eMedicine Specialties > Urology > Cancer, Testicle
Testicular Seminoma: Treatment & Medication
Updated: May 21, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- External beam radiotherapy for stage I and nonbulky stage II disease
- Refer patients with stage I and nonbulky stage II seminomas for external beam radiotherapy. Over a 3-week period, administer 2500 cGy in a hockey-stick field, including the para-aortic, paracaval, bilateral common iliac, and external iliac nodal regions. Recent protocols are reducing the radiation field to the para-aortic area only.
- A 2005 randomized trial from the Medical Research Council compared adjuvant radiotherapy at 30 Gy versus 20 Gy for stage I seminoma. The lower dose resulted in equivalent associated relapse rates and reduced morbidity, especially regarding fatigue. Further follow-up was recommended to determine if associated long-term secondary malignancies develop.23
- Mediastinal radiation was commonly administered but is currently avoided because chemotherapy is more effective. Mediastinal radiation may also diminish the ability to provide salvage chemotherapy later, if needed.
- Only 3% of patients relapse after radiation therapy. Relapses are usually located outside the radiation field.
- Short-term adverse effects include fatigue, nausea, vomiting, and GI upset.
- Long-term adverse effects have become of more concern over the last several years. Zagars and colleagues (2004) published a review of all patients who underwent radiotherapy postorchiectomy for seminoma between 1951 and 1999. They then computed standardized mortality ratios based on the person-years method. They found an increased risk after 15 years for cardiovascular and secondary cancer mortalities and recommended investigating new therapies that do not confer these long-term effects.24
- As an alternative to radiotherapy, single-agent carboplatin protocols are being studied. The Medical Research Council compared adjuvant carboplatin with radiotherapy and found equivalent relapse rates after a median follow-up period of 4 years. Long-term success of carboplatin therapy is unknown so should be considered experimental at this time.25
- Chemotherapy for stage II bulky or stage III disease
- After radical orchiectomy (see Surgical Care) and metastatic workup, administer 4 cycles of chemotherapy without radiotherapy in patients with advanced seminoma (stage IIB bulky or stage III).26
- Clinical trials have evaluated numerous chemotherapeutic regimens. While the optimal regimen is debatable, 4 cycles of bleomycin, etoposide, and cisplatin (BEP) is standard.
- Ongoing clinical trials are evaluating the omission of the fourth cycle, or bleomycin, in low-risk patients.
- For poor-risk and salvage cases, physicians may use alternative regimens using ifosfamide and vinblastine with dose escalation.
Surgical Care
- Relevant anatomy12
- Seminoma arises from abnormal germ cells in the seminiferous tubules. The TNM staging system (see Staging) stages the tumor based on its local, regional, and distant invasion.
- Testicular lymphatics relate to the embryonic origin of the testis. The male gonad initially forms near the kidney and descends through the inguinal canal to the scrotal sac. The right gonadal vein derives from the inferior cava, while the left gonadal vein derives from the left renal vein. Additional blood supply derives from the artery of the vas and the cremasteric arteries. Testicular lymphatics follow the vessels of the spermatic cord through the inguinal canal and into the retroperitoneum. Testicular cancer spreads predominantly and initially through lymphatic routes. On the right, the cancer landing zone is between the aorta and the inferior vena cava; on the left, it is on top of and lateral to the aorta. Within the retroperitoneum, there can be a crossover from the lymphatics draining the right toward those of the left.
- Scrotal skin lymphatics are different from testicular lymphatics and drain into the inguinal nodes. Perform all orchiectomies for solid masses through an inguinal route to avoid tumor spillage into the inguinal drainage basin. If a patient undergoes scrotal exploration, subsequent therapy may necessitate hemiscrotectomy and radiation treatment of the inguinal nodes.
- In patients who have undergone prior herniorrhaphy, orchiopexy, or other alteration in lymphatic drainage, extend their radiation field to include the contralateral inguinal region with contralateral testis shielding.
- Radical inguinal orchiectomy
- Preoperative details
- Draw serum tumor markers preoperatively because values fall rapidly after orchiectomy. Other staging tests can be performed preoperatively or postoperatively.
