Treatment

The treatment of testicular cancer depends on the type, size, location of the tumor, whether the cancer has spread, and the man’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 surgeon who specializes in problems related to the urinary tract and male reproductive organs).

This section outlines treatments that are the standard of care (the best treatments available) for testicular cancer. Patients are also encouraged to consider clinical trials as a treatment option when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, visit the Clinical Trials.

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.

Descriptions of the most common treatment options for testicular cancer, followed by treatment options by the cancer’s stage, are listed 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 (along the beltline). It is used to diagnose and treat both early-stage and later-stage testicular cancer, regardless of the type of tumor. For more advanced cancer, a radical inguinal orchiectomy may not be performed first so chemotherapy can be started sooner.

The removal of one testicle typically does not affect a man’s ability to achieve a normal erection and orgasm. However, men with sexual problems after orchiectomy should have their testosterone level checked. It also is very unlikely to make him 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, 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 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. A patient may want to consider storing sperm in a sperm bank prior to surgery, so that he will be able to have children later if he wishes. In addition, if both testicles are removed, testosterone replacement therapy will be needed.

Retroperitoneal lymph node dissection (RPLND)

This is surgery to remove the retroperitoneal lymph nodes that lie at the back of the abdomen. RPLNDs are performed in two different situations: (1) clinical stage I or IIa nonseminomas and (2) men with retroperitoneal masses that remain after completing chemotherapy for advanced stage disease. Masses that remain after chemotherapy are almost always removed for men with non-seminomas, but for men with pure seminomas, such masses are often left in place and observed for changes with CT scans. RPLNDs are usually performed as open operations 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.

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. 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 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 ever need 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 normal lymph nodes for men with clinical stage IIa 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 or orgasm, 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 is that 70% of patients are cured by removal of the testicle alone, and for these men, a 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 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 completely removed with three cycles of chemotherapy if the recurrence is diagnosed early through regular screening.

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 completed. About half of men going through such surgery will be found to have a mass that contains either teratoma (about 40%) or one of the other germ cell cancers (10%). The other half of men will have no tumor. 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), then 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 are often removed if it is safe to do so. This may involve surgery in multiple sites 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

As described above, after having a radical inguinal orchiectomy, one treatment option for clinical stage I seminomas and non-seminomas may be active surveillance. A doctor may recommend this approach, in which the patient is monitored closely and 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 require further treatment after surgery.

It is worth noting that 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. Patients generally have follow-up screening for at least ten years after their diagnosis.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. 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 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 may cause a small increased risk of secondary cancers many years after treatment and 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. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medications. Some people may receive chemotherapy in their doctor’s office; others may go to the hospital. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a specific time.

There are different options to consider when a doctor prescribes chemotherapy for testicular cancer, depending on the stage of the disease. Chemotherapy with bleomycin (Blenoxane), etoposide (VePesid, Etopophos, Lastet), 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 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 cisplatin 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 almost completely prevents vomiting in a majority of men, although they do not eliminate all nausea. A third drug is metoclopramide (Reglan). The combination of dexamethasone, metoclopramide, and a serotonin antagonist has been shown to be highly effective at preventing vomiting and reducing nausea for patients receiving chemotherapy regimens like BEP. 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 (Compro, Compazine), promethazine (Phenergan), or lorazepam (Ativan, Lorazepam Intensol) 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 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 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, seek help immediately if bleeding, infection, and/or fever occurs. Infections during chemotherapy can be very serious, and even fatal, 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 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. 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 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.

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.

Treatment by stage of the cancer

The treatment choices for testicular cancer depend on whether the cancer is a seminoma or nonseminoma and the stage of the cancer. After a physical examination, staging tests, and removal of the cancerous testicle, you and your doctor will discuss your treatment options. Treatment options for early stage and advanced stages of 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 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 other 70% are cured by having their testicle removed. The options for men with clinical stage I disease are:

• RPLND. As described above, this is surgery to remove the retroperitoneal lymph nodes that lie at the back of the abdomen.
  
  
• Active surveillance. This option involves CT scans of the abdomen and pelvis every three to six months for the first year, every four to six months in the second year, and every six to twelve months in the third to fifth year. Chest x-rays with physical examinations and tumor marker tests to measure LDH, HCG and AFP 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. If the cancer recurs, three cycles of chemotherapy successfully treats more than 95% of men.
  
