How Testicular Cancer Is Treated

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If you have been diagnosed with testicular cancer, there are three types of treatments that may be used: surgery, chemotherapy, and radiation. Which is recommended for you will be based largely on the stage (extent) of the cancer and the cellular characteristics of the tumor.

Thanks to advances in chemotherapeutic drugs, in stage 1 testicular cancer we are now achieving five-year survival rates approaching 99 percent. Moreover, the five-year survival rate for stage 3 testicular cancer is approximately 73 percent.

Surgeries

If testicular cancer is diagnosed, surgery will always be a facet of treatment. Surgery routinely involves the removal of the testicle and tumor in a procedure called a radical orchiectomy. Depending on whether (and how much) the cancer has spread beyond the site of the original tumor, additional surgeries may be needed to remove affected lymph nodes.

Testicle Removal (Radical Orchiectomy)

Testicular cancer is unique is that the diagnosis is almost always made by permanently removing the testicle in a surgical procedure known as a radical inguinal orchiectomy. While this may seem extreme—removing an organ to diagnose a condition—it is only done when all other tests (including an ultrasound and blood tumor marker tests) are strongly positive for cancer.

A radical orchiectomy can be both the final stage of the cancer diagnosis and the first step in treatment. 

Even if your testicle has to be removed, the remaining one can do the work for both. The surgery will not make you not sterile or interfere with your ability to have sex or achieve an erection. If desired, you can restore the appearance of the scrotum by getting a testicular silicone implant performed by a cosmetic surgeon.

How it is performed: The operation itself takes anywhere from the three to six hours. It is performed in a hospital by a urologist and often done as a same-day surgery.

It starts with a three- to six-inch incision in the pubic area just above the affected testicle. The testicle is then extracted and surgically removed along with the spermatic cord (which contains the vas deferens that shuttle sperm from the testicle). The tubes and vessels are then tied off with permanent silk or polypropylene sutures. The sutures act as markers in case the urologist needs to perform an additional surgery.

Recovery: Recovery from an orchiectomy usually takes around two to three weeks. Bed rest is usually recommended for the first 24 hours. Supportive undergarments, such as a jock strap, may be needed for the first few days. Complications of an orchiectomy are uncommon but may include bleeding, infection, localized numbness, or chronic groin or scrotal pain.

Staging and treatment decisions: Based on the results of the tissue analysis and other tests, the pathologist will stage the disease. Each of these disease stages—from stage 1 to stage 3—describes the spread and severity of the cancer:

  • Stage 1 means that the cancer is contained within the testicle.
  • Stage 2 means that the cancer has spread to nearby lymph nodes.
  • Stage 3 means that the cancer has metastasized at distance.

In addition, your doctor will want to know which type of tumor you have. Testicular cancers are classified as seminomas, a type that grows slowly and is less likely to metastasize, and non-seminomas, which tend to be aggressive and more likely to spread.

Based on a review of the accumulated information, your doctor will decide upon the appropriate course of treatment.

Less commonly, a partial orchiectomy may be performed in which only the cancerous part of a testicle is removed. This may be explored as a means to preserve fertility if you have only one testicle or if both testicles are affected. 

Retroperitoneal Lymph Node Dissection (RPLND)

If testicular cancer is positively diagnosed, a surgical procedure known as a retroperitoneal lymph node dissection (RPLND) may be performed if the cancer has either spread or there are concerns that it might.

When a testicular tumor metastasizes, it does so in a relatively predictable pattern. The first tissues usually affected are the lymph nodes of the retroperitoneum. This is the space in behind peritoneum (the membrane that lines the abdominal cavity) that is populated with blood and lymph vessels. By examining an extracted lymph node, the pathologist can determine whether the disease has spread.

RPLND is typically indicated for stage 1 and stage 2 non-seminomas because they are more likely to metastasize. (By contrast, stage 1 and stage 2 seminomas are more commonly treated with radiation alone.)

With certain stage 1 non-seminomas, the doctor will want to weigh the advantages of an RPLND versus that of a less invasive course of chemotherapy. The decision is not always cut and dry. In some cases, a watch-and-wait approach may be preferred if the tumor is confined and there no evidence of cancer in the scrotum, spermatic cord, or elsewhere.

If you have a stage 2 non-seminoma, an RPLND may be performed after chemotherapy if there is any evidence of residual cancer. This is because the cancer remnants can sometimes spread and become resistant to the chemotherapy drugs previously used. If this were to occur, the cancer would be far more difficult to treat.

