Estimated new cases and deaths from testicular cancer in the United States in 2024:[1]
Testicular cancer is a highly treatable, usually curable cancer that most often develops in young and middle-aged men. Most testicular cancers are germ cell tumors. For treatment planning, germ cell tumors are broadly divided into seminomas and nonseminomas because they have different prognostic and treatment algorithms. For patients with seminomas (all stages combined), the cure rate exceeds 90%. For patients with low-stage seminomas or nonseminomas, the cure rate approaches 100%.[2-6]
Risk factors for testicular cancer include the following:[7]
Surgical correction of an undescended testis (orchiopexy) before puberty appears to lower the risk of testicular cancer, but this is not certain.[8]
The five histopathological subtypes of testicular germ cell tumors include the following:
Tumors that are 100% seminoma are considered seminomas. All other tumors, including those that have a mixture of seminoma and nonseminoma components, are considered and should be managed as nonseminomas. Most nonseminomas consist of a mixture of the different germ cell tumor subtypes. Tumors that appear to have a seminoma histology but are accompanied by an elevated serum level of alpha-fetoprotein (AFP) should be treated as nonseminomas because seminomas do not produce AFP.
Alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (beta-hCG), and lactase dehydrogenase (LDH) play an important role as serum tumor markers in the staging and monitoring of germ cell tumors and should be measured prior to removing the involved testicle.[9] For patients with nonseminomas, one of the most significant predictors of prognosis is the degree of tumor-marker elevation after the cancerous testicle has been removed.[10] Elevated levels of serum tumor markers are often the earliest sign of relapse, making these markers useful for monitoring all stages of nonseminomas and metastatic seminomas.
AFP: Elevation of serum AFP is seen in 40% to 60% of men with nonseminomas. Seminomas do not produce AFP. Men who have an elevated serum AFP have a mixed germ cell tumor (i.e., nonseminomatous germ cell tumors [NSGCT]) even if the pathology shows a pure seminoma—unless there is a more persuasive explanation for the elevated AFP, such as liver disease.
Beta-hCG: Elevation of beta-hCG is found in approximately 14% of patients with stage I pure seminomas before orchiectomy and in about one-half of patients with metastatic seminomas.[11-13] Approximately 40% to 60% of men with nonseminomas have an elevated serum beta-hCG.
Significant and unambiguously rising levels of AFP and/or beta-hCG signal relapsed germ cell tumor in most cases and are an indication for treatment even in the absence of radiological evidence of metastatic disease. Nonetheless, tumor marker elevations need to be interpreted with caution. For example, false-positive beta-hCG levels can result from cross reactivity of the assay with luteinizing hormone in which case an intramuscular injection of testosterone should result in normalization of beta-hCG values. There are also clinical reports of marijuana use resulting in elevations of serum beta-hCG and some experts recommend querying patients about drug use and retesting beta-hCG levels after a period of abstinence from marijuana use. Similarly, AFP is chronically mildly elevated in some individuals for unclear reasons and can be substantially elevated by liver disease.
LDH: Seminomas and nonseminomas alike may result in elevated LDH but such values are of unclear prognostic significance because LDH may be elevated in many conditions unrelated to cancer. A study evaluated the utility of LDH in 499 patients with a testicular germ cell tumor who were undergoing surveillance after orchiectomy or treatment of stage II or III disease. It found that 7.7% of patients had elevated LDH unrelated to cancer, while only 1.4% of patients had cancer-related increases in LDH.[14] Among 15 patients with relapsed disease, LDH was elevated in six patients and was the first sign of relapse in one patient. Over 9% of the men had a persistent false-positive increase in LDH. The positive predictive value for an elevated LDH was 12.8%.
