Testicular CancerLast Updated: July 08, 2011 This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/11 Overview
Testicular cancer begins when normal cells in a testicle change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). Testicular cancer is almost always curable if found early, and it is usually curable even when at an advanced stage. Another name for testicular cancer is testis cancer. About the testicles The testicles are part of the male reproductive system. Each man has two testicles, and they are located under the penis in a sac-like pouch called the scrotum. They can also be called testes or gonads. The testicles produce sperm and testosterone, a hormone which plays a role in the development of the male reproductive organs and other male characteristics. Types of testicular cancer Most types of testicular cancer develop in the sperm-producing cells known as germ cells, and are referred to as germ cell tumors. Germ cell tumors in men 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 near 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 different categories of germ cell tumors that occur in the testicles: seminomas and non-seminomas. Generally, non-seminomas tend to grow and metastasize (spread) more quickly than seminomas, but prompt diagnosis and treatment are important for both types of tumors. Teratoma is a unique type of non-seminoma. Unlike the other types of germ cell tumors, it is not very sensitive to radiation therapy and chemotherapy (see Treatment). The primary treatment for teratoma is to remove it with surgery. Although a teratoma is less likely to spread, it needs to be removed because it can become a much more dangerous cancer if left in place. This article provides information only on germ cell tumors (seminoma and non-seminoma) of the testicles in males who have reached puberty. Other, less common types of testicular tumors include Leydig cell tumor, Sertoli cell tumor, and carcinomas of the rete testis (a part of the testicles). These can often be successfully treated by surgically removing the affected tissue; however, if they spread to other areas of the body, they are more difficult to treat. Testicular cancer is uncommon in boys and teenagers who have not yet reached puberty; childhood testicular cancer is approached differently than cancer in teenagers who have been through puberty and adult men. Other types of cancer, such as lymphoma and leukemia, occasionally spread to the testicles. To find out more about cancer that started in another part of the body and spread to the testicles, read about that specific type of cancer. Find out more about basic cancer terms used in this section. Looking for More of an Overview? If you would like additional introductory information, explore the following item on Cancer.Net:
Or, choose “Next” (below, right) to continue reading this detailed section. To select a specific topic within this section, use the icon panel located on the right side of your screen. Statistics
This year, an estimated 8,290 men in the United States will be diagnosed with testicular cancer. It is estimated that 350 deaths from this disease will occur this year. Almost all of these deaths are from cancer that has spread to other parts of the body and could not be effectively treated with chemotherapy, radiation therapy, and/or surgery, but some are from complications from chemotherapy and/or surgery. The overall five-year relative survival rate of people with testicular cancer is 95%. What this means is that for every 100 men diagnosed with testicular cancer, there are five additional deaths in the five years after diagnosis compared to the death rate among men the same age in the general population. This number includes all men diagnosed with testicular cancer. The survival rate is higher for men diagnosed with early-stage cancer and lower for men with later-stage cancer. For men with cancer that has not spread beyond the testicles (Stage 1; see Staging), the survival rate is about 99%. For men with cancer that has spread to the lymph nodes in the back of the abdomen (the retroperitoneum), the survival rate is about 96% but depends on the size of the lymph nodes involved with the cancer. For patients with more widely spread cancer (Stage 3), the disease is classified into one of three categories—good risk, intermediate risk, or poor risk—to better predict a man’s prognosis (chance of recovery). (For more details, refer to the chart listed in the Staging section.) For men in the good-risk Stage 3 group, the five-year survival rate is 91%. Men in the intermediate-risk group have a five-year overall survival rate of 79%, and men in the poor-risk group have a five-year overall survival rate range of 48%. However, these survival rates are based on patients treated more than 10 years ago, so they may not reflect how long a man recently diagnosed with testicular cancer will live after current treatments. Although the success rate is lower in testicular cancer patients with poor-risk disease, many men with poor-risk disease can be cured. Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of people with 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 intervals, they may not represent recent advances made in the treatment or diagnosis of this cancer. Learn more about understanding statistics. Statistics adapted from the American Cancer Society's publication, Cancer Facts Figures 2011. Medical Illustrations
Risk Factors
A risk factor is anything that increases a person’s chance of developing cancer. 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 talking about them with your doctor may help you make more informed lifestyle and health care choices. The following factors can raise a man’s risk of developing testicular cancer. However, it is important to note that the cause of testicular cancer is not known. Age. Testicular cancer is most common in men between the ages of 20 to 45. However, men of any age can develop this disease, and it’s important that any man with symptoms of testicular cancer visit the doctor. 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). Because cryptorchidism is often corrected at a young age, many men may not know if they had the condition. Family history. A man who has a close relative (particularly a brother) who has had testicular cancer has an increased risk of developing testicular cancer. Personal history. Men who have had cancer in one testicle have an increased risk of developing cancer in the other testicle. It is estimated that out of every 100 men with testicular cancer, two will develop 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. Testicular cancer is rare in black men, but black men with testicular cancer are more likely to die of the cancer than white men, particularly if the cancer has spread beyond the testicle to the lymph nodes or other parts of the body when it is diagnosed. Human immunodeficiency virus (HIV) infection. Men with HIV or AIDS (acquired immune deficiency syndrome caused by the HIV virus) have a slightly higher risk of developing seminoma. Symptoms and Signs
Men with testicular cancer may experience a variety of symptoms or signs. 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, such as a spermatocele (noncancerous cyst in the testicles), varicocele (enlargement of the blood vessels from the testicle), hydrocele (a buildup of fluid in the membrane around the testicle), and hernia (opening in the abdominal muscle). The first sign of testicular cancer is often enlargement of the testicle or a small lump or area of hardness on the testicle, which can be either painless or painful. 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 help detect the cancer at an early stage, when it is more likely to be successfully treated. If you are concerned about a symptom or sign, please talk with your doctor. Symptoms of testicular cancer may include:
