CANCER
October 1, 1999

Testicular Cancer

Testicular cancer is the most common malignancy in young adult males. An estimated 6000 new cases and 350 deaths from testicular cancer occurred in the United States in 1995. There is some evidence that the incidence is increasing. The changing history of testicular cancer has been extremely impressive in that it has gone from being the most frequent cause of cancer-related mortality in young males to being the most curable cancer in young males.

The disease is often first noted by the patient. Be on the alert for any lump under the skin of either testicle or change in the testicle's size, shape or weight. Blood tests, showing elevation of two proteins, beta HCG (human chorionic gonadotropin) and alpha-fetoprotein, help to confirm the diagnosis.

There are two broad categories of testicular cancer. In one class are patients who have pure seminomas, a kind of cancerous cell, while in the second class of patients ("non-seminoma") there are several different cell types, although some elements of seminoma may also be present.

Treating Testicular Cancer
The first phase of the treatment involves surgical removal of the diseased testicle (orchiectomy). Subsequent treatment, as for most cancers, is based on the stage of the cancer. Staging refers to how much the cancer has spread.

There are several staging systems for germ cell tumors. Some are based on what the doctor finds, others on the pathology results. Substages reflect surgical results [e.g., lymph node involvement, tumor size, spread (metastasis)]. Stage I is confined to the testis, stage II is confined to the area behind the vital organs (the retroperitoneum) and by stage III, the cancer has involved distant lymph nodes and organs above the diaphragm. Stage I usually offers the best outlook, Stage III and above the worst.

Patients with seminomas are generally managed with radiation therapy. Patients with advanced disease, i.e., greater than stage IIA (less than 2 cm sized node involved, spread to fewer than five lymph nodes and no evidence of involvement of any other organ) will need systemic chemotherapy.

For IIA mixed cell testicular tumor patients, the cancerous lymph nodes are removed. This procedure cures more than 80% of patients. If the patient is stage IIB, that is, has worse characteristics than IIA, surgical removal of the cancerous lymph nodes cannot, by itself, cure the disease. The patient will also need chemotherapy using bleomycin, etoposide and cisplatin. The usual patient is typically treated with four 28-day cycles of cisplatin-based chemotherapy. In a high percentage of patients, surgical lymph node removal and chemotherapy together will cure the disease.

If no enlarged cancer-containing lymph nodes are visible, there has been a raging controversy as to whether additional treatment, beyond removal of the testis, such as removal of nearby lymph nodes, is necessary. As surgical techniques have improved and complications (inward ejaculation) have decreased, lymph node surgery may be a good idea.

Treatment of Relapse
For patients who relapse with disease after initial appropriate therapy, a variety of regimens has been used. If the recurrence happens more than two years after initial therapy, the patient could be treated with the same regimen — etoposide, ifosfamide and cisplatin, using two of the three drugs. Ifosfamide is certainly fairly active, often causing this particular tumor to shrink ("regress").

During this chemotherapy, hospitalization may be required for approximately three weeks each time. After two cycles of the chemo, follow-up is crucial. If blood tests continue to reveal elevations of markers for testicular cancer (HCG and alpha-fetoprotein), it is most likely that the disease is still present. In this situation, more of the same therapy is not likely to be the best course of treatment. Some investigators have, instead, suggested using oral etoposide to prolong disease-free survival, although experimental high-dose chemotherapy might also be considered.

Summary
Testicular cancer is the most common cancer of young men and its incidence is rising. Fortunately, advances in surgery, chemotherapy and radiotherapy have made these tumors curable even after the cancer has spread to other parts of the body.
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