order to reduce the risk of infertility (inability to produce children).
Klinefelter's syndrome. Men with this condition have an extra X chromosome, which results in low levels of male hormones, infertility, breast enlargement, and small testicles; it also increases the risk of developing germ cell tumors that begin in the chest, but this is rare.
Human immunodeficiency virus (HIV) infection. Men infected with HIV, the virus that causes acquired immune deficiency syndrome (AIDS), have a slightly higher risk of developing testicular cancer.
Men with testicular cancer may experience the following symptoms. Sometimes, men with testicular cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom on this list, please talk with your doctor.
The first sign of testicular cancer may be a small lump on the testicle, which often does not cause any pain. Other symptoms may go unnoticed until the cancer is advanced and has spread to other parts of the body. Regular testicular self-examinations and examinations by doctors can detect the cancer in its early stages, when it is more likely to be successfully treated.
Symptoms of testicular cancer may include:
Painless lump or swelling on either testicle (If detected early, a testicular tumor may be about the size of a pea, but it can rapidly become the size of a marble or larger.) Any lump or enlargement should be evaluated by a doctor as soon as possible.
Pain or discomfort (with or without swelling) in a testicle or scrotum. Pain can result from many different conditions, including infections, injury, twisting, and cancer. Infection of the testicle is referred to as orchitis. Infection of the epididymis is called epididymitis. (The epididymis is a small organ that is attached to the testicle that is made up of coiled tubes that carry sperm away from the testicle.) If infection is suspected, a patient may be given a prescription for antibiotics. If antibiotics do not solve the problem, an evaluation for testicular cancer should be performed.
Enlargement of a testicle or change in the way it feels
Feeling of heaviness in the scrotum (For example, a testicle that feels very firm or hard may indicate a problem.)
Dull ache in the lower abdomen or groin
Sudden buildup of fluid in the scrotum
Breast tenderness or growth (Although rare, some tumors produce hormones that cause breast tenderness or growth.)
Lower back pain, shortness of breath, chest pain, and bloody sputum (phlegm) can be symptoms of advanced testicular cancer, but many other diseases can cause these symptoms, too.
Early detection: finding testicular cancer early
Most cases of testicular cancer can be detected at an early stage, and men often find the cancer themselves while performing self-examinations. Some doctors recommend that men ages 15 to 55 perform a monthly self-examination. However, some testicular cancers may not cause symptoms and may go undetected until they reach an advanced stage.
Doctors use many tests to diagnose cancer and determine if it has metastasized. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer, but biopsies are rarely used to diagnose testicular cancer. Instead, if a cancer is suspected in a testicle, the standard procedure is to surgically remove the testicle. In fact, a biopsy using a needle through the skin should NOT be performed because this can complicate future treatment options.
When a man develops a testicular lump or something else that raises a suspicion of cancer, the usual first test that is performed is an ultrasound (see below) of the testicles. Blood tests may also be done at the same time. If the ultrasound shows an abnormality that looks like a tumor, then the testicle will be surgically removed and examined under a microscope to see whether cancer is present. Imaging tests, such as x-rays and computed tomography (CT) scans, may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
Age and medical condition
The type of cancer
Severity of symptoms
Previous test results
If the doctor suspects testicular cancer, he or she will ask about a man's medical history and general health. The doctor may conduct the following tests:
Physical examination. The doctor will feel the testicles for any sign of swelling, tenderness, or hardening. The doctor will also feel the abdomen, neck, upper chest, armpits and groin for evidence of enlarged lymph nodes, which may indicate that the cancer has spread. The breasts and nipples will also be examined to look for enlargement.
Ultrasound. This imaging test allows doctors to detect growths in the testicles. The ultrasound machine produces sound waves and bounces them off tissues in the scrotum. The echoes of the sound waves produce an image called a sonogram that can help the doctor detect the presence, size, and solidness of a tumor. Solid tumors are much more likely to be cancerous.
Blood tests/tumor markers. A sample of blood may be collected to test for levels of serum tumor markers, which are substances produced by a cancerous tumor that can often be found at abnormally high levels in the blood of a person with that cancer. Results from these tests depend on whether the cancer is a seminoma or non-seminoma (see Overview). Alpha-fetoprotein (AFP) is a tumor marker that is not made by seminomas, so an elevated level of AFP indicates that some other type of cancer is probably present. Two other tumor markers, beta human chorionic gonadotropin (hCG) and/or lactase dehydrogenase (LDH), can be elevated in seminomas. Placental alkaline phosphatase (PLAP) is another tumor marker doctors may test for, although it is not commonly measured.
Biopsy. A biopsy removes a small amount of tissue for examination under a microscope. As outlined above, needle biopsies for testicular cancer are rarely done. Occasionally, a biopsy may be useful from the lung or the retroperitoneum if it appears that cancer may have spread there.
Pathology tests. In most cases of suspected testicular cancer, a surgeon will perform a radical inguinal orchiectomy, in which the entire testicle is removed through an incision in the groin. This is often all that is required to successfully treat the cancer. Then, a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease) will examine the testicle under a microscope to diagnose the type of cancer. For a cancer to be considered a seminoma, it must be pure seminoma. Non-seminoma is diagnosed if any of the following are found in the pathology specimen: choriocarcinoma, embryonal cell carcinoma, yolk sac tumor, or teratoma. Each of these can occur alone or in any combination. Sometimes, seminoma cancer can be found as a part of non-seminoma at any percentage level. For instance, a tumor that is 99% seminoma and 1% yolk sac is still diagnosed and treated as non-seminoma. If the man has one testicle to begin with or the diagnosis is uncertain, the surgeon may remove only a small sample of tissue from the testicle. The testicle may still need to be removed if there is evidence of cancerous cells.
If cancer is found, other tests may be required to determine the stage of the cancer and whether it has spread to other areas of the body.
X-ray. An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs.
Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors.
Staging is a way of describing how advanced a cancer is. The stage of a cancer is determined by how much it has grown and if or where it has spread. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.
One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. For testicular cancer, the TNM staging system also includes information on how highly elevated the three serum tumor markers, AFP, hCG, and LDH, are (see Diagnosis). The results are combined to determine the stage of cancer for each person. There are four stages of testicular cancer: stage 0 (zero) and stages I, II, and III (one, two, and three). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.
TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors, plus serum tumor markers, to determine the stage of testicular cancer:
How much has the primary tumor grown and where is it located? (Tumor, T)
Has the tumor spread to the lymph nodes? (Node, N)
Has the cancer metastasized to other parts of the body? (Metastasis, M)
Are serum tumor markers elevated and, if so, how high are they? (Serum, S)
Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe a patient's condition in more detail. There are two types of T stage: the first is a T stage that is assigned based on clinical information such as physical examination or imaging studies (such as CT scans or ultrasounds). The second type of T stage is the pathologic T stage and is often written as the pT stage. The pathologic T stage is assigned based on how a tumor appears under a microscope and is more accurate than a clinical T stage. However, the pT stage can only be assigned after the tumor has been removed. In most testicular cancers, the T stage can only be determined under a microscope. Therefore, when a T stage is assigned to a testicular cancer, it is almost always referring to a pathologic T stage. Specific tumor stage information is below.
TX: The primary tumor cannot be evaluated. If a patient has not had a radical inguinal orchiectomy (surgical removal of the testicle[s]), the term "TX" is used.
T0: There is no evidence of a primary tumor in the testicles.
Tis: In this stage, there is intratubular germ cell neoplasia (a precancerous condition in which there are germ cells that appear cancerous but are not yet behaving the way cancer cells do), also called carcinoma in situ (CIS). CIS becomes cancer when the cells invade into areas of the testicle(s) where they do not normally belong. Invasion is a telltale sign of cancer.
T1: The primary tumor is only in the testicle (with or without involvement of the epididymis), and it has not invaded blood vessels or lymph vessels in the testicles. The tumor may have invaded the tunica albuginea (the inner membrane layer surrounding the testicle) but not the tunica vaginalis (the outer membrane layer surrounding the testicle).
T2: The tumor is found in the testicle (with or without involvement of the epididymis) and has invaded blood vessels or lymphatic vessels, and/or the tumor has grown through the tunica albuginea and into the tunica vaginalis.
T3: The tumor has invaded the spermatic cord. (The spermatic cord is the structure that connects the testicle to the rest of the body. There is a left spermatic cord for the left testicle and a right spermatic cord for the right testicle.)
T4: The tumor has invaded the scrotum.
Node. The "N" in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. The lymph nodes that receive lymphatic fluid directly from the testicles are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes. As in the "T" section for Tumor, a lowercase p before the N indicates how the tissue sample looks under a microscope. The sample is obtained from a procedure called a lymph node dissection (surgical removal of lymph nodes) or, less commonly, from a biopsy of a lymph node. The regional lymph nodes for testicular cancer are in the retroperitoneum.
pNX: The regional lymph nodes (lymph nodes near the testicles) cannot be assessed.
pN0: There is no spread to regional lymph nodes.
pN1: There is metastatic cancer in five or fewer lymph nodes, and none of the involved nodes measures longer than 2 centimeters (cm) in its greatest dimension.
pN2: There is metastasis to at least one lymph node, with a mass size of larger than 2 cm but smaller than 5 cm at its greatest dimension. Or, there is metastasis to more than five lymph nodes, none larger than 5 cm at its greatest dimension.
pN3: There is metastasis to at least one lymph node, and at least one lymph node mass is larger than 5 cm at its greatest dimension.
Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread beyond the regional lymph nodes. When testicular cancer spreads beyond the regional lymph nodes, the most common sites are the lymph nodes of the chest and pelvis and the lungs. In more advanced cases, it may spread to the liver and bones. Testicular cancer rarely spreads to the brain.
MX: Distant metastasis cannot be evaluated.
M0: The disease has not metastasized to distant lymph nodes (lymph nodes beyond the reproductive area) or other organs.
M1: There is distant metastasis.
M1a: There is cancer in distant nodes and/or the lungs.
M1b: The cancer has spread to organs other than or in addition to the lung. (For example, cancers that have spread to the liver or the bones are stage M1b.)
For testicular cancer, the level of specific serum tumor markers (S) is also used to describe the stage.
Serum tumor markers (S). The levels of certain tumor markers in a man's blood also help to stage testicular cancer (see Diagnosis). The substances are produced either by the tumor itself or by the body in response to the cancer or certain noncancerous conditions.
The tumor markers that are most relevant to testicular cancer are AFP, hCG, and LDH.
SX: Marker studies are not available or not performed.
S0: Marker levels are normal.
S1: Marker study levels are above normal (LDH less than 1.5 times the upper limit of the normal range; and hCG [mIu/mL] less than 5,000, and AFP [ng/mL] less than 1,000).
S2: Marker studies are substantially above normal (LDH 1.5 to 10 times the upper limit of the normal range, or hCG [mIu/mL]) 5,000 to 50,000 or AFP [ng/mL] 1,000 to 10,000).
S3: Marker studies are very highly elevated (LDH more than 10 times the upper limit of the normal range, or hCG [mIu/mL] more than 50,000 or AFP [ng/mL] more than 10,000).
Cancer stage grouping
Doctors assign the stage of the cancer by combining the T, N, and M classifications and the S level information.
Stage 0: Refers to carcinoma in situ, also called intratubular germ cell neoplasia (pTis).
Stage I: Cancer is at any T level, and serum marker levels have not been performed or are unavailable (SX).
Stage IA: Cancer is only in the testicle (pT1) and has not spread to lymph nodes (N0) or distant sites (M0). Serum markers are normal (S0).
Stage IB: Cancer is outside the testicle or has invaded blood or lymphatic vessels within the testicles (pT2, pT3, pT4) and has not spread to lymph nodes (N0) or distant sites (M0). Serum markers are normal (S0).
Stage IS: Cancer is of any T stage and has not spread to lymph nodes (N0) or distant sites (M0). Serum markers are above normal levels (S1, S2, or S3).
Stage II: The cancer has spread to any regional lymph nodes but not to lymph nodes in other parts of the body or distant organs. Serum markers are unavailable.
Stage IIA: Cancer has spread to one to five lymph nodes in the retroperitoneum, none of which are larger than 2 cm (N1). Serum markers are at normal levels or slightly elevated (S0 or S1).
Stage IIB: Cancer has spread to lymph nodes in the retroperitoneum, at least one of which is greater than 2 cm and none of which are greater than 5 cm (N2); or cancer has spread to more than 5 nodes, none more than 5 cm. Serum markers are at normal levels or slightly elevated (S0 or S1).