Lower back pain, shortness of breath, chest pain, and bloody sputum (phlegm) can be symptoms of later-stage testicular cancer, but many other diseases can also cause these symptoms. Men with testicular cancer have an increased risk of blood clots in the veins that can cause swelling in one or both legs and shortness of breath. Swelling or shortness of breath from a blood clot in a large vein (called deep venous thrombosis or DVT) or a pulmonary (lung) artery (called pulmonary embolism) in a young or middle-aged man may be the first sign of a testicular cancer. Finding testicular cancer early Most often, 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 to identify any changes. However, some testicular cancers may not cause symptoms and may go undetected until they reach an advanced stage. Men who notice a lump, hardness, enlargement, pain, or any other change in one or both of their testicles should visit their doctor immediately. Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often. If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms. Diagnosis
Doctors use many tests to diagnose cancer and find out if it has metastasized. Some tests may also determine which treatments may be the most effective. When a man develops a testicular lump or something else that could be testicular cancer, it is important that he see his primary physician, who may refer him to a urologist (the doctor who specializes in treating a man with testicular cancer). The first tests that usually are performed are a physical examination and an ultrasound (see below) of the testicles. If these tests show an abnormality that appears to be a tumor, then blood tests are done. It may be necessary to surgically remove the testicle, so it can be examined under a microscope to see whether cancer is present. Imaging tests, such as computed tomography (CT or CAT) scans and x-rays, may also be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
If the doctor suspects testicular cancer, he or she will ask about a man's medical history and general health. The following tests may be used to diagnose testicular cancer: 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. An ultrasound uses sound waves to create a picture of the internal organs. The sound waves produced by the ultrasound bounce off tissue in the scrotum. The echoes of the sound waves produce a series of images called a sonogram. These images of the testicle help the doctor find any tumors or other abnormalities. If a tumor is found and is large enough to be seen on an ultrasound, then the sonogram will show the size, location, and solidness of the tumor. A solid tumor inside the testicle is very likely to be cancerous. Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer, but biopsies of the testicles are almost never used to diagnose testicular cancer. Instead, if cancer is suspected in a testicle, the standard procedure is to surgically remove the entire testicle (called an orchiectomy; see below). In fact, a biopsy of the testicle using a needle through the skin of the scrotum should NOT be performed because this can complicate future treatment options. Occasionally, a biopsy may be taken from the lung or the retroperitoneum or other location in the body if it appears that cancer may have spread. Orchiectomy/surgical pathology tests. If testicular cancer is suspected, a surgeon will perform a radical inguinal orchiectomy, in which the entire testicle is removed through an incision in the groin. Then, a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease) will examine very thin slices of tissue from 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 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 example, a tumor that is 99% seminoma and 1% yolk sac tumor 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 the tissue sample does not show cancer, it may be possible to repair the damage from the tissue removal and replace the testicle back into the scrotum during the same surgery. However, this procedure is very rare. Blood tests/tumor markers. If a decision is made to perform an orchiectomy, a sample of blood will be collected before surgery to test for levels of serum tumor markers, which are substances made by a cancer that are found at abnormally high levels in the blood of a person with cancer. Serum tumor marker levels do not help decide whether or not the orchiectomy should be performed, but they can help confirm whether or not a tumor is a pure seminoma and help determine the stage of the cancer. Different types of cancer make different tumor markers. High levels of any one of three tumor markers (see below) may indicate testicular cancer. It is also possible to have this type of cancer and have normal tumor marker levels. The three tumor markers used to help diagnose and plan treatment for testicular cancer are alpha-fetoprotein (AFP), beta human chorionic gonadotropin (hCG), and lactase dehydrogenase (LDH). AFP is a tumor marker that is not made by seminomas, so an elevated level of AFP indicates the tumor is not a pure seminoma, even if it looks like a pure seminoma when examined by a pathologist. The tumor marker hCG can be elevated due to either seminoma or non-seminoma. However, it is important to note that AFP and hCG levels are found to be normal in up to 40% of men with non-seminomas and in most men with seminomas. LDH can be elevated in any type of testicular cancer, as well as in many other cancers and non-cancerous diseases, such as liver disease or heart disease. Placental alkaline phosphatase (PLAP) is another tumor marker doctors may test for, although it is not commonly measured. Learn more about tumor markers for testicular cancer. If cancer is found, other tests will be needed to determine the stage of the cancer and whether it has spread to other parts of the body (see Staging). Usually, doctors recommend imaging tests of the abdomen, pelvis and chest. Images of the brain or bones are only rarely needed. Imaging tests may include: X-ray. An x-ray is a way to create a picture of the structures inside of your body, using a small amount of radiation. A chest x-ray is used to determine the stage of the cancer and for follow-up screening. If a more detailed picture of the lung is needed, then the doctor may recommend a chest CT scan (see below) but in many situations an x-ray is preferred. CT 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 can be examined to look for any abnormalities or tumors. Often, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail. CT scans are the most common imaging test for men with testicular cancer, and they can be used to evaluate the abdomen, pelvis, chest (including the lungs), brain and other areas. For men who have a normal CT scan of the abdomen and pelvis and normal serum tumor markers, a CT scan of the chest is usually not needed and a chest x-ray (see above) is used instead. CT scans of the brain are rarely needed for men with testicular cancers because it is uncommon for these cancers to spread to the brain. However, if a scan of the brain is needed, MRI (see below) is generally preferred for imaging the brain because the skull bones interfere with the ability of CT scans to show certain parts of the brain. MRI scan. An MRI scan uses magnetic fields to create a three-dimensional picture of the inside of the body. A computer then combines the images in a detailed, cross-sectional view that shows any abnormalities or tumors. For men with testicular cancer, CT scans (see above) are generally preferred to MRI for imaging the body because accurately reading MRI scans requires extensive experience. MRI is used only in specific situations. For instance, an MRI of the brain might be recommended if the patient has neurological symptoms or abnormalities on physical examination that suggest that the cancer may have spread to the brain. In addition, brain MRIs are often recommended for men who have poor-risk metastatic testicular cancer (see Staging) with very high serum tumor markers or if the cancer has spread to the liver or bones. Rarely, an MRI may be used to obtain an image of the abdomen or pelvis or other parts of the body. Your doctor will explain which test is appropriate for you. Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. Studies of PET scans have shown that they are not helpful for diagnosing or staging testicular cancer. However, they may be helpful in men with metastatic pure seminoma whose cancer does not entirely disappear after chemotherapy, but should not be done until at least six weeks after chemotherapy ends. Learn more about what to expect when having common tests, procedures, and scans. After these diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging. Learn more about the first steps to take after a diagnosis of cancer. Staging
