Treatment Guideline Chart

Testicular cancer is a rare neoplasm that arises from the testis. It commonly presents as a painless testicular mass.

It has high prevalence in young and middle-aged men in the age of 15-40 years old.

It is a highly treatable disease with a high cure rate.

Testicular primary germ cell tumors coming from the malignant transformation of primordial germ cells make up 95% of all testicular cancer.


Surgical Intervention

Radical Inguinal Orchiectomy

  • Performed once a testicular mass is detected on ultrasound
    • Inguinal approach prevents spread of cancer cells
  • Establishes the diagnosis of testicular malignancy and also serves as the primary treatment
  • Testis-sparing surgery may be done for synchronous bilateral tumors, radiographically benign-appearing tumors, a tumor in a single testis with normal presurgical levels of testosterone, or non-palpable tumors <2 cm
    • Must be performed through an inguinal approach with frozen section done intraoperatively
      • Radical orchiectomy is recommended if biopsy shows testicular cancer and contralateral testicle is normal
  • Nerve-sparing approach or template dissection is an option for patients undergoing primary RPLND for stage I nonseminoma to reduce the risk of ejaculatory disorders
  • In case of increasing serum tumor markers or a life-threatening metastatic disease, chemotherapy is started prior to orchiectomy
    • Orchiectomy after chemotherapy to remove the primary tumor is advisable
  • Inguinal biopsy of the contralateral testis may be considered if the following are present: Cryptorchid testis, pronounced atrophy, ultrasound findings suspicious for intratesticular abnormalities, eg macrocalcification or hypoechoic mass
    • Risk is high for GCNIS in the contralateral testis in patients age <40 years and with testicular atrophy and patients with EGGCT
      • Treatment typically consists of radiation therapy, surveillance, or orchiectomy

Retroperitoneal Lymph Node Dissection (RPLND)

  • The standard surgical approach to nonseminomas in the primary and post-chemotherapy setting
  • It removes the lymph nodes draining the primary site and the nodal groups near the primary landing zone
  • Standard (modified bilateral) approach removes all node-bearing tissue up to the bifurcation of the great vessels including the ipsilateral iliac nodes
    • Long-term effect is retrograde ejaculation with resulting infertility 
  • Nerve-sparing RPLND can preserve anterograde ejaculation in approximately 90% of patients
  • RPLND results in the least number of patients at risk for chemotherapy’s late toxicities

Nonseminomatous Germ Cell Tumor (NSGCT)

Stage I

  • Indicated for patients not willing to undergo chemotherapy in case of a recurrence, with teratoma with somatic malignant transformation, or interstitial cell tumors with increased risk of metastases
  • Nerve-sparing RPLND may be done if patient has contraindications to either chemotherapy or surveillance
    • Must be performed within 4 weeks of a CT scan and within 7 days of a repeat testing for serum tumor markers

Stage II

  • Preferred primary therapy for stage II patients with somatic-type tumors and may be an option for patients with teratoma predominance with normal serum markers
    • Recommended for clinical stage IIA patients with normal serum tumor markers after orchiectomy and radiographically detected lymph nodes measuring ≤2 cm
  • A modified, bilateral, nerve-sparing RPLND is performed in patients with post-orchiectomy negative tumor markers due to higher chance of bilateral disease with greater tumor burden

Postsurgical Management

  • Management of patients with stage I and II nonseminoma previously treated with primary nerve-sparing RPLND includes the following:
    • pN0: Surveillance
    • pN1: Surveillance (preferred) or chemotherapy with 2 cycles of EP
    • pN2: Chemotherapy with 2 cycles of EP (preferred) or surveillance
      • Surveillance is preferred for patients with pure teratoma
    • pN3: Chemotherapy with 4 cycles of EP or 3 cycles of BEP 
  • Surveillance may be done in patients with “low-volume” metastases, ie tumor nodes ≤2 cm in diameter and <6 nodes positive
  • Adjuvant chemotherapy is considered in “high-volume” metastases, ie any involved node >2 cm in largest diameter or >6 nodes positive or positive extranodal tumor extension
    • EP with or without Bleomycin given every 3 weeks are well tolerated and effective
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