A second study reported that among 494 patients with stage I germ cell tumors who subsequently had a relapse, 125 had an elevated LDH at the time of relapse. Of these 125 patients, all had other evidence of relapse: 112 had a concurrent rise in AFP and/or beta-hCG, one had computed tomography (CT) evidence of relapse before the elevation in LDH, one had palpable disease on examination, and one complained of back pain that led to imaging that revealed retroperitoneal relapse.[15] On one hand, measuring LDH appears to have little value for predicting relapse during surveillance of germ cell tumors. On the other hand, for patients with metastatic NSGCT, large studies of prognostic models have found the LDH level to be a significant independent predictor of survival.[10,16]
There are two major prognostic models for testicular cancer: staging[17] and, for risk stratification of men with distant and/or bulky retroperitoneal metastases, the International Germ Cell Cancer Consensus Group classification.[10] The prognosis of patients with testicular germ cell tumors is determined by the following factors:
For men with disseminated seminomas, the main adverse prognostic variable is the presence of metastases to organs other than the lungs (e.g., bone, liver, or brain). For men with disseminated nonseminomas, the following variables are independently associated with poor prognosis:
Nonetheless, even patients with widespread metastases at presentation, including those with brain metastases, may have curable disease and should be treated with this intent.[18]
Radical inguinal orchiectomy with initial high ligation of the spermatic cord is the procedure of choice in diagnosing and treating a malignant testicular mass.[19] As noted above, serum AFP, LDH, and beta-hCG should be measured before an orchiectomy. Transscrotal biopsy is not considered appropriate because of the risk of local dissemination of tumor into the scrotum or its spread to inguinal lymph nodes. A retrospective analysis of reported series in which transscrotal approaches were used showed a small but statistically significant increase in local recurrence rates, compared with when the inguinal approach was used (2.9% vs. 0.4%).[20][Level of evidence C2] However, distant recurrence and survival rates were indistinguishable in the two approaches.
Evaluation of the retroperitoneal lymph nodes, usually by CT scan, is an important aspect of staging and treatment planning in adults with testicular cancer.[21,22] Patients with a negative result have a substantial chance of having microscopic involvement of the lymph nodes. Nearly 20% of patients with seminoma and 30% of patients with nonseminoma who have normal CT scans and serum tumor markers will subsequently relapse if not given additional treatment after orchiectomy.[23-25] For patients with nonseminoma, retroperitoneal lymph node dissection (RPLND) increases the accuracy of staging, but as many as 10% of men with normal imaging, normal tumor markers, and benign pathology at RPLND will still experience a relapse.[26] After RPLND, about 25% of patients with clinical stage I nonseminomatous testicular cancer are restaged as pathological stage II, and about 25% of clinical stage II patients are restaged as pathological stage I.[26-28] In prepubertal children, the use of serial measurements of AFP has proven sufficient for monitoring response after initial orchiectomy. Lymphangiography and para-aortic lymph node dissection do not appear to be useful or necessary in the proper staging and management of testicular cancer in prepubertal boys.[29] For more information, see Childhood Testicular Cancer Treatment.
Patients who have been cured of testicular cancer have approximately a 2% cumulative risk of developing cancer in the opposite testicle during the 15 years after initial diagnosis.[30,31] Within this range, men with nonseminomatous primary tumors appear to have a lower risk of subsequent contralateral testis tumors than men with seminomas.
Men with HIV are reported to be at increased risk of developing testicular seminomas.[32] Depending on comorbid conditions such as active infection, these men are generally managed similarly to patients without HIV.
Because most patients with testicular cancer who receive adjuvant chemotherapy or radiation therapy are curable, it is necessary to be aware of possible long-term effects of the various treatment modalities, such as the following:
Radiation therapy, used to treat pure seminomatous testicular cancers, can cause fertility problems because of radiation scatter to the remaining testicle during radiation therapy to retroperitoneal lymph nodes (as evidenced in the SWOG-8711 trial, for example).[37] Depending on scatter dose, sperm counts fall after radiation therapy but may recover over the course of 1 to 2 years. Shielding techniques can be used to decrease the radiation scatter to the remaining normal testicle. Because chemotherapy, RPLND, and radiation therapy can each result in infertility, men can be offered the opportunity to bank sperm before undergoing any treatment for testicular cancer other than orchiectomy.
Although acute pulmonary toxic effects may occur with bleomycin, they are rarely fatal at total cumulative doses of less than 400 units. Because life-threatening pulmonary toxic effects can occur, the drug should be discontinued if early signs of pulmonary toxicity develop. Although decreases in pulmonary function are frequent, they are rarely symptomatic and are reversible after chemotherapy ends. Survivors of testis cancer who were treated with chemotherapy have been reported to be at increased risk of death from respiratory diseases, but it is unknown whether this finding is related to bleomycin exposure.[44]
Radiation therapy, often used in the management of pure seminomatous germ cell cancers, has been linked to the development of secondary cancers, especially solid tumors in the radiation portal, usually after a latency period of a decade or more.[45,46] These secondary cancers include melanoma and cancers of the stomach, bladder, colon, rectum, pancreas, lung, pleura, prostate, kidney, connective tissue, and thyroid. Chemotherapy has also been associated with an elevated risk of secondary cancers.
