eMedicine Specialties > Urology > Cancer, Testicle
Testicular Choriocarcinoma: Treatment & Medication
Updated: May 21, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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.11 This clinical presentation, although rare, is life-threatening and requires immediate treatment.12
- Standard chemotherapy for good-to-poor–risk NSGCT - Bleomycin, etoposide, cisplatin (BEP) for 4 cycles
- Additional agents - Vinblastine, ifosfamide
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.13
- 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.
Consultations
A multimodal approach involving the urologist and hematologist/oncologist is essential in the treatment of advanced NSGCT.
Medication
Metastatic pure choriocarcinoma is treated with the same multi-agent chemotherapy regimens used in NSGCT, which are discussed in a separate article (see Nonseminomatous Testicular Tumors).
Standard chemotherapy for poor-risk and some good-to-moderate–risk patients includes 4 cycles of BEP (ie, bleomycin, etoposide, cisplatin). Additional agents in some regimens or for salvage include vinblastine and ifosfamide.
Most case reports show a poor response to chemotherapy, and the literature offers no clear treatment guidelines.2,11,14,15,16
Antineoplastic agents
These agents inhibit cell growth and proliferation.
Bleomycin (Blenoxane)
Composed of cytotoxic glycopeptide antibiotics, which appear to inhibit DNA synthesis, with some evidence of RNA and protein synthesis inhibition to a lesser degree. Used in the management of several neoplasms as a palliative measure; however, it is an important part of curative regimens for testicular cancer.
Adult
30 U (0.25-0.5 U/kg) IV on days 1, 9, and 16
Pediatric
Not established
May decrease plasma levels of digoxin and phenytoin; cisplatin may increase toxicity of bleomycin when administered systemically
Documented hypersensitivity; significant renal function impairment; compromised pulmonary function
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal impairment; possibly secreted in breast milk; may cause mutagenesis and pulmonary toxicity (10%); idiosyncratic reactions similar to anaphylaxis (1%) may occur; monitor for adverse effects during and after treatment; vasoocclusive phenomenon with distal necrosis of digit; permanent damage to nail matrix may occur
Etoposide (Toposar, VePesid)
Arrests cells in the G2 portion of the cell cycle and induces DNA strand breaks by interacting with DNA topoisomerase II and forming free radicals.
Adult
100 mg/m2 IV on days 1-5
Pediatric
Not established
May prolong the effects of warfarin and increase the clearance of methotrexate; cyclosporine and etoposide have additive effects in the cytotoxicity of tumor cells
Documented hypersensitivity; IT administration may cause death
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Bleeding and severe myelosuppression may occur
Cisplatin (Platinol, Platinol-AQ)
Inorganic metal complex thought to act analogously to alkylating agents. Kills cells in all stages of cell cycle and inhibits DNA biosynthesis.
Adult
20 mg/m2 IV on days 1-5; repeat q3-4wk
Pediatric
Not established
Increases toxicity of bleomycin and ethacrynic acid
Documented hypersensitivity; preexisting renal insufficiency; myelosuppression; hearing impairment
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Administer adequate hydration before and 24 h after cisplatin dosing to reduce risk of nephrotoxicity; myelosuppression, ototoxicity, nausea, and vomiting may occur
Ifosfamide (Ifex)
Related to nitrogen mustards and a synthetic analog of cyclophosphamide.
Adult
1.2 g/m2/d IV on days 1-5
Pediatric
Not established
Phenobarbital, phenytoin, chloral hydrate, and other drugs that interfere with cytochrome P-450 activity may alter effects of ifosfamide
Documented hypersensitivity; depressed bone marrow function
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause hemorrhagic cystitis and severe myelosuppression; caution in renal function impairment or compromised bone marrow reserve
Vinblastine (Alkaban-AQ, Velban)
Alkaloid derivative that causes depolymerization of microtubules important to the mitotic spindle and cytoskeleton.
Adult
IV dosage varies by protocol
Pediatric
Not established
Phenytoin plasma levels may be reduced when administered concomitantly with vinblastine; with mitomycin, the toxicity of vinblastine may significantly increase
Documented hypersensitivity; bone marrow suppression
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients diagnosed with impaired liver function and neurotoxicity; when patient is receiving mitomycin C, monitor closely for shortness of breath and bronchospasm
More on Testicular Choriocarcinoma |
| Overview: Testicular Choriocarcinoma |
| Differential Diagnoses & Workup: Testicular Choriocarcinoma |
 Treatment & Medication: Testicular Choriocarcinoma |
| Follow-up: Testicular Choriocarcinoma |
| Multimedia: Testicular Choriocarcinoma |
| References |
| Further Reading |
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Keywords
testicular choriocarcinoma, trophoblastic malignant teratoma, trophoblastic neoplasia, testicular seminoma, nonseminomatous germ cell tumors, NSGCT, germ cell tumors, GCT
