Testicular Cancer Treatment by Stage

Nearly every plan starts the same way. The affected testicle is removed through a cut in the groin. This is a radical inguinal orchiectomy.

It does two jobs at once. It takes out the tumour, and it gives the lab the tissue needed to name the cancer.

Three results then steer everything else. The cell type. The stage. And what the blood markers do after surgery.

This page describes the standard options and what picks between them. It is not advice about your own care.

Germ cell tumours of the testicle fall into two families.

Seminoma is one of them. Non-seminoma covers embryonal carcinoma, teratoma, yolk sac tumour and choriocarcinoma. Most non-seminomas are a mixture of these.

NCI is strict about the dividing line. A tumour is a seminoma only if it is 100 percent seminoma. Any mixture is treated as a non-seminoma.

One blood result can override the microscope. Seminomas do not make AFP. So a man with a raised AFP is treated as having a non-seminoma even if the pathology reads pure seminoma, unless something else explains the AFP, such as liver disease.

Most cancers are staged by where they are. Testicular cancer also uses three blood markers, and they are written into the stage as an S category.

• AFP is raised in 40 to 60 percent of men with non-seminoma. It is never raised by seminoma alone.
• Beta-hCG is raised in about 14 percent of stage I pure seminomas and in about half of metastatic seminomas. It is raised in 40 to 60 percent of non-seminomas.
• LDH is less specific. It goes up in many conditions that have nothing to do with cancer.

The levels are measured before the testicle is removed and again afterwards. NCI says the degree of marker elevation after surgery is one of the strongest predictors in non-seminoma.

Markers can mislead. NCI notes that cross-reaction with luteinising hormone can give a false beta-hCG, and there are reports of cannabis use raising it. AFP is mildly raised in some people for no clear reason.

Stage I means the cancer has not spread beyond the testicle.

For stage I seminoma, the cure rate approaches 100 percent whether or not anything follows surgery. NCI lists surveillance as a treatment option. That means scheduled scans and marker tests instead of more treatment. Roughly 15 to 20 percent of men relapse over 10 years, and nearly all of them are cured with radiation or chemotherapy at that point. Tumour size over 4 cm and invasion of the rete testis both raise the risk, though they shift the odds rather than dictating the choice.

If a man does not want to wait, adjuvant carboplatin or radiation to the back of the abdomen can be given; the carboplatin dose is calculated from kidney function by the treating team. NCI notes that radiation for stage I seminoma is no longer favoured, because it raises the risk of a second cancer years later.

Stage I non-seminoma is also highly curable, above 99 percent. Orchiectomy alone cures about 70 percent. The other 30 percent relapse and are usually cured then. Three approaches are standard: surveillance, retroperitoneal lymph node dissection, or a short course of BEP chemotherapy. NCI reports a disease-specific survival of about 99 percent with each, and no consensus on which is best.

Surveillance is demanding. It means frequent visits, marker tests and scans for years. NCI says it should only be chosen if the person commits to the schedule.

Stage II means the cancer has reached lymph nodes at the back of the abdomen.

For seminoma, size matters. Non-bulky disease is under 5 cm, and radiation alone cures about 90 to 95 percent. Bulky disease is 5 cm or more, and NCI reports far more relapses after radiation there, so cisplatin-based chemotherapy has become the usual choice.

For non-seminoma, the marker result decides first. If markers stay high after orchiectomy, the disease is treated as stage III. If markers are normal, stage IIA is often confirmed by node surgery. Up to 40 percent of men with clinical stage IIA turn out to have no cancer in those nodes, which spares them chemotherapy. Stage IIB and IIC are usually treated with chemotherapy instead.

When the cancer has spread further, an international grouping agreed in 1997 sorts it into good, intermediate and poor risk. It uses the primary site, whether there are metastases outside the lungs, and the marker levels.

For non-seminoma, the 1997 analysis reported five-year survival of 92 percent for good risk, 80 percent for intermediate risk and 48 percent for poor risk. A 2006 pooled analysis of later trials reported 94 percent, 83 percent and 71 percent.

Seminoma has no poor-risk group. About 90 percent is good risk, with a five-year survival of 86 percent. Intermediate-risk seminoma means metastases outside the lungs, and five-year survival is 72 percent.

The regimens NCI lists are cisplatin-based:

• BEP is bleomycin, etoposide and cisplatin. More cycles are given for intermediate and poor risk than for good risk.
• EP is etoposide and cisplatin, used when bleomycin has to be avoided, for example where lung function is a concern.

How many cycles you have, and at what doses, is set by a specialist against your IGCCCG risk group, how your markers fall, your kidney and lung function, and your fertility plans. Ask for your regimen in writing.

• VIP is etoposide, ifosfamide and cisplatin, another option when bleomycin is not suitable.

Bleomycin can scar the lungs. Its label carries a boxed warning for pulmonary fibrosis, which the label says happens more often in elderly patients and at higher total doses, though it has also been seen in young men on low doses. Report new breathlessness or a dry cough.

Scans often still show something after chemotherapy ends. That leftover tissue is not always cancer.

In non-seminoma, a residual mass may hold dead tissue, live cancer or teratoma, and surgery is often used to find out. In seminoma, most residual masses shrink on their own. NCI describes using a PET-CT scan afterwards, and supports watching a PET-negative mass over 3 cm rather than operating on it.

Ask about sperm banking before anything starts. It cannot be done later.

Radiation to the remaining testicle or removing it causes sterility, and often low testosterone as well. Chemotherapy and radiation both carry long-term risks. In one series of 992 men, cardiac events were about 2.5 times more common after radiation or chemotherapy than after surveillance over a median of 10.2 years.

SEER puts five-year relative survival for testicular cancer at 94.6 percent for 2016 through 2022. That is a group figure, not a personal one.

• Call 911 or go to an emergency department if you have chest pain, sudden breathlessness, or you cough up blood. During and after platinum chemotherapy these can mean a blood clot in the lung.
• Call your cancer team at once, whatever the time, if you have a temperature of 100.4°F (38°C) or higher, or shaking chills, during chemotherapy. Treat this as an emergency: BEP and EP knock your white cell count down, and an infection can turn serious within hours. If nobody can be reached quickly, go to an emergency department and say you are on chemotherapy.
• Call your care team the same day if you develop a new dry cough or breathlessness on bleomycin, or new back pain, or swelling and pain in one leg.
• Call your care team within a day or two if you notice ringing in the ears, hearing loss, or numbness in the hands or feet, or a new lump in the remaining testicle.

Testicular Cancer, Testicular Cancer Stages, Testicular Cancer Types, and Fertility and Cancer Treatment.

• https://www.cancer.gov/types/testicular/hp/testicular-treatment-pdq
• https://seer.cancer.gov/statfacts/html/testis.html
• https://medlineplus.gov/ency/article/000156.htm
• https://www.cancer.gov/about-cancer/treatment/side-effects/infection
• https://www.cdc.gov/cancer-preventing-infections/patients/fever.html
• https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b5806c40-12ce-48e3-8abd-9f8997ef4428