Men with testicular cancer who have been treated with radiation therapy and/or chemotherapy are at increased risk of cardiovascular events.[47-49] Other studies have reported that chemotherapy for testicular cancer is associated with an increased risk of developing metabolic syndrome and hypogonadism.[50,51] Moreover, an international population-based study reported that men treated with either radiation therapy or chemotherapy were at increased risk of death from circulatory diseases.[44]
In a retrospective series of 992 patients treated for testicular cancer between 1982 and 1992, cardiac events were increased approximately 2.5-fold in patients treated with radiation therapy and/or chemotherapy, compared with those who underwent surveillance for a median of 10.2 years. The actuarial risks of cardiac events were 7.2% for patients who received radiation therapy (92% of whom did not receive mediastinal radiation therapy), 3.4% for patients who received chemotherapy (primarily platinum-based), 4.1% for patients who received combined therapy, and 1.4% for patients who underwent surveillance management after 10 years of follow-up.[48]
A population-based retrospective study of 2,339 testicular cancer survivors in the Netherlands, treated between 1965 and 1995 and followed for a median of 18.4 years, found that the overall incidence of coronary heart disease (i.e., myocardial infarction and/or angina pectoris) was increased 1.17 times (95% confidence interval [CI], 1.04–1.31) compared with the general population.[49] Patients who received radiation therapy to the mediastinum had a 2.5-fold (95% CI, 1.8–3.4) increased risk of coronary heart disease, and those who also received chemotherapy had an almost threefold (95% CI, 1.7–4.8) increased risk. Patients who were treated with infradiaphragmatic radiation therapy alone had no significantly increased risk of coronary heart disease. In multivariate Cox regression analyses, the older chemotherapy regimen of cisplatin, vinblastine, and bleomycin, used until the mid-1980s, was associated with a significant 1.9-fold (95% CI, 1.2–2.9) increased risk of cardiovascular disease (i.e., myocardial infarction, angina pectoris, and heart failure combined). The newer regimen of bleomycin, etoposide, and cisplatin was associated with a borderline significant 1.5-fold (95% CI, 1.0–2.2) increased risk of cardiovascular disease. Similarly, an international pooled analysis of population-based databases reported that the risk of death from circulatory disease was increased in men treated with chemotherapy (standardized mortality ratio [SMR] = 1.58) or radiation therapy (SMR = 1.70).[44][Level of evidence C2]
Although testicular cancer is highly curable, all newly diagnosed patients are appropriate candidates for clinical trials designed to decrease morbidity of treatment while further improving cure rates.
The following histological classification of malignant testicular germ cell tumors (testicular cancer) reflects the classification used by the World Health Organization (WHO).[1] Less than 50% of malignant testicular germ cell tumors have a single cell type, approximately 50% of which are seminomas. The remaining tumors have more than one cell type, and the relative proportions of each cell type should be specified. The cell type of these tumors is important for estimating the risk of metastases and the response to chemotherapy. Polyembryoma presents an unusual growth pattern and is sometimes listed as a single histological type, although it might better be regarded as a mixed tumor.[1-3]
The American Joint Committee on Cancer (AJCC) has designated staging by TNM (tumor, node, metastasis) classification to define testicular cancer.[1]
AJCC Prognostic Stage Groups-Pathological (pTNM)
| Stage | TNM/S | Description |
|---|---|---|
| T = primary tumor; N = regional lymph node; M = distant metastasis; cN = clinical regional lymph node; pN = pathological regional lymph node; pT = pathological tumor; S = serum marker. | ||
| aReprinted with permission from AJCC: Testis. In: Brimo F, Srigley J, Ryan C, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp. 727–35. | ||
| bExcept for Tis confirmed by biopsy and T4, the extent of the primary tumor is classified by radical orchiectomy, TX may be used for other categories for clinical staging. | ||
