eMedicine Specialties > Oncology > Carcinomas of the Genitourinary Tract

Testicular Cancer: Follow-up

Author: Kush Sachdeva, MD, Southern Oncology and Hematology Associates, South Jersey Healthcare, Fox Chase Cancer Center Partner
Coauthor(s): Mansoor Javeed, MD, FACP, Clinical Assistant Professor of Medicine, University of California Davis; Consultant, Sierra Hematology-Oncology Medical Center; Issam Makhoul, MD, Associate Professor, Department of Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences; Brendan Curti, MD, Director, Genitourinary Oncology Research, Robert W. Franz Cancer Research Center, Earle A. Chiles Research Institute, Providence Cancer Center
Contributor Information and Disclosures

Updated: Jul 29, 2009

Follow-up

Further Outpatient Care

Surveillance:

Seminoma stage IA, IB: History and physical examination (H & P) and AFP, beta-hCG, and LDH assays every 3 to 4 months for the first three years, every 6 months for years 4 to 7, then annually up to 10 years. Abdominal and pelvic CT scan is recommend at each visit and chest x-ray at alternate visits. Strict adherence to this surveillance program for at least 10 years is vital.

Seminoma stage IS: H & P, AFP, beta-hCG, LDH, and chest x-ray every 3 to 4 months for the first year, every 6 months for year 2, then annually. Pelvic CT scan is recommended annually for three years for patients who received only para-aortic radiation.

Seminoma stage IIA, IIB: H&P, AFP, beta-hCG, LDH, chest x-ray every 3 to 4 months for years 1 to 3, every 6 months for year 4, then annually. Abdominal CT scan is recommended at month 4 of year 1.

Seminoma stage IIC, III: H&P, chest x-ray, AFP, beta-hCG, and LDH every 2 months for year 1, every 3 months for year 2, every 4 months for year 3, every 6 months for year 4, then annually. Abdominal/pelvic CT at month 4 of year 1 status post surgery; otherwise, abdominal/pelvic CT every 3 month until stable. PET scan could be considered when clinically indicated.

Nonseminoma stage IA, IB: H&P, chest x-ray, AFP, beta-hHG, and LDH every 1-2 months for year 1, every 2 months for year 2, every 3 months for year 3, every 4 months for year 4, every 6 months for year 5, then annually. Abdominal/pelvic CT scan every 2-3 months for year 1, every 3-4 months for year 2, every 4 months for year 3, every 6 months for year 4, every 12 months for year 5, then annually.

Nonseminoma stage IIA, IIB, IIC, IIIA, IIIB, IIIC after complete response to chemotherapy and/or retroperitoneal lymph node dissection: H&P, chest x-ray, AFP, beta-hHG, and LDH every 2-3 months for year 1, every 2-3 months for year 2, every 4 months for year 3, every 4 months for year 4, every 6 months for year 5, then annually. Abdominal/pelvic CT scan every 6 months for year 1, every 6-12 months for year 2, every 12 months for year 3, every 12 months for year 4, every 12 months for year 5, then every 12-24 months.

Complications

Treatment-related toxicity 
 
Pulmonary: Bleomycin can cause pneumonitis and pulmonary fibrosis; therefore, pulmonary function tests are done before starting chemotherapy that includes this agent. Bleomycin-induced lung toxicity is cumulative and although it can be fatal, it is rarely fatal if the total cumulative dose is less than 400 units. Patients with bleomycin-induced pneumonitis present with nonproductive cough, dyspnea on exertion, and bibasilar rales. Chest x-ray may show pulmonary nodules. A decline in carbon monoxide diffusing capacity (DLCO) is the earliest sign of lung toxicity; bleomycin should be discontinued if it occurs. Smokers should be counseled regarding smoking cessation.
 
Renal toxicity: 20-30% of patients who receive cisplatin have a reduction in glomerular filtration rate. Cisplatin can also cause hypomagnesemia, hypophosphatemia, and hypokalemia.
 
