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

• 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