Staging is a way of describing where a cancer has spread. Doctors use diagnostic tests, including CT scans and blood tests, to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and helps predict a patient's prognosis. Patients with early stage cancers are more likely to be cured and often need less aggressive treatment than patients with more advanced stage cancers. There are different stage descriptions for different types of cancer. There are also two different types of staging in testicular cancer: clinical staging and pathological staging. In clinical staging, the stage is based on a physical examination of the patient or x-rays, CT scans, and other imaging tests (see Diagnosis). In pathological staging, the stage is based on evaluating tissue under a microscope after it has been removed during surgery. One tool that doctors use to describe the stage is the TNM system. This system judges three factors: the initial tumor in the organ where the cancer started (sometimes referred to as the primary tumor), whether the cancer has spread to the lymph nodes in the back of the abdomen (retroperitoneum), and whether 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 (S) tumor markers, AFP, hCG, and LDH, are (see Diagnosis). For staging purposes, these blood tests are done after surgical removal of the affected testicle(s). For patients receiving chemotherapy for metastatic cancer, the tumor marker levels on the first day of chemotherapy are the values used for staging. The results of the different tests described in the Diagnosis section are combined to determine the stage of the cancer. There are three stages of testicular cancer: stages I, II, and III (one, two, and three). The stage provides a common way of describing how advanced the cancer is so that doctors can work together to plan the best treatments. Stage I is the least advanced and stage III is the most advanced. When the stage of a cancer is based on a physical examination and CT scans or other imaging tests, the stage is called a clinical stage. When the stage is based on the examination of tissue that has been removed with surgery, the stage is called a pathological stage. Pathological staging is more accurate than clinical staging, but it is not always necessary. The staging process is described in more detail below. TNM staging system TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors, plus serum tumor markers (S), to determine the stage of testicular cancer:
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 the tumor in even more detail. For testicular cancers, the T stage can only be determined when tissue removed during surgery is examined under a microscope. This means that the T stage is only determined after the testicle is removed, and the T stage is always a pathological stage and never a clinical stage. The “p” before the T stage indicates that it is a pathological stage. Specific tumor stage information is below. pTX: The primary tumor cannot be evaluated. If a man has not had a radical inguinal orchiectomy (surgical removal of the testicle[s]), the term "TX" is used. pT0: There is no evidence of a primary tumor in the testicles. pTis: 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 spread to areas of the testicle(s) where they do not normally belong. pT1: The primary tumor is only in the testicle (with or without involvement of the epididymis or rete testis), 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). pT2: The tumor is in the testicle (with or without involvement of the epididymis or rete testis) and has invaded blood vessels or lymphatic vessels, and/or the tumor has grown through the tunica albuginea and into the tunica vaginalis. pT3: The tumor has invaded the spermatic cord. pT4: 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. Lymph is a fluid that flows from the different tissues and organs of the body and eventually drains into the blood stream. It passes through specialized tubes called lymphatic vessels and is filtered along the way by the lymph nodes. Cancer cells often buildup and grow in lymph nodes before they spread to other parts of the body. The first place the lymphatic fluid from the testicles drains into is the retroperitoneal lymph nodes located in the retroperitoneum. These are called the regional lymph nodes for testicular cancer. Lymph nodes in the pelvis, chest or other parts of the body are called distant lymph nodes, and tumors in distant lymph nodes are considered metastases (M) in the TNM system (see below). In men with testicular cancer, lymph nodes are usually neither biopsied nor removed. Instead, the “N” stage is most often estimated by using CT scans. When lymph nodes are removed, a specialized surgeon performs an operation called a retroperitoneal lymph node dissection or RPLND (see Treatment). In men with newly diagnosed testicular cancer, RPLND is most often performed when the lymph nodes are normal size or slightly enlarged lymph nodes on CT scan. Men who have much larger lymph nodes usually receive chemotherapy before or instead of RPLND. Lymph node stage (N stage) that is based on CT scans is a clinical stage and N stage based on a biopsy or RPLND is a pathological stage. When a stage has been determined pathologically, the letter “p” is added as the first letter of the stage (for example pN1). NX: The regional lymph nodes cannot be evaluated. cN0: There is no spread to regional lymph nodes as seen on imaging tests. pN0: There is no cancer found in lymph nodes removed during RPLND. cN1: Imaging tests show at least one enlarged lymph node in the retroperitoneum but none of the enlarged lymph nodes are bigger than 2 centimeters (cm). pN1: There is cancer in one to five lymph nodes and none is larger than 2 cm. cN2: Imaging tests show at least one enlarged lymph node (or lymph node mass) in the retroperitoneum that is larger than 2 cm but not larger than 5 cm. pN2: Either or both of the following conditions:
