Testicular Choriocarcinoma Treatment & Management

Updated: Sep 07, 2019
  • Author: Michael B Williams, MD, MS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Treatment

Approach Considerations

The treatment of choriocarcinoma includes orchidectomy, chemotherapy, and retroperitoneal lymph node dissection. [15]  As most cases of choriocarcinoma have poor risk features, primary chemotherapy is followed by radiographic reassessment and staging. Most radical orchiectomies are performed in the same day or in 23-hour observation settings. This surgery is comparable to an inguinal herniorrhaphy, and the patient can expect limited physical activity for a brief period following surgery. Following orchiectomy, a short course of pain management medication may be required.

High-dose chemotherapy with autologous stem cell rescue has been used in patients with incomplete responses to initial therapy. [28] A multimodal approach involving the urologist and hematologist/oncologist is essential in the treatment of advanced nonseminomatous germ cell tumors.

 

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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 for 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. Alternative regimens include etoposide and cisplatin (EP) for four cycles only for patients with good risk disease; etoposide, mesna, ifosfamide, and cisplatin (VIP) for four cycles for intermediate and poor risk disease. [29]

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.

 

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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. [30]

  • 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

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Complications

Choriocarcinoma syndrome, which was first described in 1984 by Logothetis et al, is a rare complication that typically occurs shortly after the initiation of chemotherapy in patients with metastatic germ cell tumors and a beta–human chorionic gonadotropin level over 50,000 IU/L. The syndrome results from the tendency of choriocarcinoma to invade small blood vessels and is characterized by acute hemorrhage from metastases. Any site may be involved but bleeding from lung metastases is typical and can result in acute respiratory failure. Early recognition and prompt therapy is critical as such cases have a high mortality rate. [17, 19]

Choriocarcinoma syndrome is most likely to occur in patients with pure choriocarcinoma who have widespread lung metastases and a high beta-hCG level. The optimal therapeutic approach in these patients remains uncertain, but evidence suggests that risk can be reduced by using either a reduced or shortened course of induction chemotherapy before the progressing to the full-dose chemotherapeutical regimen. In addition, the best treatment results in these “superhigh-risk” patients appear to be obtained in high-volume reference centers. [19]

 

 

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Prevention

Prior to diagnosis, testicular self-examination on a monthly basis should begin at puberty.

Following diagnosis of testicular carcinoma, a mutual understanding between the patient and his treating physician in terms of strict adherence to follow-up regimens must be discussed. Early on, the follow-up regimens are frequent, as tumors can dramatically advance within short periods.

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