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Testicular Choriocarcinoma Treatment & Management

  • Author: Michael B Williams, MD, MS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Apr 16, 2015
 

Medical Care

Metastatic nonseminomatous germ cell tumors (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 effective chemotherapy regimens that reduce toxicity. Risk-adapted protocols are also available to tailor treatment regimens toward patients with good, moderate, or poor risk factors.

Standard chemotherapy for good-to-poor–risk NSGCT is with bleomycin, etoposide, and cisplatin (BEP) for four cycles. Additional agents include vinblastine and ifosfamide.

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.[15] This clinical presentation, although rare, is life-threatening and requires immediate treatment.[16]

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Surgical Care

Radical inguinal orchiectomy

Preoperative details are as follows:

  • 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. [17]
  • 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 are as follows:

  • Spinal, general, or (uncommonly) local anesthesia may be used. 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 are as follows:

  • 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 the following:

  • Inguinal skin numbness due to injury to the genitofemoral nerve
  • Hematoma
  • 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, Leroy T Canoles, Jr, Cancer Research Center, Eastern Virginia Medical School

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

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, MD is a member of the following medical societies: American Medical Association, American Urological Association, Society of Surgical Oncology, Society of Urologic Oncology

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Additional Contributors

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, Society of Urologic Oncology

Disclosure: Received consulting fee from GSK for consulting; Received honoraria from Astra Zeneca for speaking and teaching; Received consulting fee from Watson Pharmaceuticals for consulting.

Acknowledgements

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.

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

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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)
S LDH HCG (mIU/mL) AFP (ng/mL)
Sx Not assessed Not assessed Not assessed
S0 ≤N* and Normal and Normal
S1 < 1.5 x N and < 5000 and < 1000
S2 1.5-10 x N or 5000-50,000 or 1000-10,000
S3 >10 x N or >50,000 or >10,000
*N=upper limit of reference range for the LDH assay
Table 2. Stage Grouping
Stage grouping T N M S
Stage 0 pTis N0 M0 S0
Stage I T1-T4 N0 M0 Sx
Stage IA T1 N0 M0 S0
Stage IB T2-4 N0 M0 S0
Stage IS Any T N0 M0 S1-S3
Stage II Any T Any N M0 Sx
Stage IIA Any T N1 M0 S0-S1
Stage IIB Any T N2 M0 S0-S1
Stage IIC Any T N3 M0 S0-S1
Stage III Any T Any N M1 Sx
Stage IIIA Any T Any N M1a S0-S1
Stage IIIB Any T Any N M0-M1a S2
Stage IIIC Any T Any N M0-M1a S3
Any T Any N M1b Any S
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