Medication Summary

Metastatic pure choriocarcinoma is treated with the same multi-agent chemotherapy regimens used in nonseminomatous germ cell tumors (NSGCTs), which are discussed in a separate article (see Nonseminomatous Testicular Tumors).

Standard chemotherapy for poor-risk patients 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.^{[7, 18, 31, 10, 32]}

Class Summary

These agents inhibit cell growth and proliferation.

Bleomycin (Blenoxane)

View full drug information

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.

Etoposide (Toposar, VePesid)

View full drug information

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.

Cisplatin (Platinol, Platinol-AQ)

View full drug information

Inorganic metal complex thought to act analogously to alkylating agents. Kills cells in all stages of cell cycle and inhibits DNA biosynthesis.

Ifosfamide (Ifex)

View full drug information

Related to nitrogen mustards and a synthetic analog of cyclophosphamide.

Vinblastine (Alkaban-AQ, Velban)

View full drug information

Alkaloid derivative that causes depolymerization of microtubules important to the mitotic spindle and cytoskeleton.

Reuter VE. Anatomy and Pathology of Testis Cancer. In: Scardino PT, Linehan WM, Zelefsky MJ, Vogelzang NJ, eds. Comprehensive Textbook of Genitourinary Oncology. 4th ed. Baltimore, Md: Lippincott Williams and Wilkins; 2011.
Lavoie JM, Kollmannsberger CK. Current Management of Disseminated Germ Cell Tumors. Urol Clin North Am. 2019 Aug. 46 (3):377-388. [Medline].
Chen X, Xu L, Chen X, Teng X, Zheng S. Testicular choriocarcinoma metastatic to skin and multiple organs. Two case reports and review of literature. J Cutan Pathol. 2010 Apr. 37(4):486-90. [Medline].
Batata MA, Whitmore WF Jr, Chu FC. Cryptorchidism and testicular cancer. J Urol. 1980 Sep. 124(3):382-7. [Medline].
Looijenga LH, Oosterhuis JW. Pathogenesis of testicular germ cell tumours. Rev Reprod. 1999 May. 4(2):90-100. [Medline].
Alvarado-Cabrero I, Hernández-Toriz N, Paner GP. Clinicopathologic analysis of choriocarcinoma as a pure or predominant component of germ cell tumor of the testis. Am J Surg Pathol. 2014 Jan. 38(1):111-8. [Medline].
Ramon y Cajal S, Pinango L, Barat A. Metastatic pure choriocarcinoma of the testis in an elderly man. J Urol. 1987 Mar. 137(3):516-9. [Medline].
Berney DM, Warren AY, Verma M, Kudahetti S, Robson JM, Williams MW, et al. Malignant germ cell tumours in the elderly: a histopathological review of 50 cases in men aged 60 years or over. Mod Pathol. 2008 Jan. 21(1):54-9. [Medline].
Batata MA, Chu FC, Hilaris BS. Therapy and prognosis of testicular carcinomas in relation to TNM classification. Int J Radiat Oncol Biol Phys. 1982 Aug. 8(8):1287-93. [Medline].
Requena L, Sanchez M, Aguilar A. Choriocarcinoma of the testis metastatic to the skin. J Dermatol Surg Oncol. 1991 May. 17(5):466-70. [Medline].
Lepidini G, Biancari F, D'Andrea V. Severe thrombosis after chemotherapy for metastatic choriocarcinoma of the testis maintaining complete remission for a long period. Scand J Urol Nephrol. 1997 Apr. 31(2):221-2. [Medline].
Vugrin D, Cvitkovic E, Posner J. Neurological complications of malignant germ cell tumors of testis: biology of brain metastases (I). Cancer. 1979 Dec. 44(6):2349-53. [Medline].
Bosl GJ, Geller N, Cirrincione C. Interrelationships of histopathology and other clinical variables in patients with germ cell tumors of the testis. Cancer. 1983 Jun 1. 51(11):2121-5. [Medline].
Stang A, Jansen L, Trabert B, Rusner C, Eberle A, Katalinic A, et al. Survival after a diagnosis of testicular germ cell cancers in Germany and the United States, 2002-2006: a high resolution study by histology and age. Cancer Epidemiol. 2013 Aug. 37(4):492-7. [Medline]. [Full Text].
Puri S, Sood S, Mohindroo S, Kaushal V. Cytomorphology of lung metastasis of pure choriocarcinoma of testis in a 58-year-old male. J Cancer Res Ther. 2015 Oct-Dec. 11 (4):1035. [Medline]. [Full Text].
Elkeeb D, Hopkins Z, Florell SR. Pure testicular choriocarcinoma presenting as a friable hemorrhagic nodule on the lip. JAAD Case Rep. 2018 Aug. 4 (7):705-707. [Medline]. [Full Text].