Cardiovascular: Cardiovascular disorders are late complications of cisplatin treatment. They include hypertension, dyslipidemia, coronary artery disease, thromboembolic events, and Raynaud phenomenon.
 
Infertility
 
Hematological: Anemia, leukopenia/neutropenia, and thrombocytopenia may occur. Prophylactic treatment with hematopoietic growth factors is recommended to avoid the need for dose attenuation or treatment delays.
 
Gastrointestinal: Nausea and vomiting.
 
Neurological: Cisplatin and oxaliplatin can cause neuropathy.

Ototoxicity: tinnitus and high-frequency sensorineural loss. 
 
Secondary malignancy: Secondary malignancies are the most common cause of death in testicular cancer survivors. A second testicular cancer develops in 1% to 2% of testicular cancer survivors.

Solid tumors: A followup study of more than 40,000 testicular cancer survivors in Europe and North America showed that the relative risk of developing a secondary tumor was 1.9 (95% confidence index, 1.8 to 2.1) for 10 years and 1.7 for 35 years.14 Cancers of the lung, colon, bladder, pancreas, stomach, mesothelioma, and esophagus were found. Testicular cancer patients who were treated with radiation alone were at higher risk of having bladder, stomach, pancreas, and kidney cancers.

Leukemia: Patients treated with regimens that contain etoposide have an increased risk of developing leukemia, mainly of the myeloid lineage. In such cases, the Hallmark chromosomal translocation involving the long arm of chromosome 11 (11q23) occurs 2 to 3 years following treatment. Leukemia develops in 16 per 10,000 patients treated with standard-dose chemotherapy.

Prognosis

The International Germ Cell Consensus Classification (IGCCC),7 an easily applicable, clinically based prognostic instrument, is now used in clinical practice for risk classification and is the current standard for all practice guidelines, including that of the National Comprehensive Cancer Network.

The IGCCC is based on a retrospective analysis of 5,202 patients with metastatic nonseminomatous germ cell tumor (NSGCT) and 660 patients with metastatic seminomatous germ cell tumors from 10 countries, who were treated between 1975 and 1990. All patients received treatment with cisplatin- or carboplatin-containing therapy as their first chemotherapy course. Median followup was 5 years. For NSGCT, independent adverse factors were identified: mediastinal primary site; degree of elevation of alpha-fetoprotein, human chorionic gonadotropin (HCG), and lactate dehydrogenase (LDH); and presence of nonpulmonary visceral metastates (NPVM), such as liver, bone, and brain. For seminoma, the predominant adverse feature was the presence of NPVM.

The IGCCC distinguishes NSGCT patients with a good, intermediate, or poor prognosis; these have reported 5-year overall survival of 92%, 80%, and 48%, respectively. 
 
A subsequent meta-analysis of survival of patients with NSGCT, treated after 1989 and classified according to the IGCC classification, included 10 papers describing 1775 patients with NSGCT with good (n = 1087), intermediate (n = 232), or poor (n = 456) prognosis. Pooled 5-year survival estimates were 94%, 83%, and 71%, respectively. There was a small increase in survival for good-prognosis and intermediate-prognosis patients, and a large increase in survival for patients with a poor prognosis. The researchers suggested that the improved survival was most likely due to both more effective treatment strategies and more experience in treating NSGCT patients.15

Good-prognosis nonseminoma (56% to 61% of nonseminomas): 5-year progression-free survival (PFS) is 89%; 5-year survival is 92% to 94%

  • Testis/retroperitoneal primary, and
  • No nonpulmonary visceral metastases, and
  • Good serum tumor markers; all of:
    • Alpha-fetoprotein (AFP) less than 1,000 ng/mL, and
    • Human chorionic gonadotropin (hCG) less than 5,000 IU/mL (1,000 ng/mL), and
    • Lactate dehydrogenase (LDH) less than 1.5 times the upper limit of normal
Good-prognosis seminoma (90% of seminomas): 5-year PFS is 82%; 5-year survival is 86%
  • Any primary site, and
  • No nonpulmonary visceral metastases, and
  • Normal AFP, any hCG, any LDH