Stage IIC: Cancer has spread to at least one lymph node that is larger than 5 cm (N3). Serum markers are at normal levels or slightly elevated (S0 or S1).
Stage IIIA: Cancer has spread to distant lymph nodes or the lungs (M1a). Serum markers are at normal levels or slightly elevated (S0 or S1).
Stage IIIB: Cancer has spread to at least one lymph node (N1 to N3) and/or the lungs but not to any other organs, AND serum markers are at substantially elevated levels (S2).
Stage IIIC: Either or both of the following:
(1) Serum marker levels are highly elevated (S3), and the cancer has spread to at least one lymph node or organ (N1-3 or M1a or M1b).
(2) The cancer has spread to an organ other than the lungs (M1b).
Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, www.springer-ny.com.
Advanced testicular cancer: risk group classification
If the disease has spread to lymph nodes or other organs, the following system is used to classify germ cell tumors into good-risk, intermediate-risk, or poor-risk groups. This is based on the ability to successfully treat patients with this disease. It needs to be emphasized that patients with poor-risk disease still have about a 50% chance of successful treatment.
Good Risk
Non-Seminoma
Seminoma
Testis/retroperitoneum primary
and
No non-pulmonary visceral metastasis
and
Good marker levels – all of
AFP < 1,000 ng/mL
B-hCG < 5,000 iU/L
LDH < 1.5 x ULN
Any primary site
and
No non-pulmonary visceral metastasis
and
Normal AFP, any B-hCG, any LDH
Intermediate Risk
Non-seminoma
Seminoma
Testis/retroperitoneum primary
and
No non-pulmonary visceral metastasis
and
Intermediate markers – any of
AFP ≥ 1,000 and ≤ 10,000 ng/mL
B-hCG ≥ 5,000 and ≤ 50,000 iU/L
LDH ≥ 1.5 x ULN and ≤ 10 x ULN
Any primary site
and
Non-pulmonary visceral metastasis
and
Normal AFP, any B-hCG, any LDH
Poor Risk
Non-seminoma
Seminoma
Mediastinal primary
or
Non-pulmonary visceral metastasis
or
Poor markers – any of
The treatment of testicular cancer depends on the size and location of the tumor, whether the cancer has spread, and the person's overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan, including a urologist (a doctor who specializes in urinary tract problems), surgeon, medical oncologist, and radiation oncologist.
Most cases of testicular cancer can be successfully treated with surgery, and/or radiation therapy, and/or chemotherapy. Men with testicular cancer may have concerns about how their treatment will affect their sexual function and fertility, and these topics should be discussed with their doctor before treatment begins. Sometimes, more than one treatment option is available. The final decision is often made depending on the patient's unique situation.
The main treatment options are explained below. In addition, treatment options by the cancer's stage follow the general descriptions below.
Surgery
Radical inguinal orchiectomy. Treatment of testicular cancer usually starts with surgery to remove the affected testicle, called radical inguinal orchiectomy. This is done through an incision in the groin. It is used to diagnose and treat both early-stage and later-stage testicular cancer, regardless of the type of tumor.
The removal of one testicle typically does not affect a man's ability to achieve a normal erection. It also is unlikely to make him sterile (unable to produce children) because the remaining testicle will still produce sperm. However, men with testicular cancer are more likely to be infertile than other men, even before being diagnosed with cancer. It appears that the cancer itself may cause some men to become infertile, and sperm counts usually improve after the testicle with cancer is removed. Men can choose to have an artificial testicle implanted in the scrotum that has a weight and texture similar to a normal testicle. A man may develop cancer in both testicles either at the same time or at different times, but this is rare (about 2% of patients with testicular cancer). If a bilateral orchiectomy (removal of both testicles) is performed, the man will no longer produce sperm or testosterone and will not be able to biologically produce children. A patient may want to consider storing sperm in a sperm bank prior to surgery, so that he will be able to produce children later if he wishes. In addition, if both testicles are removed, then testosterone replacement therapy will be needed.
Retroperitoneal lymph node dissection (RPLND). This is surgery to remove the retroperitoneal lymph nodes, involving an incision (usually made down the middle of the abdomen) and removal of the lymph nodes that lie at the back of the abdomen. RPLNDs are performed in two different situations: (1) clinical stage I nonseminomas and (2) men with residual retroperitoneal masses after completing chemotherapy for advanced stage disease. Residual masses after chemotherapy are almost always removed in men with non-seminomas, but in men with pure seminomas, such masses are often left in place and observed with CT scans.
RPLND for stage I non-seminomas
About 30% of patients with clinical stage I non-seminoma who have an RPLND are found to have lymph nodes with cancer; in other words, the surgery reveals that they have stage II disease. If the lymph node involvement is minimal (pN1), about 90% are successfully treated with this surgery alone. If a greater amount of cancer is found (pN2 or pN3), about 50% of patients are successfully treated with surgery alone, while the other 50% will have a relapse (return of cancer after treatment). The advantage of the RPLND is that it can cure most patients with small lymph node metastases, provide a more accurate assessment of the extent of disease, and avoid the need for frequent CT scans of the abdomen during follow-up care. It also reduces the chance that a man with early-stage (stage I) testicular cancer will ever need chemotherapy.
It is important to remember that the RPLND is a complex operation requiring substantial experience and technical skill in order to remove all of the appropriate lymph nodes and to minimize the side effects of the operation. RPLND should only be done by a surgeon who is highly experienced with this operation.
Some patients may experience temporary complications from RPLND, such as bowel obstruction or wound infections. This procedure should not affect a man's ability to have an erection or orgasm, but it may cause infertility because it may interfere with nerves that control the ejaculation of sperm. There are surgical techniques that are usually successful at sparing the nerves involved with ejaculation, and it is recommended that a man discuss this with his surgeon. The main disadvantage of this surgery is that 70% of patients are cured by removal of the testicle alone and for these men, an RPLND is of no benefit except, possibly, peace of mind.
Also, despite the surgery, about 10% of testicular cancers recur even if the lymph nodes were not found to have cancer. If the RPLND finds that the lymph nodes have cancer, then a decision needs to be made whether to give two courses of chemotherapy (see below) to decrease the chance of recurrence to about 1%. However, it is equally reasonable to "watch and wait" (also called surveillance, see below) and begin treatment with chemotherapy only if the cancer recurs. This is because this type of cancer has a greater than 95% chance of being eradicated (removed) with three cycles of chemotherapy if the recurrence is diagnosed early through regular surveillance.