| 0 | pTisb, N0, M0, S0 | pTis = Germ cell neoplasia in situ. |
| cN0 = No regional lymph node metastasis. | ||
| pN0 = No regional lymph node metastasis. | ||
| M0 = No distant metastases. | ||
| S0 = Marker study levels within normal limits. | ||
| Stage | TNM/S | Description |
|---|---|---|
| T = primary tumor; N = regional lymph node; M = distant metastasis; AFP = alpha-fetoprotein; cN = clinical regional lymph node; beta-hCG = beta-human chorionic gonadotropin; LDH = lactate dehydrogenase; pT = pathological tumor; S = serum marker. | ||
| aReprinted with permission from AJCC: Testis. In: Brimo F, Srigley J, Ryan C, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp. 727–35. | ||
| bSubclassification of pT1 applies only to pure seminoma. | ||
| cN indicates the upper limit of normal for the LDH assay. | ||
| I | pT1–4, N0, M0, SX | pT1 = Tumor limited to testis (including rete testis invasion) without lymphovascular invasion. |
| –pT1ab = Tumor <3 cm in size. | ||
| –pT1bb = Tumor ≥3 cm in size. | ||
| pT2 = Tumor limited to testis (including rete testis invasion) with lymphovascular invasion OR tumor invading hilar soft tissue or epididymis or penetrating visceral mesothelial layer covering the external surface of tunica albuginea with or without lymphovascular invasion. | ||
| pT3 = Tumor directly invades spermatic cord soft tissue with or without lymphovascular invasion. | ||
| pT4 = Tumor invades scrotum with or without lymphovascular invasion. | ||
| cN0 = No regional lymph node metastasis. | ||
| pN0 = No regional lymph node metastasis. | ||
| M0 = No distant metastases. | ||
| SX = Marker studies not available or not performed. | ||
| IA | pT1, N0, M0, S0 | pT1 = Tumor limited to testis (including rete testis invasion) without lymphovascular invasion. |
| –pT1aa = Tumor <3 cm in size. | ||
| –pT1bb = Tumor ≥3 cm in size. | ||
| cN0 = No regional lymph node metastasis. | ||
| pN0 = No regional lymph node metastasis. | ||
| M0 = No distant metastases. | ||
| S0 = Marker study levels within normal limits. | ||
| IB | pT2, N0, M0, S0 | pT2 = Tumor limited to testis (including rete testis invasion) with lymphovascular invasion OR tumor invading hilar soft tissue or epididymis or penetrating visceral mesothelial layer covering the external surface of tunica albuginea with or without lymphovascular invasion. |
| cN0 = No regional lymph node metastasis. | ||
| pN0 = No regional lymph node metastasis. | ||
| M0 = No distant metastases. | ||
| S0 = Marker study levels within normal limits. | ||
| pT3, N0, M0, S0 | pT3 = Tumor directly invades spermatic cord soft tissue with or without lymphovascular invasion. | |
| cN0 = No regional lymph node metastasis. | ||
| pN0 = No regional lymph node metastasis. | ||
| M0 = No distant metastases. | ||
| S0 = Marker study levels within normal limits. | ||
| pT4, N0, M0, S0 | pT4 = Tumor invades scrotum with or without lymphovascular invasion. | |
| cN0 = No regional lymph node metastasis. | ||
| pN0 = No regional lymph node metastasis. | ||
| M0 = No distant metastases. | ||
| S0 = Marker study levels within normal limits. | ||
| IS | Any pT/TX, N0, M0, S1–3 | pTX = Primary tumor cannot be assessed. |
| pT0 = No evidence of primary tumor. | ||
| pTis = Germ cell neoplasia in situ. | ||
| pT1 = Tumor limited to testis (including rete testis invasion) without lymphovascular invasion. | ||
| –pT1ab = Tumor 3 cm in size. | ||
| –pT1 bb = Tumor ≥3 cm in size. | ||
| pT2 = Tumor limited to testis (including rete testis invasion) with lymphovascular invasion OR tumor invading hilar soft tissue or epididymis or penetrating visceral mesothelial layer covering the external surface of tunica albuginea with or without lymphovascular invasion. | ||
| pT3 = Tumor directly invades spermatic cord soft tissue with or without lymphovascular invasion. | ||
| pT4 = Tumor invades scrotum with or without lymphovascular invasion. | ||
| cN0 = No regional lymph node metastasis. | ||
| pN0 = No regional lymph node metastasis. | ||
| M0 = No distant metastases. | ||
| S1 = LDH < 1.5 × Nc and beta-hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000. | ||