cN3: Imaging tests show at least one enlarged lymph node or a lymph node mass in the retroperitoneum larger than 5 cm. pN3: There is cancer in at least one enlarged lymph node or lymph node mass that is larger than 5 cm. Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body. When testicular cancer spreads, it most commonly spreads to the lung and the lymph nodes of the chest, pelvis, and the base of the neck. More advanced stages may have spread to the liver and bones. Testicular cancer rarely spreads to the brain unless the primary tumor is a choriocarcinoma. MX: Distant metastasis cannot be evaluated. M0: The disease has not metastasized to distant lymph nodes or other organs. M1: There is at least one distant metastasis. M1a: There is cancer in distant lymph nodes and/or the lungs. M1b: The cancer has spread to organs other than the lung (the lungs may or may not also be involved). For example, a testicular cancer that has spread to the liver or the bones is stage M1b. Serum tumor markers (S). Serum tumor markers also help to stage testicular cancer. As noted in the Diagnosis section, blood tests for tumor markers will be done before and after surgical removal of the testicle(s). For the purposes of staging, it is only the levels after the testicle is removed that matter. For patients with metastatic testicular cancer who will receive chemotherapy, the tumor marker levels on the first day of chemotherapy should be used to determine the patient’s risk group (see below). SX: Tumor marker levels are not available or tests have not performed. S0: Tumor marker levels are normal. S1: At least one tumor marker level is 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: At least one tumor marker level is 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) and none of the tumor markers is elevated high enough to qualify as S3 (see below). S3: One or more tumor marker level is 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 there is no evidence of spread to either lymph nodes or other organs. Serum tumor marker levels have not been performed or are not available (any T, N0, M0, SX). Stage IA: Cancer is in the testicle and may have invaded the rete testis and the epididymis but has not invaded the lymphatic or blood vessels in the testis or spread to lymph nodes or distant sites. The tumor in the testis may have invaded the inner membrane surrounding the testis (the tunica albuginea) but not the outer membrane (the tunica vaginalis). Serum markers are normal (pT1, N0, M0, S0). Stage IB: The testicular tumor has invaded the outer membrane surrounding the testicle (the tunica vaginalis), invaded blood or lymphatic vessels within the testicle, spread to the spermatic cord or invaded the scrotum. The cancer has not spread to lymph nodes or distant sites. Serum markers are normal (pT2, pT3, or pT4, and N0, M0, S0). Stage IS: Cancer is of any T stage (T1, 2, 3 or 4) and has not spread to lymph nodes or distant sites. Serum markers remain above normal levels after the cancerous testicle has been removed (any T, N0, M0, and S1-3). Stage IS nonseminoma testicular cancer is treated the same as stage III testicular cancer. Stage II: The cancer has spread to any number of regional lymph nodes but not to lymph nodes in other parts of the body or distant organs. Serum markers are unavailable (any T, N1-3, M0, SX). Stage IIA: Cancer has spread to retroperitoneal lymph nodes, either clinical or pathological stage N1, but none is larger than 2 cm and, if a lymph node dissection has been performed, no more than five lymph nodes contain cancer. In addition, serum tumor markers are at normal levels or slightly elevated (S0 or S1), and there is no evidence of cancer having spread anywhere other than the retroperitoneum (any T, N1, M0, S0-1). 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, if a lymph node dissection has been performed, cancer has spread to at least one lymph node (or lymph node mass) between 2 cm and 5 cm or to more than five nodes, none more than 5 cm. Serum markers are at normal levels or slightly elevated (S0 or S1) and there is no evidence of cancer having spread anywhere other than the retroperitoneum (any T, N2, M0, S0-1). Stage IIC: Cancer has spread to at least one lymph node (or lymph node mass) that is larger than 5 cm (N3). Serum markers are at normal levels or slightly elevated (S0 or S1) and there is no evidence of cancer having spread anywhere other than the retroperitoneum (any T, N3, M0, S0-1). Stage III: Cancer has spread to distant lymph nodes or to any organ, and serum tumor marker levels are unknown (any T, N0-3, M1, SX). Stage IIIA: Cancer has spread to distant lymph nodes or the lungs. Serum markers are at normal levels or slightly elevated (any T, N0-3, M1a, S0-1). Stage IIIB: Cancer has spread to any lymph nodes (N1, N2, or N3) and/or the lungs but not to any other organs, and serum markers are at substantially and persistently elevated levels (S2) (any T, N1-3, M0, S2; or any T, N0-3, M1a, S2). Stage IIIC: Either or both of the following:
Recurrent: Recurrent cancer is cancer that comes back after treatment. If there is a recurrence, the cancer may need to be staged again (re-staging) using the system above. 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, Seventh Edition (2010) published by Springer-Verlag New York, www.cancerstaging.net. Advanced testicular cancer: risk group classification If the disease has spread to lymph nodes or other organs, the following system is used to classify a germ cell tumor into a good-risk, intermediate-risk, or poor-risk group. This helps to determine the treatment plan and the likelihood of cure. Patients in the intermediate and poor-risk groups usually receive more chemotherapy than patients in the good-risk category. Even patients with poor-risk disease have about a 50% chance of successful treatment (see Statistics).
Source: Journal of Clinical Oncology. Treatment
This section outlines treatments that are the standard of care (the best proven treatments available) for testicular cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, see the Clinical Trials and Current Research sections. Treatment overview In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team and includes a urologist and medical oncologist (a doctor who specializes in treating cancer with medication) and sometimes a radiation oncologist (a doctor who specializes in giving radiation therapy to treat cancer). Descriptions of the most common treatment options for testicular cancer are listed below, followed by treatment options by the cancer’s stage. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the man’s preferences and overall health. Most often, 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, fertility, and quality of life, and these topics should be discussed with their doctor before treatment begins. Sometimes, more than one treatment option is available. The final choice of a treatment plan depends on the patient’s specific situation. Learn more about making treatment decisions. Surgery Surgery is the removal of the tumor and surrounding tissue during an operation. There are different types of surgery used to treat testicular cancer, each is described further below. If a decision is made to perform an orchiectomy, a sample of blood will be collected before surgery to test for levels of serum tumor markers because they are often helpful in planning treatment and follow-up care. 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 (along the beltline). It is used to diagnose and treat both early-stage and later-stage testicular cancer, regardless of the type of tumor. In stage I nonseminoma testicular cancer, a man’s blood serum markers should return to normal after this surgery. For late-stage cancer, a radical inguinal orchiectomy may, in rare cases, be delayed until after treatment with chemotherapy is finished. The removal of one testicle typically does not affect a man’s testosterone level if the other testicle is present and of normal size. If a man’s testosterone level is reduced, symptoms may include decreased sex drive (libido), inability to achieve a normal erection and orgasm, fatigue, hot flashes, and mood changes as well as loss of muscle mass. Orchiectomy is unlikely to make a man infertile (unable to bear 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. Sperm counts usually improve after the testicle with cancer is removed. A man may develop cancer in both testicles either at the same time or at different times, but this is rare (about 2% of men 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. If the doctor recommends removing either one or both testicles, a patient should consider storing sperm in a sperm bank prior to surgery if possible, so that he will be able to have children later if he wishes. In addition, if both testicles are removed, testosterone hormone replacement therapy will be needed. Men can choose to have an artificial (prosthetic) testicle implanted in the scrotum that has a weight and texture that is somewhat similar