TREATMENT

What are the main types of treatment for testicular cancer?

The type of treatment is based on the results of tests, the stage of the disease and whether the cancer has spread to other parts of the body.

The main types of treatment that may be used either on their own or together to treat testicular cancer are:

• Surgery (orchidectomy)
  to remove the affected testis is the first stage of treatment for all suspected cases of testicular cancer.  The removed testis is then sent to a pathology laboratory to define the stage and type of cancer. 
• Radiotherapy and Chemotherapy
  is usually given after surgery to kill off any cancer cells that may have spread to other parts of the body.  The level or amount of chemotherapy and radiotherapy will vary according to the stage and type of cancer. 
• Retroperitoneal lymph node dissection (RPLND)
  is only done in advanced cases of testicular cancer if the cancer has spread to other parts of the body, and chemotherapy was not completely successful.  It is not a common procedure.

Ongoing follow-up for at least 10 years after treatment will also be needed to regularly check that the cancer does not return.

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Treatment of different types of testicular cancer

Treatment of testicular cancer may be different depending on the stage and type of cancer identified from the pathology of the removed testis.  The types of testicular cancer depend on the type of cells it contains:

• Carcinoma in-situ is a type of pre-cancer.  Men with this condition have a 50% chance of developing testicular cancer within 5 years. 
• Seminoma is one type of testicular cancer and accounts for 40% of all testicular cancers; 
• Non-seminomas, which account for 60% of all testicular cancers, can be many different types of testicular cancer that are generally all grouped together.

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Treatment of carcinoma in-situ

Low dose radiation therapy is used to treat carcinoma in-situ, as these cells are very sensitive to radiotherapy. Treatment involves delivering low dose radiation to the testis to destroy any pre-cancerous cells.

Most men diagnosed with carcinoma in-situ have been diagnosed when presenting for infertility treatment. This makes treatment difficult when trying to destroy the pre-cancerous cells as any normal sperm present will also be destroyed. When fertility is an issue, it is important to store sperm before radiation treatment.

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Treatment of early stage disease

If there is no evidence of cancer on chest x-ray or abdomen and pelvic CT scan, most men will be cured after they have had surgery to remove the affected testis.  However, in approximately 20-30% of men, tiny deposits of the cancer may still be present and may only show up some time after the surgery.  To kill any cancer cells that may have spread, most men have a small course of chemotherapy or radiotherapy after surgery.  The type of follow-up treatment depends on whether the testicular cancer is a seminoma or non-seminoma. This will be determined after surgery when the doctor reviews the pathology results.

Furthermore, because of the chance of the cancer returning, follow-up consultations with a doctor after surgery are very important for all testicular cancer patients.

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Treatment for seminomas

Radiotherapy is commonly used after testicular surgery to treat seminomas.  It is used to stop the cancer from coming back by destroying any cancer cells that may have spread to the lymph nodes in the abdomen.  The radiotherapy is used to kill microscopic spread of cancer in that area.  Radiotherapy is given even if there is no evidence of spread of the disease to the abdomen on a CT scan. Most men, whose chest x-rays and abdomen and pelvic CT scans are clear, are cured after surgical removal of the affected testis and post-operative radiotherapy to the lymph nodes in the abdomen.

A short course of 2 to 3 weeks of low dose radiation therapy will usually be delivered to the abdomen area and often to the pelvis on the side from which the cancer was removed. There are usually very few side effects from this treatment and the cure rate is close to 100%.

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Treatment for non-seminomas

Non-seminoma germ cell tumours (NSGCT) are less predictable in the way they spread through the body.  NSGCTs tend to be more widely distributed in the body.  This makes them less suitable for preventative localised treatment such as radiation.  However non-seminomas are very sensitive to chemotherapy.  Therefore this more generalised treatment may be given.

Some NSGCTs are considered “high-risk” and likely to return.  Chemotherapy is recommended in these cases.

Close follow-up by the specialist is the usual management in Australia for men with non-seminomas. Follow-up is usually every 1 to 2 months over the first 12 months and then less often after that.

During each of these follow-up visits, the doctor will do a physical examination and will order blood tests to check the tumour markers in the blood (AFP and beta-hCG). Chest x-rays and CT scans of the abdomen and pelvis will also be done at regular times during the first 1 to 2 years.

In about 30% of men with non-seminomas, who simply go through “surveillance” after surgery, further tumours develop.  Chemotherapy is generally recommended if a new tumour grows.

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Treatment of advanced stage disease

Men with advanced disease that has spread to other body parts (both seminomas and non-seminomas), or those in which early stage disease has returned, are generally referred for chemotherapy with excellent results.  Even men with extensive cancer spread usually have successful outcomes with modern day treatment.

Cisplatinum is a chemotherapy drug that was found to be extremely effective in testicular cancer in the 1970’s and is still widely used today. Alternative chemotherapy drugs are Bleomycin and Etoposide which may be used in combination with Cisplatinum.

The course of treatment is usually for approximately 4 months, with one cycle of chemotherapy given every month. In some cases it may be given more often.

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