  
• 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, but one major study showed that a single three-week cycle of BEP can be effective. The advantage of this approach is that it lowers the recurrence rate from 30% down to less than 3%. The main disadvantage is that 70% of patients do not need chemotherapy because they have already been cured with the surgical removal of the testicle. Therefore, some have recommended using adjuvant chemotherapy only for men who have a higher risk of recurrence so that fewer men 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. Most recurrences occur about 15 months after treatment 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 require chemotherapy.

• Active 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 next three years, and annually for the next four years. 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 (radiation therapy after surgery). Seminoma is much different from non-seminoma, and early-stage seminoma can be effectively treated with radiation therapy. Radiation therapy after orchiectomy is a treatment option for patients with stage I, IIA, or IIB seminoma. The chance of recurrence can be decreased to less than 5% with about 15 treatments of radiation therapy to the retroperitoneum. Additional radiation therapy to the pelvis does not reduce the overall risk of recurrence, but it does reduce the risk of a recurrence in the pelvis. Some doctors prefer to treat only the retroperitoneum. Others prefer to include the pelvis in order to prevent recurrences in that area and to eliminate the need to perform scans of the pelvis to monitor for recurrence.

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.

• Adjuvant chemotherapy (chemotherapy after surgery). 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 recurrence 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 the use of carboplatin is a newer approach, there is less information on long-term effects after treatment. Therefore, many experts believe that more information is needed before recommending this treatment approach. However, many other doctors have accepted carboplatin as a new treatment option for stage I seminoma. The hope is that carboplatin will cause fewer complications than radiation therapy, but more research is needed to determine the possible complications of carboplatin compared with radiation therapy.

Metastatic non-seminoma testicular cancer

• Chemotherapy. Chemotherapy is used for men 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 (IV; injected into a vein). Cisplatin and etoposide are given each day on the first five days. IV fluid is also given 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 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 (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 metastatic non-seminomas 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. After chemotherapy is completed, x-rays and CT scans are repeated to see if there are any masses of cancer remaining. If cancer is seen, then surgery to remove the masses is considered. The chance of the surgery curing the cancer 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 removal 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 needed. Often in this situation the nerves that are responsible for ejaculation cannot be spared. It is recommended that men discuss this with their doctors, in addition to the option of sperm banking, preferably prior to any chemotherapy.

During surgery, there is about a 45% chance that 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 chemotherapy typically either etoposide and cisplatin, or cisplatin and ifosfamide combined with either vinblastine (Velban) or paclitaxel (Taxol) are usually given.

Metastatic seminoma testicular cancer

• Chemotherapy. Chemotherapy for metastatic seminoma is identical for metastatic non-seminoma (see above). Most (approximately 90%) of metastatic seminomas are good-risk disease, and about 90% are successfully treated. Approximately 10% of metastatic seminomas are intermediate-risk disease and need four cycles of BEP.
  
  
• Radiation therapy. Radiation therapy is more effective for seminoma than non-seminoma. For patients with stage IIA or IIB seminoma, radiation therapy is usually the preferred treatment because it is thought to be safer, have 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 treatment options are active 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. Another approach is to perform a specific type of positron emission tomography (PET) scan, called an FDG-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 and absorbed by the organs or tissues being studied. This substance gives off energy that is detected by a scanner, which produces the images. After the FDG-PET scan is done, the surgeon will operate only if the scan results show evidence of cancer in the remaining mass. One study showed that PET scans are more accurate than CT scans to determining if a remaining mass contains cancer. If surgery is decided upon but the surgeon determines that it cannot be removed, then biopsies are often performed to try to determine whether cancer is present. If a decision is made to observe a mass through active surveillance and the mass grows, chemotherapy is often 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 typically shrinks the size of such tumors in the brain. If there are any masses remaining after chemotherapy, they should be surgically removed if possible. 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.

Recurrent testicular cancer

Regular follow-up examinations to check for signs that the cancer may be returning (called recurrent cancer) 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 was stage I and returns during active surveillance 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. A recurrence more than two years after prior treatment should be removed if possible, and chemotherapy is usually given, either before or after surgery.

Find out more about common terms used during cancer treatment.