to a normal testicle but not exactly the same. Each man is encouraged to talk with his doctor about the best timing of this implantation. Some men prefer to wait until after the active treatment period is over to give this option full consideration. And, some men do not like the prostheses after they are implanted and choose to have it removed. Retroperitoneal lymph node dissection (RPLND) This is surgery to remove the retroperitoneal lymph nodes that lie at the back of the abdomen. RPLND is recommended for men with clinical stage I and IIa nonseminomas and men with retroperitoneal masses that remain after completing chemotherapy for late-stage disease. In men with nonseminomas, any masses that remain after chemotherapy are removed if it is surgically feasible, but for men with pure seminomas, masses smaller than 3 centimeters are usually left in place and monitored for changes with CT scans. RPLND is usually performed as an open operation with an incision down the middle of the abdomen. Doctors are studying the use of laparoscopic RPLND, which uses several smaller incisions instead of the one large incision, but that approach is not yet widely used and may not be as effective. RPLND for stage I and IIa 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 shows that they have stage II disease. Doctors are now able to better determine which stage I tumors are at a higher risk of having spread to the lymph nodes or beyond, based on the results of the pathology tests performed on the tumor in the testicle after it is removed. This makes it possible to determine which men are more likely to have cancer discovered in the lymph nodes during RPLND and which are most likely to need chemotherapy after RPLND. Decisions about whether to have an RPLND may be based on the individual patient’s risk factors. If 5 or fewer lymph nodes have cancer but none are larger than 2cm (pN1), 80% to 90% of men are successfully treated with this surgery alone, while about 10% to 20% of men will have a recurrence. If more lymph nodes have cancer (pN2 or pN3), about 50% of patients are successfully treated with surgery alone, while the other 50% will have a recurrence. 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 be given unnecessary chemotherapy. Just as RPLND may show cancer in lymph nodes that appeared normal on CT scans for men with clinical stage I non-seminomas, surgery may also show that there is no cancer in lymph nodes that were enlarged on a CT scan (men with clinical stage II disease). For men with clinical stage IIa testicular nonseminomas, 20% to 40% will actually have pathological stage I cancer, meaning that the cancer has not spread to any lymph nodes. In these situations, the use of RPLND can help many men avoid unneeded 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 side effects from RPLND, such as bowel obstruction (blockage) or infection. This procedure should not affect a man's ability to have an erection, orgasm, or sexual intercourse, but it may cause infertility because it can 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 for stage I nonseminoma is that 70% of patients are cured by removal of the testicle alone; for these men, a RPLND offers no curative benefit, although it does allow the man to avoid the regular CT scans needed with active surveillance, as well as, 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 active 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 cured with three cycles of chemotherapy if the recurrence is diagnosed early through regular monitoring. 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 side effects. However, the surgical removal of any masses that remain after chemotherapy for non-seminomas is believed to be an essential part of treating the disease when such an operation can be safely done. About half of men going through such surgery will be found to have a mass that contains either teratoma (about 35-40%) or one of the other germ cell cancers (10-15%). The other 40% to 50% of men will have no tumor. Some treatment centers will perform an RPLND after chemotherapy in men who had enlarged retroperitoneal lymph nodes before chemotherapy even if the lymph nodes return to normal size, which is less than 1 cm, after chemotherapy. So, any enlarged lymph nodes or other masses after chemotherapy should be removed. However, some treatment centers may not recommend RPLND if a CT scan taken after chemotherapy is normal. For men found to have teratoma, no additional treatment is given after RPLND. For men found to have one of the other germ cell tumors (seminoma, embryonal carcinoma, yolk sac tumor, or choriocarcinoma), additional chemotherapy may be given after RPLND. Other types of surgery to remove tumors remaining after chemotherapy After chemotherapy, some men may have tumors remaining in lymph nodes outside the retroperitoneum or in the lungs, liver or other organs. These tumors should also be removed if it is safe to do so. This may involve surgery in more than one part of the body. If only some of the remaining tumors can be removed, then surgery is not usually performed. This type of surgery is complex and requires an experienced team of surgeons. Learn more about cancer surgery. Active surveillance for clinical Stage I testicular cancer As described above, after having a radical inguinal orchiectomy, one option for clinical stage I seminomas and non-seminomas may be active surveillance. Active surveillance will only be considered as an option if the serum tumor markers are normal or return to normal after the cancerous testicle is removed. A doctor may recommend this approach, in which the patient is monitored closely and active treatment begins only if the cancer recurs. 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) for the 80% of men with seminoma and 70% of men with non-seminoma who do not need more treatment after surgery. For an individual patient, the risk of recurrence may be higher or lower based on certain risk factors determined by the pathologist’s examination of the testicular tumor after the testicle has been removed. 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 two to three years and less often thereafter. Patients generally have follow-up screening for at least ten years after their diagnosis. Chemotherapy Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time. In general, patients with later-stage disease receive more chemotherapy. The appropriate chemotherapy depends on the stage of the cancer and whether it is a seminoma or a nonseminoma. Chemotherapy for specific stages is discussed further below. Chemotherapy works very well for testicular cancer but can cause side effects and complications, most of which occur during treatment but some that show up much later (called late effects). Balancing the risks and benefits of chemotherapy is an important issue for men with testicular cancer. However, metastatic testicular cancer (stage IIC-III) can generally only be cured with chemotherapy, so for men with metastatic testicular cancer, the benefits of chemotherapy typically outweigh the risks. On the other hand, men with stage I testicular cancer almost never die of the disease regardless of which treatment they receive, so risks of chemotherapy may outweigh the benefits for these men. The side effects of chemotherapy depend on the individual and the dose used, but they can include the following side effects. 