Testicular Choriocarcinoma Treatment & Management

  • Author: Michael B Williams, MD, MS; Chief Editor: Bradley Fields Schwartz, DO, FACS   more...
 
Updated: Jan 20, 2012
 

Medical Care

Metastatic NSGCTs are highly sensitive to cisplatin-based chemotherapy, with cure rates of approximately 80% for advanced disease and nearly 100% for early-stage disease. Furthermore, numerous randomized clinical trials conducted for NSGCT have identified efficacious chemotherapy regimens that reduce toxicity. Risk-adapted protocols are also available to tailor treatment regimens toward patients with good, moderate, or poor risk factors.

Pure choriocarcinoma, an extremely rare variant comprising less than 1% of NSGCT cases, is not as sensitive to chemotherapy as mixed NSGCT. The authors' exhaustive search of major textbooks and the literature revealed no clear guidelines as to how to treat these patients. Most case reports describe patients presenting with advanced metastatic disease, with varying responses to chemotherapy. In general, standard chemotherapy for poor-risk NSGCT is the initial therapy. However, these patients may require salvage regimens and may benefit from referral to a major cancer center to be treated under protocols that can involve cyclical regimens or dose escalation with growth factor/stem cell support. Cases responsive to chemotherapy may require additional surgical debulking.

Further, as described by Logothetis et al (1986), choriocarcinoma syndrome entails hemorrhage from metastatic sites of choriocarcinoma corresponding with significant elevation of beta-hCG.[12] This clinical presentation, although rare, is life-threatening and requires immediate treatment.[13]

  • Standard chemotherapy for good-to-poor–risk NSGCT - Bleomycin, etoposide, cisplatin (BEP) for 4 cycles
  • Additional agents - Vinblastine, ifosfamide
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Surgical Care

Radical inguinal orchiectomy

  • Preoperative details
    • Serum tumor markers must be drawn preoperatively because they fall rapidly postorchiectomy. Other staging tests can be performed preoperatively or postoperatively.
    • Because of the rapid doubling time of a potential choriocarcinoma, testis tumors are often scheduled for surgery rapidly to avoid upstaging.
    • Most patients with testicular choriocarcinoma are young and healthy and require only routine preoperative preparation.
    • Semen donation for subsequent fertility should be discussed if the contralateral testis function is in question; however, many patients with poor semen quality demonstrate improvement after orchiectomy.
    • Cosmetic testicular prostheses are readily available to interested patients. Coloplast, formerly Mentor, has an FDA-approved saline-filled testicular prosthesis that has been in use since 2002. This prosthesis can be placed at a later date, if desired, in an outpatient procedure. Bodiwala et al (2007) published an excellent review article on rationale and patient discussion.[14]
    • In a patient who presents with symptomatic metastatic lesions from a testis tumor, proceeding with platinum-based chemotherapy and delaying radical orchiectomy is reasonable. Radical orchiectomy is not a very morbid procedure but may delay the initiation of chemotherapy.
    • Differentiation of seminoma versus NSGCT for advanced disease is not important at the outset of treatment, as both groups receive the same regimen.
    • Although chemotherapy may result in disappearance of the testicular mass, orchiectomy is always indicated.
  • Intraoperative details
    • Patients may be administered spinal, general, or (uncommonly) local anesthesia. The inguinal area is shaved and prepared in standard fashion.
    • An inguinal incision is made to allow exposure of the external and internal iliac canal.
    • The external iliac fascia is opened, exposing the spermatic cord and the internal iliac canal. The spermatic cord is controlled with a Penrose drain in tourniquet fashion to stop retroperitoneal lymphatic and venous drainage of tumor cells.
    • The testis is then delivered from the scrotum, and the vas deferens and spermatic arteries are ligated separately.
    • A long nonabsorbable tie is left on the patient side of the spermatic cord to facilitate identification should retroperitoneal lymph node dissection become necessary, requiring dissection of the remaining spermatic cord structures from the abdominal exposure.
    • The external oblique fascia is reapproximated and the skin closed in standard fashion.
  • Postoperative details
    • Radical orchiectomy is usually an outpatient procedure or is performed as a 23-hour admission, often accompanied by the staging workup.
    • As follow-up, patients are staged and referred for the appropriate adjuvant therapies.
  • Complications are rare but may include wound infection, inguinal skin numbness due to injury to the genitofemoral nerve, hematoma, and standard anesthetic risks.
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Consultations

A multimodal approach involving the urologist and hematologist/oncologist is essential in the treatment of advanced NSGCT.

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Contributor Information and Disclosures
Author

Michael B Williams, MD, MS  Assistant Professor, Department of Urology, Eastern Virginia Medical School

Michael B Williams, MD, MS is a member of the following medical societies: American Association for Cancer Research, American Association of Clinical Urologists, American Society of Clinical Oncology, American Urological Association, Society of Urologic Oncology, and Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Paul F Schellhammer  MD, Professor of Urology, Eastern Virginia Medical School; Urologist, Urology of Virginia, PC

Paul F Schellhammer is a member of the following medical societies: American Medical Association, American Urological Association, Society of Surgical Oncology, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

John W Davis, MD  Assistant Professor, Department of Urology, University of Texas MD Anderson Cancer Center

John W Davis, MD is a member of the following medical societies: American College of Surgeons and American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Leonard Gabriel Gomella, MD, FACS  The Bernard W Godwin Professor of Prostate Cancer Chairman, Department of Urology, Associate Director of Clinical Affairs, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Leonard Gabriel Gomella, MD, FACS is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Urological Association, Sigma Xi, Society for Basic Urologic Research, Society of University Urologists, and Society of Urologic Oncology

Disclosure: GSK Consulting fee Consulting; Astra Zeneca Honoraria Speaking and teaching; Watson Pharmaceuticals Consulting fee Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Dan Theodorescu, MD, PhD  Paul A Bunn Professor of Cancer Research, Professor of Surgery and Pharmacology, Director, University of Colorado Comprehensive Cancer Center

Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology

Disclosure: Key Genomics Ownership interest Co-Founder-50% Stock Ownership; KromaTiD, Inc Stock Options Board membership

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS  Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists

Disclosure: Nothing to disclose.

References

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Testicular choriocarcinoma has multinucleated syncytiotrophoblastic cells that drape over smaller cytotrophoblastic cells, which together appear to form a border along a blood-filled villouslike space (upper right). Used with permission from Ernstoff MS, Heaney JA, and Peschel RE, eds. Testicular and Penile Cancer. Malden, Mass: Blackwell Science, Inc; 1998:20.
Table 1. Serum Tumor Markers (S)
SLDHHCG (mIU/mL)AFP (ng/mL)
SxNot assessedNot assessedNot assessed
S0≤ N*andNormalandNormal
S1< 1.5 x Nand< 5000and< 1000
S21.5-10 x Nor5000-50,000or1000-10,000
S3>10 x Nor>50,000or>10,000
*N=upper limit of reference range for the LDH assay
Table 2. Stage Grouping
Stage groupingTNMS
Stage 0pTisN0M0S0
Stage IT1-T4N0M0Sx
Stage IAT1N0M0S0
Stage IBT2-4N0M0S0
Stage ISAny TN0M0S1-S3
Stage IIAny TAny NM0Sx
Stage IIAAny TN1M0S0-S1
Stage IIBAny TN2M0S0-S1
Stage IICAny TN3M0S0-S1
Stage IIIAny TAny NM1Sx
Stage IIIAAny TAny NM1aS0-S1
Stage IIIBAny TAny NM0-M1aS2
Stage IIICAny TAny NM0-M1aS3
…Any TAny NM1bAny S
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