An RPLND may be appropriate for a stage 2 or stage 3 seminoma if there are any cancer remnants remaining after radiation or chemotherapy treatment.

How it is performed: The surgery involves an incision starting just below the breastbone and continuing to the navel. After the bowels are gently displaced, around 40 to 50 lymph nodes are removed, taking care not to damage any surrounding nerves. It is highly technical surgery requiring a skilled surgeon.

After the bowels have been replaced and the wound sutured, the lymph nodes are sent off to the lab for analysis. All told, the surgery can take several hours to perform.

Recovery: Following surgery, you are taken to post-anesthetic care unit for several hours, after which you are transferred to a hospital room for the remainder of your recovery. A urinary catheter will have been placed at the time of surgery to help drain the bladder; it will be kept there for two to four days to monitor your urine output. For the first two or three days, you are placed on a liquid diet. Oral and intravenous pain medications may also be prescribed.

Generally speaking, you should be well enough to be discharged within seven to 10 days. Once home, it can take anywhere from three to seven weeks to fully recover.

Post-surgical complications: Complications may include damage to the sympathetic nerve that runs parallel to the spinal cord. If this occurs, you may experience retrograde ejaculation in which semen is redirected to the bladder rather than the urethra. While this may affect your ability to conceive, certain drugs, such as Tofranil (imipramine), may help improve muscle response.

Other post-operative complications include infection, bowel obstruction, and a reaction to the anesthetic medications. Contrary to popular belief, an RPLND will not cause erectile dysfunction as the nerves regulating erections are located elsewhere in the body.

Laparoscopic surgery (also known as "keyhole" surgery) may sometimes be considered for an RPLND. While less invasive than a traditional RPLND, it is extremely time-consuming and may not be as effective as an "open" surgery.

Chemotherapy

Chemotherapy involves the use of toxic drugs to kill cancer cells. Typically, two or more drugs are delivered intravenously (into a blood vein) to ensure the drugs are widely dispersed through the body.

This is the standard treatment for seminomas that have undergone metastasis (stage 2 to stage 3). An RPLND may also be performed afterward if there are any cancer remnants. Chemotherapy is less commonly used for a stage 1 seminoma unless cancer cells are detected outside of the testicles but not seen on imaging tests.

By contrast, chemotherapy can be used to treat stage 1 non-seminomas and may even be preferred over an RPLND in stage 2. As with stage 3 seminomas, stage 3 non-seminomas are standardly treated with chemotherapy.

The six drugs most commonly used to treat testicular cancer are:

  • Bleomycin
  • Platinol (cisplatin)
  • Etoposide (VP-16)
  • Ifex (ifosfamide)
  • Taxol (paclitaxel)
  • Vinblastine

The drugs are commonly prescribed in combination therapy. There are three standard regimens, which are referred to by the following acronyms:

  • BEP: bleomycin + etoposide + Platinol (cisplatin)
  • EP: etoposide + Platinol (cisplatin)
  • VIP: VP-16 (etoposide) or vinblastine + ifosfamide + Platinol (cisplatin)

Patients usually undergo two to four cycles of chemotherapy administered every three to four weeks. The treatment begins soon after the orchiectomy is performed.

Side effects: Chemotherapy drugs work by targeting fast-replicating cells like cancer. Unfortunately, they also attack other fast-replicating cells such as hair follicles, bone marrow, and tissue of the mouth and intestines. The resulting side effects may include:

  • Hair loss
  • Fatigue (due to bone marrow suppression)
  • Mouth sores
  • Diarrhea
  • Nausea and vomiting
  • Loss of appetite
  • Easy bruising (due to low platelets)
  • Increased risk of infection

While most of these side effects will go away after the treatment ends, some can last for a long time and may never go away. If you experience serious or worsening side effects, speak with your doctor who may be able to prescribe drugs to prevent nausea and vomiting or reduce diarrhea or the risk of infection.

In some cases, the chemotherapy may need to be altered or stopped if the side effects become intolerable. Other options for treatment would then be explored.

Chemotherapy With Stem Cell Transplantation

While most testicular cancers will respond to chemotherapy, not all cancers are easily cured. Some require high-dose therapy that can severely damage the bone marrow where new blood cells are produced. If this occurs, chemotherapy may result in potentially life-threatening bleeding or an increased risk of serious infection due to lack of white blood cells.