| S2 = LDH 1.5–10 × Nc or beta-hCG (mIU/mL) 5,000–50,000 or AFP (ng/mL) 1,000–10,000. | ||
| S3 = LDH > 10 × Nc or beta-hCG (mIU/mL) >50,000 or AFP (ng/mL) >10,000. | ||
| Stage | TNM/S | Description |
|---|---|---|
| T = primary tumor; N = regional lymph node; M = distant metastasis; AFP = alpha-fetoprotein; cN = clinical regional lymph node; beta-hCG = beta-human chorionic gonadotropin; LDH = lactate dehydrogenase; pN = pathological regional lymph node; pT = pathological tumor; S = serum marker. | ||
| aReprinted with permission from AJCC: Testis. In: Brimo F, Srigley J, Ryan C, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp. 727–35. | ||
| bN indicates the upper limit of normal for the LDH assay. | ||
| II | Any pT/TX, N1–3, M0, SX | Any pT/TX = See descriptions in Table 2, Stage IS. |
| cN1 = Metastases with a lymph node mass ≤2 cm in greatest dimension OR multiple lymph nodes, none >2 cm in greatest dimension. | ||
| cN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension. | ||
| cN3 = Metastasis with a lymph node mass >5 cm in greatest dimension. | ||
| pN1 = Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension. | ||
| pN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor. | ||
| pN3 = Metastasis with a lymph node mass >5 cm in greatest dimension. | ||
| M0 = No distant metastases. | ||
| SX = Marker studies not available or not performed. | ||
| IIA | Any pT/TX, N1, M0, S0 | Any pT/TX = See descriptions in Table 2, Stage IS. |
| cN1 = Metastases with a lymph node mass ≤2 cm in greatest dimension OR multiple lymph nodes, none >2 cm in greatest dimension. | ||
| pN1 = Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension. | ||
| M0 = No distant metastases. | ||
| S0 = Marker study levels within normal limits. | ||
| Any pT/TX, N1, M0, S1 | Any pT/TX = See descriptions in Table 2, Stage IS. | |
| cN1 = Metastases with a lymph node mass ≤2 cm in greatest dimension OR multiple lymph nodes, none >2 cm in greatest dimension. | ||
| pN1 = Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension | ||
| M0 = No distant metastases. | ||
| S1 = LDH < 1.5 × Nb and beta-hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000. | ||
| IIB | Any pT/TX, N2, M0, S0 | Any pT/TX = See descriptions in Table 2, Stage IS. |
| cN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension. | ||
| pN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor. | ||
| M0 = No distant metastases. | ||
| S0 = Marker study levels within normal limits. | ||
| Any pT/TX, N2, M0, S1 | Any pT/TX = See descriptions in Table 2, Stage IS. | |
| cN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension. | ||
| pN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor. | ||
| M0 = No distant metastases. | ||
| S1 = LDH < 1.5 × Nb and beta-hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000. | ||
| IIC | Any pT/TX, N3, M0, S0 | Any pT/TX = See descriptions in Table 2, Stage IS. |
| cN3 = Metastasis with a lymph node mass >5 cm in greatest dimension. | ||
| pN3 = Metastasis with a lymph node mass >5 cm in greatest dimension. | ||
| M0 = No distant metastases. | ||
| S0 = Marker study levels within normal limits. | ||
| Any pT/TX, N3, M0, S1 | Any pT/TX = See descriptions in Table 2, Stage IS. | |
| cN3 = Metastasis with a lymph node mass >5 cm in greatest dimension. | ||
| pN3 = Metastasis with a lymph node mass >5 cm in greatest dimension. | ||
| M0 = No distant metastases. | ||
| S1 = LDH < 1.5 × Nb and beta-hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000. | ||
| Stage | TNM/S | Description |
|---|---|---|
| T = primary tumor; N = regional lymph node; M = distant metastasis; AFP = alpha-fetoprotein; cN = clinical regional lymph node; beta-hCG = beta-human chorionic gonadotropin; LDH = lactate dehydrogenase; pN = pathological regional lymph node; pT = pathological tumor; S = serum marker. | ||
| aReprinted with permission from AJCC: Testis. In: Brimo F, Srigley J, Ryan C, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp. 727–35. | ||
| bN indicates the upper limit of normal for the LDH assay. | ||
| III | Any pT/TX, Any N, M1, SX | Any pT/TX = See descriptions in Table 2, Stage IS. |
| cNX = Regional lymph nodes cannot be assessed. | ||
| cN0 = No regional lymph node metastasis. | ||