Zeitjian VS, Arslan W, Borja-Alvarez A, Amar S. Choriocarcinoma Syndrome: A Potentially Fatal Complication of Testicular Cancer. Case Rep Oncol Med. 2019. 2019:4092941. [Medline]. [Full Text].
Logothetis CJ, Samuels ML, Selig DE, Ogden S, Dexeus F, Swanson D, et al. Cyclic chemotherapy with cyclophosphamide, doxorubicin, and cisplatin plus vinblastine and bleomycin in advanced germinal tumors. Results with 100 patients. Am J Med. 1986 Aug. 81 (2):219-28. [Medline].
Rejlekova K, Cursano MC, De Giorgi U, Mego M. Severe Complications in Testicular Germ Cell Tumors: The Choriocarcinoma Syndrome. Front Endocrinol (Lausanne). 2019. 10:218. [Medline]. [Full Text].
Tatokoro M, Kawakami S, Sakura M, Kobayashi T, Kihara K, Akamatsu H. Successful management of life-threatening choriocarcinoma syndrome with rupture of pulmonary metastatic foci causing hemorrhagic shock. Int J Urol. 2008 Mar. 15(3):263-4. [Medline].
Salazar-Mejía CE, García-Gutiérrez ME, Contreras-Salcido MI, Rodríguez-Álvarez CJ, Wimer-Castillo BO, Lara-Campos JG, et al. Choriocarcinoma Syndrome as an Initial Presentation of Testicular Cancer. Case Rep Oncol Med. 2018. 2018:8065615. [Medline]. [Full Text].
Klein EA. Tumor markers in testis cancer. Urol Clin North Am. 1993 Feb. 20(1):67-73. [Medline].
Chieffi P. Recent advances in molecular and cell biology of testicular germ-cell tumors. Int Rev Cell Mol Biol. 2014. 312:79-100. [Medline].
Bezan A, Gerger A, Pichler M. MicroRNAs in testicular cancer: implications for pathogenesis, diagnosis, prognosis and therapy. Anticancer Res. 2014 Jun. 34(6):2709-13. [Medline].
Horstman WG. Scrotal imaging. Urol Clin North Am. 1997 Aug. 24(3):653-71. [Medline].
Bredael JJ, Vugrin D, Whitmore WF Jr. Autopsy findings in 154 patients with germ cell tumors of the testis. Cancer. 1982 Aug 1. 50(3):548-51. [Medline].
Testis. Amin MB, Edge SB, Compton CC, et al, eds. AJCC Cancer Staging Manual. 8th ed. New York: Springer; 2017. 735-746.
Pagliaro LC. Role of High-Dose Chemotherapy With Autologous Stem-Cell Rescue in Men With Previously Treated Germ Cell Tumors. J Clin Oncol. 2017 Apr 1. 35 (10):1036-1040. [Medline].
[Guideline] National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Testicular Cancer version 1.2019. NCCN.org. Available at https://www.nccn.org/professionals/physician_gls/pdf/testicular.pdf. October 22, 2018; Accessed: March 15, 2019.
Bodiwala D, Summerton DJ, Terry TR. Testicular prostheses: development and modern usage. Ann Royal Coll Surg Engl. 2007. 89:349-53. [Medline]. [Full Text].
Mead GM. Chemotherapeutic Management of Metastatic Germ Cell Testis Cancer. Risk-Adapted Therapy/Poor Risk Patients. Vogelzang et al, eds. Comprehensive Textbook of Genitourinary Oncology. 2nd ed. Philadelphia, Pa: Lippincott Williams & Williams; 2000. 1024-31.
Saxman SB, Loehrer PJ. Chemotherapeutic Management of Metastatic Germ Cell Testicular Cancer. Overview of Initial Therapy for Metastatic Seminoma and Nonseminoma. Vogelzang et al, eds. Comprehensive Textbook of Genitourinary Oncology. 2nd ed. Philadelphia, Pa: Lippincott Williams & Williams; 2000: 1010-7.

Media Gallery

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.

of 1

Table 1. Serum Tumor Markers (S)

S	LDH		HCG (mIU/mL)		AFP (ng/mL)
Sx	Not assessed		Not assessed		Not assessed
S0	Normal	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	pT1-T4	N0	M0	Sx
Stage IA	pT1	N0	M0	S0
Stage IB	pT2-4	N0	M0	S0
Stage IS	Any pT/TX	N0	M0	S1-S3
Stage II	Any pT/TX	N1-3	M0	Sx
Stage IIA	Any pT/TX	N1	M0	S0-S1
Stage IIB	Any pT/TX	N2	M0	S0-S1
Stage IIC	Any pT/TX	N3	M0	S0-S1
Stage III	Any pT/TX	Any N	M1	Sx
Stage IIIA	Any pT/TX	Any N	M1a	S0-S1
Stage IIIB	Any pT/TX	N1-3	M0	S2
…	Any pT/TX	Any N	M1a	S2
Stage IIIC	Any pT/TX	N1-3	M0	S3
…	Any pT/TX	Any N	M1a	S3
…	Any pT/TX	Any N	M1b	Any S

Back to List

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society Board of Directors; President Elect North Central Section of the American Urological Association<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical.

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, The Scientific Research Honor Society, 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