Intermediate-prognosis nonseminoma (13-28% of nonseminomas): 5-year PFS is 75%; 5-year survival is 80% to 83%

  • Testis/retroperitoneal primary, and
  • No nonpulmonary visceral metastases, and
  • Intermediate serum tumor markers; any of:
    • AFP 1,000 to 10,000 ng/mL, or
    • hCG 5,000 IU/L to 50,000 IU/L, or
    • LDH 1.5 to 10 times normal

Intermediate-prognosis seminoma (10% of seminomas): 5-year PFS is 67%; 5-year survival is 72%

  • Any primary site, and
  • Nonpulmonary visceral metastases, and
  • Normal AFP, any hCG, any LDH

Poor-prognosis nonseminoma (16%–26% of nonseminomas): 5-year PFS is 41%; 5-year survival is 71%

  • Mediastinal primary, or
  • Nonpulmonary visceral metastases, or
  • Poor serum tumor markers; any of:
    • AFP more than 10,000 ng/mL, or
    • hCG more than 50,000 IU/mL (10,000 ng/mL), or
    • LDH more than 10 times the upper limit of normal

Poor-prognosis s eminoma: No seminoma patients are classified as poor prognosis.

Patient Education

http://www.cancer.gov/cancertopics/factsheet/sites-types/testicular

 
Acknowledgments

The author and editors wish to thank Salah Almokadem, MD, Assistant Professor of Medicine, Department of Medicine, Penn State Milton S Hershey Medical Center; and Charles J Ryan, MD, Assistant Clinical Professor, Department of Medicine, Division of Hematology and Oncology, University of California at San Francisco, for their contributions to previous versions of this article.



More on Testicular Cancer

Overview: Testicular Cancer
Differential Diagnoses & Workup: Testicular Cancer
Treatment & Medication: Testicular Cancer
Follow-up: Testicular Cancer
References
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Further Reading

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Keywords

testicular cancer symptoms, testicular cancer diagnosis, testicular cancer treatment, germ cell tumors, GCT, seminoma, embryonal carcinoma, teratoma, choriocarcinoma, yolk sac tumor

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Contributor Information and Disclosures

Author

Kush Sachdeva, MD, Southern Oncology and Hematology Associates, South Jersey Healthcare, Fox Chase Cancer Center Partner
Disclosure: Nothing to disclose.

Coauthor(s)

Mansoor Javeed, MD, FACP, Clinical Assistant Professor of Medicine, University of California Davis; Consultant, Sierra Hematology-Oncology Medical Center
Mansoor Javeed, MD, FACP is a member of the following medical societies: American College of Physicians and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Issam Makhoul, MD, Associate Professor, Department of Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences
Issam Makhoul, MD is a member of the following medical societies: American Society of Clinical Oncology and American Society of Hematology
Disclosure: Nothing to disclose.

Brendan Curti, MD, Director, Genitourinary Oncology Research, Robert W. Franz Cancer Research Center, Earle A. Chiles Research Institute, Providence Cancer Center
Brendan Curti, MD is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, Oregon Medical Association, and Society for Biological Therapy
Disclosure: Nothing to disclose.

Medical Editor

Philip Schulman, MD, Chief, Medical Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center; Clinical Professor, Department of Medicine, New York University School of Medicine
Philip Schulman, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology, and Medical Society of the State of New York
Disclosure: celgene Honoraria Speaking and teaching; Amgen Honoraria Speaking and teaching; genetech/idec Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

Rajalaxmi McKenna, MD, FACP, Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, Clinical Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, Arizona Cancer Center
Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research
Disclosure: GlobeImmune Salary Consulting; Amplimed Consulting fee Consulting; FibroGen Consulting fee Consulting

 
 
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