RPLND to remove residual tumors after chemotherapy
RPLND performed after chemotherapy is a more complex operation and is more likely to result in infertility (due to failure to ejaculate) and other complications. However, the surgical removal of any residual masses after chemotherapy for non-seminomas is believed to be an essential part of treating the disease when such an operation can be safely completed. About half of men going through such surgery will be found to have a residual mass that contains either teratoma (about 40%) or one of the other germ cell cancers (10%). No tumor will be found in the other half. In men found to have teratoma, no additional treatment is given after RPLND. In men found to have one of the other germ cell cancers (seminoma, embryonal carcinoma, yolk sac tumor, or choriocarcinoma), then additional chemotherapy is usually given after RPLND.
Surveillance
As described above, after having a radical inguinal orchiectomy, one treatment option for clinical stage I seminomas and non-seminomas may be surveillance to watch for signs of cancer recurrence. A doctor may recommend this approach (also called active surveillance, watchful waiting, and watch and wait), in which the patient is monitored closely and treatment begins only if the cancer reappears. This option involves regular doctor appointments for CT scans, chest x-rays, physical examinations, and blood tests for tumor markers. This approach requires dedication by the doctor and patient to stick to the surveillance schedule so that any recurrence can be detected at an early stage. The main advantage of this approach is that it avoids any further treatment after orchiectomy (such as chemotherapy, radiation therapy, or additional surgery) in the 80% of patients with seminoma and 70% of patients with non-seminoma who do not require further treatment.
It is worth noting that while the surveillance schedule for non-seminomas involves testing every one to two months for the first two years and less often thereafter. The surveillance schedule for seminomas is much less intense, with testing performed every four months for the first three years and less often thereafter.
Radiation therapy
Radiation therapy is the use of high-energy x-rays or other radioactive particles to kill cancer cells. For testicular cancer, the most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. The radiation is generally directed at lymph nodes in the abdomen. Radiation therapy is more effective with seminoma than non-seminoma. The only common use of radiation therapy in testicular cancer is for stage I, IIA, or IIB pure seminomas.
Side effects from radiation therapy include mild skin reactions, nausea and vomiting, peptic ulcers, heartburn, loose bowel movements, and fatigue. Medications may be helpful in preventing or reducing nausea and vomiting during radiation therapy. Radiation therapy can also cause problems with sperm production and the remaining testicle needs to be shielded if the man wishes to try to preserve fertility. Radiation therapy has been shown to result in an increased risk of second cancers many years after treatment and has also been linked to an increased risk of cardiovascular disease and gastrointestinal disease.
Chemotherapy
Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. There are different options to consider when a doctor prescribes chemotherapy in testicular cancer, depending on the stage of the disease.
Chemotherapy with bleomycin (Blenoxane), etoposide (VePesid, VP-16), and cisplatin (Platinol) is a common combination, called BEP, used in testicular cancer treatment.
The side effects of chemotherapy depend on the individual and the dose used, but can include the items listed below. Most of these side effects usually go away once treatment is finished.
Nausea and vomiting. This is common during each cycle of chemotherapy. Vomiting can often be prevented using the appropriate medications. Drugs that prevent nausea and vomiting are given before chemotherapy on each of the days the cisplatin is given. These drugs are very effective. One of these antinausea drugs is a cortisone-like steroid called dexamethasone (Decadron). Another class of drugs, called serotonin antagonists, blocks a chemical called serotonin from entering the brain and triggering the vomiting center. The combination of these drugs almost completely prevents vomiting in a majority of patients, although they do not eliminate all nausea. A third active drug is metoclopramide (Reglan). The combination of metoclopramide, dexamethasone, and a serotonin antagonist has been shown to be highly effective at preventing vomiting and reducing nausea in patients receiving chemotherapy regimens like BEP. However, if nausea and/or vomiting occur, other drugs such as prochlorperazine (Compazine), promethazine (Phenergan), or lorazepam (Ativan) may be helpful. Another class of drugs called NK-1 inhibitors are sometimes used to prevent nausea and vomiting that may occur a few days after the last dose of cisplatin. For more information, read the ASCO Patient Guide: Preventing Nausea and Vomiting Caused by Cancer Treatment.
Fatigue. Tiredness and loss of energy are among the most common side effects of chemotherapy. Almost all men undergoing chemotherapy for testicular cancer will experience some degree of fatigue, but the extent varies widely from person to person.
Reduction in the number of white cells (cells that fight infections), red blood cells (cells that carry oxygen), or platelets (cells that cause blood to clot). The most important issue is to make sure to seek help if bleeding and/or infection and/or fever occurs.
Loss of hair. In most patients, hair loss occurs after four weeks. However, it grows back about four months after completion of the chemotherapy. At times, it may grow back a different texture (such as curly, if it used to be straight) or a different color. However, patients who are balding before chemotherapy do not grow more hair after completing chemotherapy than they had before chemotherapy.
Numbness and tingling. The chemotherapy used for testicular cancer sometimes causes nerve damage that results in a partial loss of sensation in the hands and/or feet. Numbness and tingling after chemotherapy often improves over time but may be permanent.
Hearing loss. Chemotherapy can cause loss of hearing for high-pitch sounds and can cause ringing in the ears, which is referred to as tinnitus. Hearing loss, when it occurs, is usually permanent.
Kidney damage. Studies of kidney function before and after chemotherapy for testicular cancer have shown that mild reductions in kidney function are common after chemotherapy, but it is unknown whether mild reductions actually cause any medical problems. Rarely, chemotherapy can cause more severe kidney damage that compromises the kidneys' capacity to function adequately.
Skin marks. Bleomycin can sometimes leave some brown patches on the skin.
Other side effects that can last for a prolonged period after chemotherapy are described in the After Treatment section.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications you've been prescribed, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions through Cancer.Net's Drug Information Resources, which provides links to searchable drug databases.
