Medical Care
Fertility evaluation/sperm banking
As a group, patients with testicular cancer are more likely to have subfertility characteristics (eg, lower motile sperm count, decreased sperm mobility, suboptimal motility characteristics) than a healthy, age-matched cohort. [18]
Modern adjuvant therapies for seminoma have a limited propensity to further negatively affect semen quality. [19]
All male cancer patients of reproductive age who have treatment that may affect testicular function and who may desire children in the future should cryopreserve sperm before initiation of therapy. [20, 21, 22]
Adjuvant radiation therapy
Most men with seminoma present with clinical stage I disease (confined to the testis); only 15-20% of patients are found to have pelvic or para-aortic lymphadenopathy during postoperative radiographic staging. However, in another 15-20% of patients, disease that is apparently confined locally ultimately relapses in subdiaphragmatic lymph nodes if treated with orchiectomy alone. [23] Adjuvant postoperative radiotherapy remains the current standard method to significantly reduce the incidence of regional nodal failure, and its use is determined by disease stage. [24, 25]
Stage I
After radical orchiectomy, patients with stage I seminoma are treated with moderate-dose external beam radiotherapy to retroperitoneal and ipsilateral pelvic lymph nodes, typically 2500 cGy in 20 fractions (125 cGy per fraction). Using this approach, the in-field disease control rate approaches 100%. [26] Contraindications to the use of adjuvant radiotherapy for these patients include the presence of a horseshoe kidney (more common among these patients than among the general population), previous abdominopelvic radiotherapy, and severe inflammatory bowel disease. Some reports have indicated that para-aortic lymph node irradiation may suffice without adverse impact on overall survival. [27, 28, 29, 30]
The recommended follow-up for patients receiving para-aortic and ipsilateral pelvic radiotherapy includes 2 examinations per year for the first 3 years after treatment, followed by yearly examinations in years 4-6 after treatment. Chest radiography is performed during each follow-up visit. For patients receiving para-aortic radiotherapy only, a CT scan of the pelvis is recommended during the follow-up schedule detailed above. [31]
Some patients with stage I disease prefer to avoid adjuvant radiation because their risk of relapse after orchiectomy is relatively low (15-20%) and because disease recurrences are usually treated with subsequent salvage radiation or chemotherapy. [32] However, patients who choose this approach must understand that they will require frequent (and therefore expensive) follow-up evaluations with serum tumor markers and CT scanning of the abdomen and pelvis so that nodal recurrences may be identified early. [33] For patients who undergo surveillance, follow-up includes 3 examinations per year for the first 2 years, 2 examinations in years 3 and 4, and 1 examination in years 5-10. At each follow-up examination, chest radiography and CT scanning of the abdomen and pelvis are recommended. [31]
An accumulating amount of literature states that 1 or 2 courses of carboplatin may give results similar to adjuvant radiotherapy without the carcinogenic risks of irradiation. [34, 2, 35, 36] A recent randomized trial comparing radiotherapy versus carboplatin showed a reduction in risk for development of second germ cell tumor in patients receiving carboplatin. [35] Patients should be examined 2 times during the first 3 years with chest radiography; thereafter, the follow-up schedule is unclear because limited data are available with regards to patterns of relapse. [31] Note the image below.
Radiotherapy fields for stage I seminoma.
Stage IIA-B
Patients with stage IIA or IIB seminoma are found to have regional nodal metastases no larger than 5 cm on postoperative imaging studies. Historically, these patients have been treated with external beam radiotherapy to the pelvic and paraaortic lymph nodes to a dose of 2500 cGy in 20 fractions (125 cGy per fraction) followed by a boost of 1000 cGy in 5-8 fractions (125-200 cGy per fraction); this has provided freedom from any relapse in approximately 90% of patients. As in patients with stage I disease, in-field control remains nearly universal. [37, 24]
Contraindications to the use of adjuvant radiotherapy for these patients include the presence of a horseshoe kidney (more common among these patients than among the general population), previous abdominopelvic radiotherapy, and severe inflammatory bowel disease. Adjuvant combination chemotherapy in lieu of radiotherapy has been used with increasing frequency over the past 2 decades, according to patterns of care studies; [38] current randomized protocols are attempting to define which approach (adjuvant radiation versus adjuvant chemotherapy) carries the lowest morbidity while maximizing the cure rate. A study from the Spanish Germ Cell Cancer Group showed a 5-year progression-free survival of 100% and 87% for Stage IIA and IIB testicular seminoma treated with 4 cycles of cisplatin and etoposide or 3 cycles of cisplatin, etoposide, and bleomycin. [39]
Adjuvant carboplatin chemotherapy
Accumulating reports in the literature state that 1 or 2 courses of carboplatin may yield results similar to adjuvant radiotherapy without the carcinogenic risks of irradiation in stages IA and IB testicular seminoma. [34, 2, 35, 36] A recent randomized trial comparing radiotherapy to carboplatin showed a reduction in risk for the development of a second germ cell tumor in patients receiving carboplatin. [35] Patients should be examined 2 times during the first 3 years with chest radiography; thereafter, the follow-up schedule is unclear because limited data are available with regard to patterns of relapse. [31]
Adjuvant combination chemotherapy
In advanced seminoma (stage IIC or III), although local control with radiotherapy remains excellent, the risk of distant relapse is high. This risk mandates the use of systemic chemotherapy to achieve cure. Approximately 70-80% of these patients are curable with platinum-based chemotherapeutic regimens.
In selected stage IIB seminoma, where the location of nodal involvement and treatment with adjuvant radiotherapy is likely to cause renal dysfunction, combination chemotherapy should be considered.
Patients with bulky nodal disease or systemic metastases are best treated with combination chemotherapy using cisplatin-containing regimens; a representative regimen is 4 cycles of cisplatin/etoposide administered intravenously in an outpatient setting.
Surgical Care
The appropriate surgical treatment for any patient with suspected testicular tumor is radical inguinal orchiectomy with high ligation of the spermatic cord. Transscrotal biopsy or transscrotal orchiectomy is inappropriate because the testis and scrotum have different lymphatic drainage patterns and these procedures can result in tumor recurrence in the scrotal skin or inguinal/pelvic lymph nodes. [40] In addition, an inguinal approach allows for more generous resection of the spermatic cord, improving surgical margins. Orchiectomy provides pathologic material for histologic diagnosis and primary pathologic staging information as well.
Consultations
Consultation with the following specialists may be appropriate:
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Pediatric urologist
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Radiation oncologist
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Pediatric oncologist
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Reproductive endocrinologist or sperm banking specialist
Diet and Activity
Diet
No specific dietary concerns are associated with the care of these patients.
Activity
Any activity limitations are related to surgery (orchiectomy); for example, the patient's surgeon may recommend avoidance of heavy lifting or contact sports for a short time.
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Radiotherapy fields for stage I seminoma.