| cN1 = Metastases with a lymph node mass ≤2 cm in greatest dimension OR multiple lymph nodes, none >2 cm in greatest dimension. | ||
| cN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension. | ||
| cN3 = Metastasis with a lymph node mass >5 cm in greatest dimension. | ||
| pNX = Regional lymph nodes cannot be assessed. | ||
| pN0 = No regional lymph node metastasis. | ||
| pN1 = Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension. | ||
| pN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor. | ||
| pN3 = Metastasis with a lymph node mass >5 cm in greatest dimension. | ||
| M1 = Distant metastases. | ||
| –M1a = Nonretroperitoneal nodal or pulmonary metastases. | ||
| –M1b = Nonpulmonary visceral metastases. | ||
| SX = Marker studies not available or not performed. | ||
| IIIA | Any pT/TX, Any N, M1a, S0 | Any pT/TX = See descriptions in Table 2, Stage IS. |
| Any N = See descriptions in this table, Stage III. | ||
| M1a = Nonretroperitoneal nodal or pulmonary metastases. | ||
| S0 = Marker study levels within normal limits. | ||
| Any pT/TX, Any N, M1a, S1 | Any pT/TX = See descriptions in Table 2, Stage IS. | |
| Any N = See descriptions in this table, Stage III. | ||
| M1a = Nonretroperitoneal nodal or pulmonary metastases. | ||
| S1 = LDH < 1.5 × Nb and beta-hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000. | ||
| IIIB | Any pT/TX, N1–3, M0, S2 | Any pT/TX = See descriptions in Table 2, Stage IS. |
| cN1 = Metastases with a lymph node mass ≤2 cm in greatest dimension OR multiple lymph nodes, none >2 cm in greatest dimension. | ||
| cN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension. | ||
| cN3 = Metastasis with a lymph node mass >5 cm in greatest dimension. | ||
| pN1 = Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension. | ||
| pN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor. | ||
| pN3 = Metastasis with a lymph node mass >5 cm in greatest dimension. | ||
| M0 = Distant metastases. | ||
| S2 = LDH 1.5–10 × Nb or beta-hCG (mIU/mL) 5,000–50,000 or AFP (ng/mL) 1,000–10,000. | ||
| Any pT/TX, Any N, M1a, S2 | Any pT/TX = See descriptions in Table 2, Stage IS. | |
| Any N = See descriptions in this table, Stage III. | ||
| M1a = Nonretroperitoneal nodal or pulmonary metastases. | ||
| S2 = LDH 1.5–10 × Nb or beta-hCG (mIU/mL) 5,000–50,000 or AFP (ng/mL) 1,000–10,000. | ||
| IIIC | Any pT/TX, N1–3, M0, S3 | Any pT/TX = See descriptions in Table 2, Stage IS. |
| cN1 = Metastases with a lymph node mass ≤2 cm in greatest dimension OR multiple lymph nodes, none >2 cm in greatest dimension. | ||
| cN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension OR multiple lymph nodes, any one mass >2 cm but ≤5 cm in greatest dimension. | ||
| cN3 = Metastasis with a lymph node mass >5 cm in greatest dimension. | ||
| pN1 = Metastasis with a lymph node mass ≤2 cm in greatest dimension and ≤5 nodes positive, none >2 cm in greatest dimension. | ||
| pN2 = Metastasis with a lymph node mass >2 cm but ≤5 cm in greatest dimension; or >5 nodes positive, none >5 cm; or evidence of extranodal extension of tumor. | ||
| pN3 = Metastasis with a lymph node mass >5 cm in greatest dimension. | ||
| M0 = No distant metastases. | ||
| S3 = LDH > 10 × Nb or beta-hCG (mIU/mL) >50,000 or AFP (ng/mL) >10,000. | ||
| Any pT/TX, Any N, M1a, S3 | Any pT/TX = See descriptions in Table 2, Stage IS. | |
| Any N = See descriptions in this table, Stage III. | ||
| M1a = Nonretroperitoneal nodal or pulmonary metastases. | ||
| S3 = LDH > 10 × Nb or beta-hCG (mIU/mL) >50,000 or AFP (ng/mL) >10,000. | ||
| Any pT/TX, Any N, M1b, Any S | Any pT/TX = See descriptions in Table 2, Stage IS. | |
| Any N = See descriptions in this table, Stage III. | ||
| M1b = Nonpulmonary visceral metastases. | ||
| SX = Marker studies not available or not performed. | ||
| S0 = Marker study levels within normal limits. | ||
| S1 = LDH < 1.5 × Nb and beta-hCG (mIU/mL) <5,000 and AFP (ng/mL) <1,000. | ||
| S2 = LDH 1.5–10 × Nb or beta-hCG (mIU/mL) 5,000–50,000 or AFP (ng/mL) 1,000–10,000. | ||
| S3 = LDH > 10 × Nb or beta-hCG (mIU/mL) >50,000 or AFP (ng/mL) >10,000. | ||
In addition to the clinical stage definitions, surgical stage may be designated based on the results of surgical removal and microscopic examination of tissue.