Treatment by stage of the cancer
The treatment choices depend on whether tests show cancer has spread outside of the testicle. If the doctor's physical examination and CT scan of the abdomen, pelvis, and chest reveal no abnormalities and the serum tumor markers are normal after the testicle is surgically removed, then a patient is considered to have clinical stage I disease. Then, the doctor will conduct tests to find out if the cancer type is seminoma or non-seminoma (see Diagnosis). Treatment options for early stage and advanced stages of each type are addressed below:
Clinical stage I non-seminoma testicular cancer
About one-third of patients with clinical stage I non-seminoma have small metastatic sites of cancer that cannot be seen by CT scans at the time of diagnosis but will grow and become visible with time. The options are:
RPLND. As described above, this is surgery to remove the retroperitoneal lymph nodes, involving an incision down the middle of the abdomen and removal of the lymph nodes that lie at the back of the abdomen.
Surveillance. Close surveillance means periodic physical examinations, CT scans, chest x-ray, and blood test. This option involves CT scans of the abdomen and pelvis every three to four months for the first year, every four months in the second year, and every six months in the third to fifth year. Chest x-rays with physical examinations and tumor marker tests are done monthly for the first 12 months, every two months in the second year, every three months in the third year, every four months in the fourth year, every six months in the fifth year, and then annually after that. This approach requires dedication by the doctor and patient to find the 30% of cancers that recur. If the cancer recurs, three cycles of chemotherapy successfully treats more than 95% of patients. The main advantage of this approach is that it avoids any further treatment in the 70% of patients who do not require further treatment.
Chemotherapy. This option involves undergoing chemotherapy shortly after the testicle has been removed surgically, called adjuvant chemotherapy. There are numerous studies evaluating a variety of different drugs given for periods ranging from three to nine weeks. The most commonly used approach has been to give two, three-week cycles of BEP. The advantage of this approach is that it lowers the relapse rate from 30% down to less than 3%. The main disadvantage is that 70% of patients receive chemotherapy unnecessarily because they have already been cured with the surgical removal of the testicle. Therefore, some have recommended reserving adjuvant chemotherapy for those men who are at higher risk for relapse so that fewer men will receive unnecessary treatment.
Clinical stage I seminoma testicular cancer
More than 80% of men with clinical stage I seminoma are cured with orchiectomy alone while the remaining 18% to 20% will experience a recurrence if given no additional treatment. The average time to relapse is about 15 months and the location of relapse is typically in the retroperitoneum. Recurrences of stage I seminoma can almost always be cured with radiation therapy at the time of recurrence, although a small number of men will also require chemotherapy.
Surveillance. Using a surveillance program, the risk of death from stage I seminoma is less than 1%. Unlike surveillance for non-seminomas, surveillance for seminomas does not require frequent visits to the doctor. Men are seen every four months for the first three years, every six months for the subsequent three years (for example, during years 4 through 6) and annually for the next four years (for example, years 7 to 10). At each visit the following are performed: a CT scan of the abdomen and pelvis; a chest radiograph; a physical examination; and a blood test to measure the serum tumor markers LDH, hCG, and AFP.
Adjuvant radiation therapy. Seminoma is much different from non-seminoma, and early-stage seminoma can be effectively eliminated with radiation treatment. Therefore, radiation therapy after orchiectomy (called adjuvant radiation therapy) is a treatment option for patients with stage I, IIA, or IIB seminoma. As mentioned above, cancer will recur in 18% to 20% of men unless additional treatment is given after orchiectomy. This chance of relapse can be decreased to less than 5% with about 15 treatments of radiation therapy to the back of the abdomen (referred to as the retroperitoneum). Additional radiation therapy to the pelvis does not reduce the risk of relapse overall, but it does reduce the risk of a relapse in the pelvis. Some doctors prefer to treat only the retroperitoneum. Others prefer to include the pelvis in order to prevent pelvic relapses and to eliminate the need to perform scans of the pelvis to monitor for relapse.
The disadvantage of radiation therapy for clinical stage I seminoma is that more than 80% of men treated receive treatment that they do not need because they were cured with the orchiectomy. Side effects and complications from radiation therapy include fatigue, peptic ulcer disease, an increased risk of other types of cancer, and an increased risk of cardiovascular (heart) and gastrointestinal disease.
Adjuvant chemotherapy. Chemotherapy for stage I seminoma is a newer and more controversial treatment option than surveillance or radiation therapy. Using carboplatin (Paraplatin), numerous studies have shown that the risk of relapse after orchiectomy can be reduced from 18% to about 2% using two doses of carboplatin and to about 5% using a single dose of carboplatin. Because carboplatin represents a newer approach, there is less information on long-term outcomes after treatment. Therefore, many experts believe that more information is needed before recommending this treatment approach. On the other hand, many others have accepted carboplatin as a new treatment option for stage I seminoma. The hope is that carboplatin will result in fewer complications than radiation therapy, but whether that is the case remains to be determined by clinical studies.
Metastatic non-seminomatesticular cancer
Chemotherapy. Chemotherapy is used for patients with non-seminoma that can be seen outside of the testicles on CT scans or chest x-ray. The most common regimen given is BEP. The treatments are given over three week cycles and each drug is given intravenously (by vein). The blood then carries the chemotherapy around the body and delivers it to the cancer cells. Cisplatin and etoposide are given each day on the first five days. Fluid is also given by vein before and after the cisplatin to reduce the risk of damaging the kidneys. The treatment takes about six hours on these days. Bleomycin is given once each week, typically on the first, eighth, and 15th day of the 21-day cycles. The treatment takes about 30 minutes on the days when only bleomycin is given.
The likelihood of chemotherapy successfully treating this cancer depends on the risk group category (see Staging). More than half of all cases of metastatic non- seminoma testicular cancer will be good-risk disease, and more than 90% of these will be successfully treated with three cycles of BEP chemotherapy or four cycles of chemotherapy using etoposide and cisplatin (EP). About 25% of metastatic non-seminomas are intermediate-risk disease, and 80% of these are successfully treated with four cycles of BEP. Finally, about 15% of these testicular cancers are poor-risk disease, and about 50% of these are cured with four cycles of BEP. For patients with intermediate-risk or poor-risk disease who cannot be given bleomycin due to side effects, the combination of etoposide, ifosfamide (Ifex), and cisplatin (called VIP) has been shown to be just as effective.