Since non-seminomas cannot effectively be treated with radiation, sometimes doctors will turn to using high dose chemotherapy followed by a peripheral blood stem cell transplant (PBSCT) as a way to "boost" the body’s production of blood cells. By using PBSCT, higher doses of chemotherapy can be prescribed without the risk of severe complications.

In the past, stem cells were taken directly from bone marrow. Today, they are more commonly harvested from the bloodstream using a special machine. This can be done in the weeks leading to your treatment. Once collected, the stem cells will be kept frozen until needed.

Once chemotherapy is started, the stem cells will be gently defrosted and returned to your bloodstream via an intravenous (IV) infusion. The stem cells will then settle into your bone marrow and start producing new blood cells within six weeks.

The procedure is most often used in men who have had a cancer relapse. Even among the population of hard-to-treat men with non-seminomatous tumors, the combined use of high dose chemotherapy and PBSCT may translate to a long term disease-free survival rate of 60 percent, according to research published in 2017 in the Journal of Clinical Oncology.

While the procedure is time-consuming, it is usually tolerable with only minor side effects. Both the harvesting and infusion of stem cells may cause localized pain, redness, and swelling at the infusion site. Some people may react to the preserving agents used in the stored stem cells and experience chills, shortness of breath, fatigue, lightheadedness, and hives. The side effects tend to be mild and resolve quickly.

If for any reason you are unable to tolerate the procedure (or the treatment fails the deliver the results hoped for), your doctor may be able to refer to clinical trials using investigative medications and treatments.

Radiation Therapy

Radiation therapy involves high-energy rays (such as gamma rays or X-rays) or particles (such as electrons, protons, or neutrons) to destroy cancer cells or slow their rate of growth. Also known as external beam radiation, the procedure is generally reserved for seminomas, which are more sensitive to radiation.

In stage 1 seminoma, radiation is sometimes used as a form of adjuvant (preventive) therapy to ensure that any errant cancer cells are wiped out. With that being said, it is only used under specific conditions.

For a stage 2 seminoma, radiation may be started soon after a radical orchiectomy. It is considered the preferred form of treatment stage 2 seminomas unless the affected lymph nodes are either too large or too widespread. Chemotherapy is an alternative option.

Radiation therapy begins as soon as you have adequately healed from orchiectomy. The dosage you get will vary based on the stage of your cancer.

The treatment is delivered five times per week in 2.0 Gy doses. For a stage 2 seminoma, that translates to 10 doses over two weeks. For stage 3, you would need 15 doses over three weeks.

The procedure itself is relatively quick and simple. You simply lie on a table beneath an open-air radiation emitter. A shield is used to protect the remaining testicle. Oftentimes, a towel is placed between your legs to help you maintain the correct position. Once in place, the radiation will be delivered in a sustained burst. You will neither see it nor feel the radiation.

Side effects: Side effects of radiation therapy may occur immediately or happen years down the road. Short-term side effects may include fatigue, nausea, and diarrhea. Some men will also experience redness, blistering, and peeling at the delivery site, although this is relatively uncommon.

More concerning are the long-term side effects, including damage to nearby organs or blood vessels that may only manifest later in life. Radiation may also trigger the development of new cancers, including leukemia and cancers of bladder, stomach, pancreas, or kidneys. Fortunately, the risk of this is far less than it used to be given that treatment is more targeted and delivered at lower dosages.

Treatment Risks

Testicular cancer and its treatment may affect hormone levels and your ability to father children. It is important to discuss these possibilities with your doctor before treatment so that you are better appraised of what lies ahead and what your future options may be.

While a single testicle can usually make enough testosterone to keep you healthy, a bilateral orchiectomy (the removal of both testicles) would require you to be placed on some form of permanent testosterone replacement therapy. This may involve a testosterone gel, a transdermal patch, or a monthly testosterone injection at your doctor’s office.

In terms of treatment side effects, it is not uncommon for chemotherapy to cause temporary infertility. The risk tends to increase in tandem with the drug dosage. For many men, fertility will return within a few months. For some, it may take up to two years, while others may not recover at all. There is no way in advance to know who will or will not be affected.

With regards to radiation, the risk of infertility has decreased in recent years due to lower radiation dosages, greater safeguards, and more targeted external beam technologies. If affected, fertility will usually be restored within two to three years.

If you have every intention to have a baby one day, you may want to consider sperm banking prior to your treatment. This preserves your fertility options and allows you to pursue in vitro fertilization (IVF) should you, for any reason, be unable to conceive.

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