Stage 0
Stage 0 testicular cancer is testicular intraepithelial neoplasia (TIN), also referred to as intratubular germ cell neoplasia (ITGCN). TIN is analogous to carcinoma in situ. In most cases, TIN is diagnosed as a result of an orchiectomy that was performed to remove an invasive germ cell tumor (pT1–T4); generally, TIN has already been removed from the body at the time of diagnosis and requires no treatment. A more challenging situation arises if a biopsy is performed of the contralateral testis and TIN is discovered. Because of the low incidence and low mortality rates associated with contralateral germ cell tumors, such biopsies are performed rarely in the United States. Therefore, TIN is almost never diagnosed in testicles that do not also have an invasive tumor. Consequently, a treatment decision about TIN in stage 0 testicular cancer is rarely faced in the United States. Treatment options for ITGCN include radiation therapy, surveillance, and orchiectomy.
Stage I
Stage I testicular cancer is limited to the testis. Invasion of the scrotal wall by tumor or interruption of the scrotal wall by previous surgery does not change the stage but does increase the risk of spread to the inguinal lymph nodes, and this must be considered in treatment and follow-up. Invasion of the epididymis tunica albuginea and/or the rete testis does not change the stage. Invasion of the tunica vaginalis or lymphovascular invasion signifies a T2 tumor, while invasion of the spermatic cord signifies a T3 tumor, and invasion of the scrotum signifies a T4. Increases in T stage are associated with increased risk of occult metastatic disease and recurrence. Men with stage I disease who have persistently elevated serum tumor markers after orchiectomy are staged as IS, but stage IS nonseminomas are treated as stage III. Elevated serum tumor markers in stage I or II seminoma are of unclear significance except that a persistently elevated or rising beta-hCG usually indicates metastatic disease.
Stage II
Stage II testicular cancer involves the testis and the retroperitoneal or periaortic lymph nodes usually in the region of the kidney. Retroperitoneal involvement should be further characterized by the number of nodes involved and the size of involved nodes. The risk of recurrence is increased if more than five nodes are involved or if the size of one or more involved nodes is more than 2 cm. Bulky stage II disease (stage IIC) describes patients with extensive retroperitoneal nodes (>5 cm), which portends a less favorable prognosis.
Stage III
Stage III disease has spread beyond the retroperitoneal nodes based on physical examination, imaging studies, and/or blood tests (i.e., patients with retroperitoneal adenopathy and highly elevated serum tumor markers are stage III). Stage III can be further stratified based on the location of metastasis and the degree of elevation of serum tumor markers. In the favorable group (IIIA), metastases are limited to lymph nodes and lung, and serum tumor markers are no more than mildly elevated. Stage IIIB patients have moderately elevated tumor markers, while stage IIIC patients have highly elevated markers and/or metastases to liver, bone, brain, or some organ other than the lungs. These subclassifications of stage III correspond to the International Germ Cell Consensus Classification system for disseminated germ cell tumors.[2]
Testicular cancer is broadly divided into seminomas and nonseminomas for treatment planning. Seminomatous types of testicular cancer are more sensitive to radiation therapy and chemotherapy and are less prone to distant metastases than nonseminomatous types. Nonseminomas may include teratomatous elements, which tend to be resistant to chemotherapy and often require surgery for cure. By definition, pure seminomas do not contain elements of teratoma. Therefore, surgery plays a larger role in the management of nonseminomas than in the management of seminomas. Nonseminomatous testicular tumors include the following:
An international germ cell tumor prognostic classification has been developed based on a retrospective analysis of 5,202 patients with metastatic nonseminomatous and 660 patients with metastatic seminomatous germ cell tumors.[1] All patients received treatment with cisplatin- or carboplatin-containing therapy as their first chemotherapy course. The prognostic classification, shown below, was agreed on in 1997 by all major clinical trial groups worldwide. It is used for reporting clinical trial results of patients with germ cell tumors.
A meta-analysis of treatment outcomes for patients with advanced nonseminoma suggested that 5-year survival rates have improved for those patients with a poor prognosis during the period of 1989 to 2004.[2] In addition to improved therapy, the improvement in survival rates could be the result of publication bias, changes in patient selection in reported clinical trials, or more sensitive staging methods that could migrate less-advanced stages to more-advanced stage categories (i.e., stage migration).