Surgery after chemotherapy. At the completion of chemotherapy, x-rays and CT scans are repeated to see if there are any residual (remaining) masses of cancer. If residual cancer is seen, then surgery to remove them is considered. The chance of the surgery being curative is higher if the serum tumor markers have been reduced to a normal range by chemotherapy. This surgery is difficult and requires an experienced surgeon who regularly performs either post-chemotherapy RPLND or resections of masses from the lungs. Very rarely, if the mass is pressing on the kidney or major blood vessels in the retroperitoneum, then major surgery, such as removal of the kidney and/or blood vessel grafts, may be required. Often in this situation the nerves that coordinate ejaculation cannot be spared. It is recommended that men discuss this matter with their doctors, in addition to the option of sperm banking, preferably prior to any chemotherapy.
At surgery, there is about a 45% chance only scar tissue will be found, a 45% chance there will be teratoma, and about a 10% chance of some other type of germ cell tumor (for example, embryonal carcinoma, seminoma, yolk sac tumor, or choriocarcinoma). If cancer is found, two more cycles of etoposide and cisplatin are usually given.
Metastatic seminoma testicular cancer
Chemotherapy. Chemotherapy for metastatic seminoma is identical for metastatic non-seminoma (see above). Most (approximately 90%) metastatic seminomas are good-risk disease, and about 90% are successfully treated. In approximately 10% of cases, metastatic seminomas are intermediate-risk disease and require four cycles of BEP.
Radiation therapy. Radiation therapy is more effective for seminoma than non-seminoma. For patients with stage IIA or IIB seminoma (cancer that has spread only to the retroperitoneum and there is no mass larger than 5 cm), radiation therapy is the preferred treatment in most treatment guidelines because it is thought to be safer, produce fewer side effects, and be as effective as three cycles of BEP or four cycles of EP chemotherapy.
Surgery after chemotherapy/radiation therapy. It is quite common for a mass to be found on imaging scans after completing chemotherapy or radiation therapy. There is less than a 10% chance that this mass contains cancer and almost no chance that it contains teratoma. The main options in this situation are surveillance or surgery. Such surgery is often very difficult due to a "scar-like" reaction, making the mass difficult to remove. This is unique to seminoma. Larger masses are more likely to contain cancer, so some believe surveillance should be used when a mass is smaller than 3 cm and surgery should be used for a mass 3 cm or larger. If surgery is decided upon but the surgeon determines that it cannot be removed, then extensive biopsies are often performed to try to determine whether cancer is present. If a decision is made to observe a mass through surveillance and the mass grows, chemotherapy will be recommended. Surgery can be considered if the mass remains after the chemotherapy.
Advanced testicular cancer with brain metastasis
If testicular cancer has spread to the brain, the initial treatment is chemotherapy unless immediate treatment of the brain is medically necessary. Chemotherapy will usually at least reduce the size of any tumors in the brain. If there are any residual masses after chemotherapy, they should be surgically removed if possible. Radiation therapy is controversial in this setting. If immediate treatment of a tumor in the brain is needed due to bleeding or swelling or other issues, then removing the mass surgically is usually preferred if it can be done safely, but radiation therapy may be recommended instead of or in addition to surgery depending on the specific situation.
Recurrent testicular cancer
Testicular cancer sometimes recurs (comes back) after initial treatment. Regular follow-up examinations to check for signs that the cancer may be returning are extremely important. If testicular cancer returns, treatment usually includes chemotherapy and surgery. Sometimes, high-dose chemotherapy with stem cell transplantation may be used. If the cancer returns in only the retroperitoneal lymph nodes, surgical removal alone may be considered or chemotherapy may be used. If the cancer is widespread in the lymph nodes or it returns elsewhere in the body, chemotherapy will be used first and may be followed by surgery to remove any remaining tumors.
Doctors and scientists are always looking for better ways to treat patients with testicular cancer. A clinical trial is a way to test a new treatment in order to prove that it is safe, effective, and possibly better than a standard treatment. Patients who participate in clinical trials are among the first to receive new treatments, such as new chemotherapy, before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.
Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that finding new drugs and other therapies is the only way to make progress in treating testicular cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with testicular cancer. Generally, clinical trials for advanced testicular cancer are aimed at newer treatments for patients with poor-risk disease (see Staging) or those men whose cancer recurs after first-line chemotherapy who have a decreased chance of cure compared with the majority of patients with this type of cancer.
To join a clinical trial, patients must complete a learning process known as informed consent. During informed consent, the doctor should list all of the patient's options, so that the person understands the standard treatments and how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials.
Cancer and cancer treatment can cause a variety of side effects; some are easily controlled and others require specialized care. In addition to the side effects listed in the Treatment section, below are some of the side effects that are more common to testicular cancer and its treatments. For more detailed information on managing these and other side effects of cancer and cancer treatment, visit the Cancer.Net Managing Side Effects section.
Anemia. Anemia is common in people with cancer, especially those receiving chemotherapy. Anemia is an abnormally low level of red blood cells (RBCs). RBCs contain hemoglobin (an iron protein) that carries oxygen to all parts of the body. If the level of RBCs is too low, parts of the body do not get enough oxygen and cannot work properly. Most people with anemia feel tired or weak. The fatigue (tiredness) associated with anemia can seriously affect quality of life and make it more difficult for patients to cope with cancer and treatment side effects.
Diarrhea. Diarrhea is frequent, loose, or watery bowel movements. It is a common side effect of certain chemotherapy or of radiation therapy to the pelvis, such as in women with uterine, cervical, or ovarian cancers. It can also be caused by certain tumors, such as pancreatic cancer.
Hormone deprivation symptoms in men. Many men who experience a halt in their hormone levels because of certain types of cancer treatment (particularly those treatments that stop the production of testosterone, such as removal of the testicles or androgen ablation [hormone treatment]) experience symptoms, such as hot flashes, osteoporosis (loss of bone mass that makes bones break and fracture easily), decreased libido (desire for sex), erectile dysfunction (problems with erections), fatigue, and depression or irritability, that are caused by the body's lack of testosterone. In men treated for testicular cancer, treatments to raise testosterone levels can help relieve these symptoms. Since testosterone helps prostate cancer grow, this is not an option for men with prostate cancer.
Infection. An infection occurs when harmful bacteria, viruses, or fungi (such as yeast) invade the body and the immune system is not able to destroy them quickly enough. Patients with cancer are more likely to develop infections because both cancer and cancer treatments (particularly chemotherapy and radiation therapy to the bones or extensive areas of the body) can weaken the immune system. Symptoms of infection include fever (temperature of 100.5°F or higher); chills or sweating; sore throat or sores in the mouth; abdominal pain; pain or burning when urinating or frequent urination; diarrhea or sores around the anus; cough or breathlessness; redness, swelling, or pain, particularly around a cut or wound; and unusual vaginal discharge or itching.