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 drug cisplatin (Platinol) is given. These drugs are very effective. One of these antinausea drugs is a cortisone-like steroid called dexamethasone (multiple brand names). Another class of drugs, called serotonin antagonists, blocks a chemical called serotonin from entering the brain and triggering the part of the brain that controls vomiting. The combination of these drugs significantly reduces or even prevents vomiting in a majority of men, although they do not get rid of all nausea. A third drug is metoclopramide (Reglan). If a stronger antinausea treatment is needed, aprepitant (Emend) can be added to the combination of dexamethasone and a serotonin antagonist. Other drugs, such as prochlorperazine (Compazine), promethazine (Phenergan, Provigan, Zipan), or lorazepam (Ativan) may also be helpful. Learn more about 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 who have chemotherapy for testicular cancer will experience some fatigue, but the severity varies widely from person to person. Reduction in the number of blood cells. Chemotherapy may cause a 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). Because lower levels of these cells can interfere with blood clotting and the body’s ability to fight infections, it is important to seek help immediately if you have bleeding, infection, and/or a fever. Infections during chemotherapy can be very serious, and even life-threatening, if they are not treated immediately, and fever is often the only warning of an infection. Loss of hair. For most patients, hair loss occurs after four weeks. However, it grows back about four months after chemotherapy has ended. 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 feeling 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 called tinnitus. Hearing loss, when it occurs, is usually permanent. Kidney damage. 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 prevents the kidneys’ from functioning adequately. Skin marks. Bleomycin (Blenoxane) can sometimes leave some brown patches on the skin. Fertility. Chemotherapy can cause lowered sperm counts and increase the risk of infertility. Lung damage. Slightly reduced lung function is common after chemotherapy with bleomycin. Rarely, the effects of bleomycin on the lungs can cause death. Learn more about common side effects. Other side effects that can last for a prolonged period after chemotherapy are described in the After Treatment section and include an increased risk of other cancers and heart disease. Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases. Radiation therapy Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. For testicular cancer, the radiation is generally directed at lymph nodes in the abdomen. Often, the radiation is also targeted at lymph nodes on the same side of the pelvis as the testicle where the cancer started. Radiation therapy is more effective for treating seminoma than non-seminoma and is used in specific circumstances for testicular cancer. The only common use of radiation therapy in testicular cancer is for stage I, IIA, and IIB pure seminomas. However, at many treatment centers, active surveillance (or, less commonly, carboplatin chemotherapy) is used instead of radiation therapy as the preferred treatment of stage I seminomas because of the risk that radiation therapy may cause other cancers and cardiovascular (heart) disease. Radiation therapy is also sometimes used to treat brain metastases from either seminomas or nonseminomas, but testicular cancer rarely spreads to the brain. Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, loose bowel movements, and peptic ulcers. Medications may be helpful to prevent or reduce nausea and vomiting during radiation therapy. Most side effects go away soon after treatment is finished. 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 appears to increase risk of second cancers many years after treatment and an increased risk of cardiovascular disease and gastrointestinal disease. Talk with your doctor about your risk of long-term side effects before starting radiation therapy. Learn more about radiation therapy. Treatment by stage of the cancer The treatment choices for testicular cancer depend on whether the cancer is a seminoma or nonseminoma (see Overview) and the stage of the cancer (see Staging). After a physical examination, staging tests, and the removal of the cancerous testicle, you and your doctor will discuss your treatment options. Treatment options for early stage, later stages, and recurrent seminoma and nonseminoma are described in more detail below. Clinical stage I non-seminoma testicular cancer About one-third of patients with clinical stage I non-seminoma have small areas of metastatic cancer that cannot be seen by CT scans when diagnosed but will grow and be found with time. The rest are cured by having their testicle removed. Most recurrences of stage I non-seminoma occur within nine months after diagnosis and occur in the retroperitoneum. The options for men with clinical stage I disease are:
Clinical stage I seminoma testicular cancer More than 80% of men with clinical stage I seminoma are cured with orchiectomy alone while the remaining 15% to 20% will experience a recurrence if given no additional treatment. Most recurrences occur within 12 months after diagnosis and the location of the recurrence 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 need chemotherapy.
The disadvantage of radiation therapy for clinical stage I seminoma is that more than 80% of men receive treatment that they do not need because they were cured with the orchiectomy. This is a concern because radiation therapy increased the risk of developing heart disease and second cancers.
Clinical stage II non-seminoma testicular cancer Surgery to remove the affected testicle is done first, followed by additional treatment. Factors affecting the post-orchiectomy treatment decision are the patient’s serum tumor marker levels, as well as the size of retroperitoneal lymph nodes. The post-surgical options for men with clinical stage II non-seminoma are:
Clinical stage II seminoma testicular cancer Surgery to remove the affected testicle and affected lymph nodes is done first, followed by additional treatment. The main factor in the post-surgical treatment decision for a stage II seminoma is the size of the retroperitoneal lymph nodes.
Metastatic testicular cancer If cancer has spread to another location in the body, it is called metastatic cancer. The most common place for testicular cancer to spread is the lungs. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. Patients may want to talk with doctors experienced in the treatment of brain metastasis, including seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials studying new treatments. The treatment plan your health care team may recommend is based on many individual factors. Initial treatment is usually chemotherapy unless immediate treatment of the brain is medically necessary. Chemotherapy typically shrinks the size of such tumors in the brain and may eliminate them entirely. If there are any masses remaining after chemotherapy, surgery may be recommended. Radiation therapy to treat the spread of testicular cancer to the brain is controversial. 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 situation. Descriptions of the treatment options for metastatic testicular cancer are described below: Metastatic (stage III) non-seminoma testicular cancer
The likelihood of chemotherapy successfully treating this cancer depends on the risk group category (see Staging). More than half of metastatic non-seminoma testicular cancers are classified as good-risk, 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 (a regimen called EP) plus surgical removal of any remaining masses. About 25% of metastatic non-seminomas are intermediate-risk disease, and 80% of these are successfully treated with four cycles of BEP plus surgical resection of any residual masses. Finally, about 15% of metastatic non-seminomas are poor-risk disease, and about 50% to 70% of these are cured with four cycles of BEP plus surgical removal of any remaining masses. For patients with intermediate-risk or poor-risk disease who cannot be given bleomycin due to side effects, the combination of etoposide, ifosfamide (Cyfos, Ifex, Ifosfamidum), and cisplatin (called VIP) has been shown to be just as effective.