- Because of the rapid doubling time of a potential choriocarcinoma, schedule surgery for testis tumors rapidly to avoid upstaging.
- Most patients with seminoma are young and healthy and require only routine preoperative preparation.
- Discuss semen donation for subsequent fertility if the contralateral testis function is in question; however, many patients have poor semen quality that improves after orchiectomy.
- Cosmetic testicular prostheses are currently available from Coloplast (formerly Mentor). The saline-filled testicular prosthesis has been FDA-approved since 2002 and can be implanted in an outpatient setting if desired by the patient.
- If a patient presents with symptomatic metastatic lesions from a testis tumor, proceed with platinum-based chemotherapy and delay radical orchiectomy. Radical orchiectomy is not a morbid procedure, but it may delay initiation of chemotherapy.
- Differentiation of seminoma versus NSGCT for advanced disease is not important at the outset of treatment because 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. Shave the inguinal area, and prep in a standard fashion.
- Create an inguinal incision to allow exposure of the external and internal iliac canal.
- Open the external iliac fascia, exposing the spermatic cord and internal iliac canal. Control the spermatic cord with a Penrose drain in a tourniquet fashion to stop retroperitoneal lymphatic and venous drainage of tumor cells.
- Then, deliver the testis from the scrotum and ligate separately the vas deferens and spermatic arteries.
- Leave a long nonabsorbable tie on the patient side of the spermatic cord. This is to facilitate identification if retroperitoneal lymph node dissection (RPLND) becomes necessary and the patient requires dissection of the remaining spermatic cord structures from the abdominal exposure.
- Reapproximate the external oblique fascia and close the skin in standard fashion.
- Postoperative details
- Radical orchiectomy is usually performed on an outpatient or 23-hour admission basis, often accompanied by the staging workup.
- Conduct a follow-up study by staging and referring the patient for 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.
- Preoperative details
Consultations
- Low-stage disease - Radiation oncologist for external beam radiotherapy
- Advanced disease - Medical oncologist for platinum-based chemotherapy
Medication
BEP is the most common chemotherapy regimen administered for GCTs. It is usually administered in 4 cycles. Additional agents involved in primary, high-risk, and salvage protocols may include ifosfamide and vinblastine.
Antineoplastic agents
These agents inhibit deregulated growth of cells.
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.
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
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
Etoposide (VP-16)
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 effects of warfarin and increase clearance of methotrexate; cyclosporine and etoposide have additive effects in 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; inhibits DNA synthesis and thus cell proliferation by causing DNA crosslinks and denaturation of double helix.
Adult
20 mg/m2 IV on days 1-5 and 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 dosing to reduce risk of nephrotoxicity; myelosuppression, ototoxicity, nausea, and vomiting may occur
Ifosfamide (Ifex)
Related to nitrogen mustards and is a synthetic analog of cyclophosphamide; inhibits DNA and protein synthesis and thus cell proliferation by causing DNA cross-linking and denaturation of double helix.
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 P450 activity may alter effects
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)
Inhibits microtubule formation, which in turn, disrupts the formation of mitotic spindle, causing cell proliferation to arrest at metaphase.
Adult
4-20 mg/m2 (0.1-0.5 mg/kg) IV q7-10d or 5 d continuous infusion of 1.4-1.8 mg/m2/d or 0.1-0.5 mg/kg/wk
Pediatric
Not established
Phenytoin plasma levels may be reduced when coadministered; toxicity may significantly increase with mitomycin
Documented hypersensitivity; severe bone marrow suppression; granulocytopenia; bacterial infections
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 Seminoma |
| Overview: Testicular Seminoma |
| Differential Diagnoses & Workup: Testicular Seminoma |
 Treatment & Medication: Testicular Seminoma |
| Follow-up: Testicular Seminoma |
| Multimedia: Testicular Seminoma |
| References |
| Further Reading |
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References
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Keywords
testicular seminoma, testis cancer, cancer of the testes, testis germ cell carcinoma, testicular cancer, seminoma, germ cell tumor, GCT, radical orchiectomy, germ cell carcinoma in situ, germ cell CIS, classic seminoma, anaplastic seminoma, spermatocytic seminoma