Nervous system disturbances. Nervous system disturbances can be caused by many different factors, including cancer, cancer treatments, medications, or other disorders. Symptoms that result from a disruption or damage to the nerves caused by cancer treatment (such as surgery, radiation treatment, or chemotherapy) can appear soon after treatment or many years later. See Managing Side Effects: Nervous System Disturbances for the most common symptoms.
Sexual dysfunction. Sexual dysfunction is common in all people, affecting up to 43% of women and 31% of men. It may be even more common in patients with cancer, as a result of treatments, the tumor, or stress. Many people, with or without cancer, find it intimidating to discuss sexual problems with their doctors. Sexual problems are most commonly caused by body changes from cancer surgery, chemotherapy or radiation therapy, hormone changes, fatigue, pain, nausea and/or vomiting, medications that reduce libido, fear of recurrence, stress, depression, and anxiety. Symptoms of sexual dysfunction generally fall into four categories: desire disorders, arousal disorders, orgasmic disorders, and pain disorders.
Skin problems. The skin is an organ system that contains many nerves. Because of this, skin problems can be very painful. Many patients find skin problems especially difficult to cope with because the skin is on the outside of the body and visible to others. Because the skin protects the inside of the body from infection, skin problems can often lead to other serious problems. As with other side effects, prevention or early treatment is best. In other cases, treatment and wound care can often improve pain and quality of life. Skin problems can have many different causes. Many of the drugs used to fight cancer can cause rashes and other skin reactions and radiation therapy can cause peeling or burned skin. Other causes of skin problems include chemotherapeutic drugs leaking out of the intravenous (IV) tube, which can cause pain or burning; pressure ulcers (bed sores) caused by constant pressure on one area of the body; and pruritus (itching) in patients with cancer, most often caused by leukemia, lymphoma, myeloma, or other cancers.
After treatment for testicular cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years.
Below are some of the long-term health considerations following treatment for testicular cancer. Talk with your doctor for more information.
Long-term side effects. After more than 30 years of experience with curative chemotherapy and radiation therapy for testicular cancer, researchers continue to investigate the long-term side effects of these treatments. In particular, studies are trying to determine the true frequency of secondary cancers due to treatment. It has long been known that radiation can cause cancer and studies of men treated with radiation therapy have repeatedly shown that these men have a higher risk of developing other cancers than men who have not been diagnosed with testicular cancer.
More recently, data has emerged that chemotherapy for testicular cancer also can increase the risk of other cancers and the risk appears to be highest in men who receive both radiation therapy and chemotherapy. Similarly, heart disease has been found to be more common after radiation therapy and/or chemotherapy. However, the men in these studies were treated during a time when treatments for testicular cancer were more intensive. Radiation therapy today treats smaller areas of the body and uses lower doses of radiation compared with radiation therapy as it was practiced 10 or 15 years ago. Similarly, there have been changes in which chemotherapy drugs are used and the number of treatments each patient receives has declined. Therefore, it is not clear whether current treatments for testicular cancer significantly increase the risk of other cancers or the risk of cardiovascular disease.
Another issue is that men who develop other cancers after treatment do not necessarily develop those cancers because of the treatment. It is possible that the unknown factors that led to testicular cancer also predispose men to other cancers. Distinguishing treatment-induced malignancies from malignancies associated with a history of germ cell tumors is challenging. The information on treatment toxicity is especially important with regard to choosing treatment for stage I seminoma and non-seminoma as these patients have a greater than 70% chance of being cured with an orchiectomy alone and thus any toxicity from treatment is more difficult to justify than in men who are known to have advanced cancer that requires treatment.
Effects of bleomycin on lungs. The rate of significant lung damage with nine doses of bleomycin is about 5% and is fatal in less than 1% of men receiving the drug. Lung scarring is a potential long-term complication. The risk factors for lung scarring are age (greater than 70), underlying lung injury, prior chest radiation therapy, impaired kidney function, or receiving additional doses. It is rare to have lung effects in the absence of these risk factors. Therefore, if a patient has risk factors and good risk disease, four cycles of EP can be substituted for three cycles of BEP. If four cycles of chemotherapy are required, ifosfamide can be used in place of bleomycin, but it is associated with more short-term risks, such as lowered white blood cells and injury to the bladder.
Two particularly important issues are:
Patients who smoke should stop smoking for many health reasons, but in particular to diminish the chance of lung injury from bleomycin.
The doctor should examine the patient's lungs prior to each dose of bleomycin and stop giving this drug at the first sign of injury.
Effects of chemotherapy on kidneys. It is well-known that cisplatin can cause kidney damage. However, it is a very important drug to treat testicular cancer, and its less toxic "cousin," carboplatin, has been shown to be less effective. The best way to prevent this problem is for cisplatin to be "flushed" out by giving the patient at least 1 liter of fluid by vein before and after the cisplatin dose. With this precaution, the chance of significant kidney injury is low. Studies evaluating kidney function years after the doses have been given have shown low rates of long-term kidney impairment and where it does occur, it is generally mild.
Effects of chemotherapy on blood vessels and risk factors for heart disease. A condition called Raynaud's phenomenon may occur and is due to bleomycin. This condition is associated with the blood vessels (especially of the hands) constricting and the skin turning white, then blue, and then red when exposed to certain triggers. The most common trigger is cold water or cold temperatures outside. Significant problems occur in less than 10% of patients. However, the incidence was higher when vinblastine (Velban) and bleomycin were combined. This regimen is almost never used now. Avoiding the triggers (for example, preventing the fingers from becoming cold) is the main treatment.
There is a suggestion that patients who receive BEP chemotherapy have higher cholesterol and blood pressure levels and possibly have an increased risk of heart disease and/or stroke. Radiation therapy has also been associated with an increased risk of heart disease. The increase is modest and clearly outweighed by the fact that the treatment is essential to remove the cancer. However, these side effects are more important when the oncologist considers chemotherapy or radiation therapy to prevent the cancer from coming back for patients with clinical stage I disease. A healthy diet, exercise, avoidance of smoking, and medications (when needed to lower cholesterol, control blood high pressure, or treat diabetes) are the key interventions for this concern.