During surgery, there is about a 40% to 50% chance that only scar tissue will be found, a 35% to 40% chance there will be teratoma, and a 10% to15% 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 chemotherapy may be given. The chemotherapy administered is typically either cisplatin plus etoposide, cisplatin plus etoposide and ifosfamide, or cisplatin and ifosfamide combined with either vinblastine (Velban, Velsar) or paclitaxel (Taxol). Metastatic (stage III) seminoma testicular cancer
In addition to treatment to slow, stop, or eliminate the cancer (also called disease-directed treatment), an important part of cancer care is relieving a person’s symptoms and side effects. It includes supporting the patient with his or her physical, emotional, and social needs, an approach called palliative or supportive care. People often receive disease-directed therapy and treatment to ease symptoms at the same time. If disease-directed treatment is not successful, this may also be called advanced cancer. This diagnosis is stressful, and it may be difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Learn more about advanced cancer care planning. Recurrent testicular cancer Once your treatment is complete and there is a remission (absence of cancer symptoms; also called “no evidence of disease” or NED), talk with your doctor about the possibility of the cancer returning. Many survivors feel worried or anxious that the cancer will come back. Learn more about coping with this fear. Regular follow-up examinations to check for signs that the cancer may be returning are extremely important. If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as surgery, chemotherapy, and radiation therapy) but may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer. For recurrent testicular cancer, treatment usually includes chemotherapy and surgery. If the cancer was stage I and returns during active surveillance, then the most common treatment is chemotherapy with three or four cycles of BEP or four cycles of EP depending on the stage of the cancer. If the cancer is only in the retroperitoneal lymph nodes and is a pure seminoma, then radiation therapy is the usual treatment. If the cancer is only in the retroperitoneal lymph nodes and is a nonseminoma, RPLND alone may be considered instead of chemotherapy. The standard treatment for recurrent testicular cancer that has previously been treated with chemotherapy is four cycles of additional chemotherapy. The standard chemotherapy regimens include VeIP (vinblastine, ifosfamide, and cisplatin) and TIP (paclitaxel, ifosfamide, and cisplatin). Sometimes, high-dose chemotherapy with stem cell transplantation may be used but it is not known if high-dose chemotherapy works better than standard-dose chemotherapy. If chemotherapy is given, residual masses are managed the same way that they are after initial chemotherapy (see above). A recurrence more than two years after treatment should be removed surgically if possible. Chemotherapy may or may not be recommended. A man with recurrent testicular cancer is encouraged to talk with doctors who have experience in treating recurrent testicular cancers. People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence. Find out more about common terms used during cancer treatment. About Clinical Trials
Doctors and scientists are often looking for better ways to treat patients with testicular cancer. To make scientific advances, doctors create research studies involving people, called clinical trials. Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment. There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease. 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 these studies are 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 later-stage testicular cancer are aimed at newer treatments for patients with poor-risk disease (see Staging) or men whose cancer recurs after initial chemotherapy who have a decreased chance of cure compared with the majority of patients with this type of cancer. Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials. To join a clinical trial, patients must participate in a 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 clinical trials. For specific topics being studied for testicular cancer, learn more in the Current Research section. Patients who participate in a clinical trial may stop participating at any time, for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends. Side Effects
Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects occur. For more information about the specific side effects of testicular cancer treatment, see the Treatment and After Treatment sections. Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatments you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and your overall health. Common side effects for each treatment option are described in detail within the Treatment section. Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health care team. Also, be sure to communicate with the doctor about side effects you experience during and after treatment. Care of a patient’s symptoms and side effects is an important part of a person’s overall treatment plan; this is called palliative or supportive care. It helps people with cancer at any stage of illness be as comfortable as possible. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Be sure to talk with your doctor about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with testicular cancer. Learn more about caregiving. In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. For many patients, a diagnosis of testicular cancer is stressful and can bring difficult emotions. Patients and their families are encouraged to share their feelings with a member of their health care team, who can help with coping strategies. Learn more about the importance of addressing these needs, including concerns about managing the cost of your cancer care. Treatment of late effects is also an important part of survivorship care. Learn more about late effects of long-term side effects by reading the After Treatment section or talking with your doctor. After Treatment
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. Men who had testicular cancer usually receive follow-up screening for at least 10 years after their treatment ends. However, even after this specific follow-up period ends, men should be sure to let any doctor treating them in the future know that he has a history of testicular cancer. This includes the man’s general physician, who can then monitor for possible long-term side effects throughout the man’s lifetime. ASCO offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed. Talk with your doctor for more information. Below are some of the long-term side effects following treatment for testicular cancer. Long-term side effects. After more than 30 years of experience with chemotherapy and radiation therapy for testicular cancer, researchers continue to investigate the long-term side effects of these treatments. In particular, research studies are trying to determine how often treatments cause secondary cancers. 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, studies have shown that chemotherapy for testicular cancer also can increase the risk of other cancers. 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 that was used 10 or 15 years ago. Similarly, there have been changes to the types of chemotherapy used, and men receive fewer treatments than in the past. Therefore, it is not clear whether current treatments for testicular cancer greatly increase the risk of other cancers or the risk of cardiovascular disease. Also, 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 cause a higher risk of other cancers. Knowing which cancers were caused by previous cancer treatment and which are caused by other factors is difficult. The information on treatment side effects is important when choosing treatment for stage I seminoma and non-seminoma as these men have a greater than 70% chance of being cured with an orchiectomy alone and any side effects from treatment are more difficult to justify than in men who are known to have later-stage cancer that requires treatment. Effects of bleomycin on lungs. Nine doses of bleomycin causes lung damage for about 5% of men and is fatal for less than 1% of men receiving the drug. Lung scarring is a potential long-term side effect. The risk factors for lung scarring are age (older than 70), cigarette smoking, previous lung injury, previous radiation therapy to the chest, impaired kidney function, or receiving additional doses. It is rare to have lung effects without these risk factors. Therefore, if a man has these risk factors and good-risk disease, four cycles of EP can be used instead of three cycles of BEP. If four cycles of chemotherapy are needed, ifosfamide can be used instead of bleomycin, but it is associated with more short-term side effects, such as infections and injury to the bladder. Two particularly important issues are:
Effects of chemotherapy on kidneys. Cisplatin can cause kidney damage. However, it is a very important drug to treat testicular cancer, and has fewer side effects than carboplatin, which 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 one liter of IV fluid before and after the cisplatin is given. This reduces the risk of kidney damage. Research studies evaluating kidney function years after the doses have been given have shown low rates of long-term kidney damage and when 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 be caused by bleomycin. This condition is associated with the blood vessels (especially in the hands) narrowing and the skin turning white, then blue, and then red when exposed to certain triggers, such as cold. Less than 10% of men develop Raynaud’s phenomenon. However, more men developed this condition when vinblastine 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. Men who receive BEP chemotherapy may have higher cholesterol and blood pressure levels and an increased risk of heart disease and/or stroke. Radiation therapy has also been associated with an increased risk of heart disease. The increased risk is small and clearly outweighed by the fact that the treatment is necessary to remove the cancer. However, these side effects are more important when the doctor considers chemotherapy or radiation therapy to prevent the cancer from coming back for men with clinical stage I disease. A healthy diet, exercise, not smoking, and medications (when needed to lower cholesterol, control high blood pressure, or treat diabetes) are ways to reduce the risk of heart disease and stroke. Effects of cisplatin on nerves and hearing. Cisplatin can sometimes damage the nerves, causing feelings of 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 or even years to completely go away. Rarely, it can affect a person’s functioning, such as being clumsy when buttoning shirt buttons. Sometimes, men who received cisplatin may notice that they can no longer hear high-pitch sounds. This is more common with higher doses, and it is more likely for older men or men with previous hearing problems. It rarely affects young men but may be relevant for musicians or others who depend on having very fine hearing abilities. Another hearing-related side effect of cisplatin may be tinnitus, which is ringing in the ears. Secondary cancers. Many researchers from different countries have evaluated tumor registries to determine if there is an increased risk of cancers caused by chemotherapy or radiation therapy. As stated above, the risks are small and probably less now as the doses and medications are more refined. However, research has shown the following information.
Fertility. The issue of fertility in men with testicular cancer is a complex topic because patients with testicular cancer often have a lower sperm count prior to any treatment. A man who has fertility problems should talk with his doctor about these factors:
A low sperm count does not necessarily mean that a man will be infertile after treatment because most patients will develop very low to no sperm counts while receiving chemotherapy. However, the chance of fertility returning after treatment increases over time but is lower for men with no or low sperm counts before chemotherapy. It is also important to ask about sperm banking before treatment. Effects on testosterone level. In addition to damage to the ability to make sperm, there may be injury to the cells that make testosterone. If a man has a low testosterone level, then hormone replacement therapy can be used. As outlined in the Treatment section, symptoms of a reduced testosterone level include decreased sex drive (libido), inability to achieve a normal erection and orgasm, fatigue, hot flashes, depression, and mood changes. Chemobrain. Men being treated with cisplatin may have trouble concentrating, an effect referred to as chemobrain. One small research study compared men with testicular cancer who received chemotherapy with men with testicular cancer who did not have chemotherapy and those with no history of cancer. In this small study, the men who had received chemotherapy may have had a slightly lower attention span. More research is needed to determine if cisplatin causes this side effect. Most often, any effect to a man’s attention span is small. Although the treatment of testicular cancer can cause some long-term side effects, 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, not smoking, 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 the next steps to take in survivorship, including making positive lifestyle changes. Find out more about common terms used after cancer treatment is complete. Current Research
Doctors are working to learn more about testicular cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you. Since most men with testicular cancer are treated successfully, one of the major goals for the future is to reduce side effects and complications from treatment for men with early-stage or favorable-risk cancers. In addition, treatments for poor-risk and recurrent cancers are being studied in clinical trials, along with basic research studies on the causes and genetics of testicular cancer. High-dose chemotherapy followed by stem cell transplantation. Higher doses of chemotherapy can result in remission (temporary or permanent absence of symptoms) of recurrent testicular cancer. A stem cell transplant is a medical procedure in which diseased bone marrow is replaced by highly specialized cells, called hemotopoietic stem cells. Hematopoietic stem cells are found both in the bloodstream and in the bone marrow. For testicular cancer, a man’s own stem cells are obtained before high-dose chemotherapy is given. After chemotherapy, blood stem cells are infused back into the patient’s vein to replace the bone marrow and restore normal blood counts. Despite many studies, this has never been shown to be better than either the standard chemotherapy combination of BEP for first-line therapy for patients with poor-risk disease or the standard chemotherapy regimens of vinblastine, ifosfamide and cisplatin (VeIP) or paclitaxel, ifosfamide and cisplatin (TIP) for men who have a recurrence after BEP. Additional clinical trials are being done to investigate whether changes in high-dose chemotherapy are more effective. Genetic studies. Researchers are analyzing the DNA 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 possible inherited genetic factors leading to cryptorchidism and risk of testicular cancer. Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current testicular cancer treatments in order to improve patients’ comfort and 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 studies focus on sperm quality and heart disease risk for testicular cancer survivors. Learn more about common statistical terms used in cancer research. Looking for More about Current Research? If you would like additional information about the latest areas of research regarding testicular cancer, explore these related items:
Or, choose “Next” (below, right) to continue reading this detailed section. Questions to Ask the Doctor
Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you.
Patient Information Resources
In addition to Cancer.Net, there are other sources of information about this type of cancer available online. Cancer.Net maintains a list of national, not-for-profit organizations that may be helpful in finding additional information, services, and support. As always, be sure to talk with your doctor about questions you may have about information you find about this disease. View organizations that offer information on this specific type of cancer. |
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