Effects of cisplatin on nerves and hearing. Cisplatin can sometimes cause injury to the nerves that is felt as numbness or "pins and needles." When this occurs, it most often starts during the chemotherapy and lessens and goes away with time. It may take months to completely go away. Rarely, it can affect a person's functioning, such as being clumsy when buttoning shirt buttons.
In some cases, cisplatin can cause high-frequency hearing loss, which is more likely with a higher total dose. It is more likely to occur in older age or in patients with hearing problems unrelated to the cancer treatment. It is rarely a significant problem in young patients being treated for testicular cancer but may be relevant for musicians or others who depend on having very fine hearing capabilities.
Secondary malignancies. Many researchers from different countries have evaluated tumor registries in an attempt to determine whether there is an increased incidence of cancers caused by the treatment itself (chemotherapy or radiation therapy). As stated above, the risks are small and probably less now as the doses and medications are more refined. The most notable findings are:
Radiation therapy: Men who have received radiation therapy for testicular cancer are twice as likely to be diagnosed with another cancer compared with men in the general population.
Chemotherapy: Men who have received chemotherapy are 80% more likely to be diagnosed with another cancer compared with men in the general population.
Radiation therapy plus chemotherapy: Men who have received both radiation therapy and chemotherapy for testicular cancer are three times more likely to be diagnosed with another cancer compared with men in the general population.
On average, these increased risks translate into 10 additional cancers for every 100 men treated using historical treatment plans.
It is unknown to what extent these secondary cancers result from the treatment as opposed to other factors.
It is unknown to what extent these risk estimates are still valid because both radiation therapy and chemotherapy are now used more conservatively.
Leukemia occurs in fewer than four out of every 1,000 patients who receive BEP and is also elevated, though less so, after radiation therapy. These risks are much smaller than the overall risk of developing a second cancer discussed above.
Fertility. The issue of fertility in men with testicular cancer is a complex topic because patients with testicular cancer often have lower sperm count prior to any treatment. A man experiencing fertility problems should talk with his doctor about these factors:
The sperm count prior to chemotherapy
Whether a patient has received chemotherapy or radiation therapy
How long ago the treatment was given
Whether an experienced surgeon performed a nerve-sparing retroperitoneal lymph node dissection to preserve ejaculation
It is important to note that oligospermia (low sperm count) does not translate into absolute infertility and that most patients will develop very low to no sperm counts while receiving chemotherapy. However, the chance of restoring fertility is increased with the more years that pass after the chemotherapy but is lower in patients with no or low sperm counts before chemotherapy. It is also important to ask about sperm banking prior to any treatment.
Effects on testosterone level. In addition to impairment of spermatogenesis (sperm making), there may be injury to the Leydig cell function (cells that make testosterone). If a patient is found to have a low testosterone level, then hormone replacement therapy can be helpful.
Chemobrain. Cisplatin is a heavy metal and people with testicular cancer may have trouble concentrating, an effect referred to as chemobrain. This area needs more research for testicular cancer. One small study compared patients with testicular cancer who received chemotherapy with patients with testicular cancer who did not have chemotherapy and those with no history of cancer. In this small study, the group who had received chemotherapy may have had a slightly lower attention span. More work needs to be done in this area to make firm conclusions; if there is a problem, it appears to be minimal. Many men treated for testicular cancer with chemotherapy have gone on to be high achievers in the sporting, business, and academic worlds.
In summary, the treatment of testicular cancer has some notable, long-term side effects. However, the chance for a cure, even with disease that has spread, far outweighs these risks.
Men recovering from testicular cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about Healthy Living After Cancer.
Research for testicular cancer is ongoing. The following advancements may still be under investigation in clinical trials and may not be approved or available at this current time. Always discuss all diagnostic and treatment options with your doctor.
Since many men with testicular cancer are treated successfully, one of the major goals for the future is to minimize side effects and complications from treatment for men with early-stage or favorable risk cancers. In addition, treatment for poor-risk and recurrent cancers are being studied in clinical trials, along with basic research studies regarding the causes and underlying genetics of testicular cancer.
High-dose chemotherapy followed by peripheral stem cell transplantation. There is evidence that higher doses of chemotherapy can result in remission (temporary or permanent absence of symptoms) of recurrent testicular cancer. Before chemotherapy, some of the patient's own bone marrow stem cells are removed by a special blood filtering technique and saved. After chemotherapy, the stem cells are given back to the patient to replace the ones that were destroyed during treatment, so the blood counts rise to normal more quickly. This has not been shown to be better than the standard chemotherapy combination of BEP for first-line therapy for patients with poor-risk disease. Two cycles of high-dose chemotherapy with peripheral stem cell transplantation in patients that have relapsed after first-line therapy may successfully treat more men than standard-dose chemotherapy. However, clinical trials have not been done to answer this question.
There is also an ongoing study comparing an older chemotherapy combination of vinblastine (Velban), ifosfamide, and cisplatin (VIP) with paclitaxel (Taxol), ifosfamide, and cisplatin (TIP) for testicular cancer that has recurred after front-line chemotherapy
Genetic studies. Researchers are analyzing DNA samples from tumor samples of men with testicular cancer to determine if any genes are associated with testicular cancer. In addition, there are studies underway to examine potential inherited genetic factors leading to cryptorchidism and risk of testicular cancer.
Quality of life. Because more men are surviving testicular cancer, doctors are exploring the long-term effects of high-dose chemotherapy on brain function, such as memory loss, decreased speed of processing information, lowered attention span, anxiety, depression, and fatigue. Other parallel projects focus on sperm quality and vascular disease risk in testicular cancer survivors.
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:
What type of testicular cancer do I have?
Are other tests or surgery needed to confirm this diagnosis?
Why can't I have a needle biopsy?
What stage is my cancer? What does this mean?
What treatment options do I have?
What treatment plan do you recommend for me?
How often do you treat men with testicular cancer?
How experienced is the surgeon in orchiectomy and/or RPLNDs?
What are the short-term and long-term side effects of treatment?
Will this treatment affect my sex life?
What are the chances that I will become infertile after treatment? Should I bank sperm? Should I talk with a fertility specialist before treatment begins?
How can I keep myself as healthy as possible during and after treatment?
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