Nonseminoma:
Seminoma:
Nonseminoma:
Seminoma:
Nonseminoma:
Seminoma:
Among men diagnosed with an invasive testicular germ cell tumor (stages I–III), 0.5% to 1.0% will present with tumors in both testes, and another 1% to 2% will develop a subsequent invasive germ cell tumor in the contralateral testis.[1-3] Death from metachronous contralateral germ cell tumors is rare. One study of 29,515 U.S. men with testicular germ cell tumors who were diagnosed between 1973 and 2001 reported that 287 men developed a metachronous contralateral testis cancer, one of whom died.[3] As a result, there is limited rationale for performing biopsies to search for testicular intraepithelial neoplasia (TIN) in men diagnosed with invasive testicular cancer.
If biopsies of the contralateral testis are performed in men with testicular cancer, 4% to 8% of men will be found to have contralateral TIN. The treatment is typically radiation therapy (18 Gy–20 Gy), surveillance, or orchiectomy. Men undergoing radiation therapy or orchiectomy will subsequently be sterile. Men undergoing orchiectomy will also be hypogonadal as will many men undergoing radiation therapy.[4]
Treatment options:
Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.
Patients with stage I seminomas have a cure rate that approaches 100%, regardless of whether postorchiectomy adjuvant therapy is given.
Treatment options:
Results of multiple clinical series, including more than 1,200 patients with stage I seminoma managed by postorchiectomy surveillance, have been reported.[2-9] The overall 10-year tumor recurrence rate is 15% to 20%, and nearly all patients whose disease recurred were cured by radiation therapy or chemotherapy. Thus, the overall cure rate is indistinguishable from that achieved with adjuvant radiation therapy or carboplatin chemotherapy. Relapses after 5 years are unusual but can occur in as many as 4% of patients.[6] Independent risk factors for relapse include tumor size greater than 4 cm and invasion of the rete testis.[2] The 5-year risk of relapse is about 10% without either risk factor, 16% with one risk factor, and 32% with both risk factors.
Treatment options when surveillance is not chosen:
The surveillance-after-orchiectomy treatment option is associated with a cure rate that approaches 100%. Relapses requiring additional therapy occur in about 15% of patients who are treated with the surveillance treatment option. The surveillance strategy avoids the need for radiation or chemotherapy in most patients. However, some patients are uncomfortable with surveillance only and wish to minimize the risk of relapse. For such patients, one of the following options may be used; however, there is controversy about which strategy is preferred:[10]
One of the following two treatment fields is typically used: a para-aortic strip covering the retroperitoneal nodes or a dog-leg field that includes the ipsilateral iliac lymph nodes as well as the retroperitoneum. The dose ranges from 20 Gy to 26 Gy. Relapse rates and toxic effects were studied in a randomized comparison (MRC-TE10) of para-aortic radiation therapy alone versus para-aortic radiation therapy with an added ipsilateral iliac lymph node field.[13,18] The 5-year RFS rates were virtually identical (96.1% for patients who were treated with the para-aortic strip vs. 96.2% for patients who were treated by a dog-leg field) as were overall survival (OS) rates (one death from seminoma occurred in the para-aortic radiation therapy arm). Pelvic RFS rates were 98.2% versus 100%; the 95% confidence interval (CI) for the difference in pelvic RFS rates was 0% to 3.7%. A statistically significant increase was observed in leukopenia and diarrhea associated with the ipsilateral iliac radiation therapy.
In a randomized trial (MRC-TE18), a radiation dose of 20 Gy over 10 daily fractions was clinically equivalent to 30 Gy over 15 fractions after a median follow-up of 7 years in both RFS and OS. Patients reported that lethargy and their ability to perform normal work were better in the lower-dose regimen.[14,18][Level of evidence A1]
Radiation therapy for clinical stage I testicular seminoma is no longer favored because of evidence that this treatment is associated with an increased risk of secondary malignancies and an increased risk of death from secondary malignancies. An analysis of data from the population-based Surveillance, Epidemiology, and End Results (SEER) Program registries in the United States between the years 1973 and 2001 indicated that among 7,179 men receiving radiation therapy for stage I seminoma, 246 had an increased risk of death from secondary cancers compared with the general population (standardized mortality ratio, 1.89; 95% CI, 1.67–2.14).[19] An international study of more than 40,000 testicular cancer survivors reported that among the 7,885 survivors who had been followed for 20 to 29 years, radiation therapy was associated with a doubling of the risk of secondary cancers (relative risk, 2.0; 95% CI, 1.8–2.3).[20]
In a large, randomized, controlled, noninferiority trial (MRC-TE19 [NCT00003014]), 1,477 men with stage I seminomas were assigned to undergo para-aortic (or dog-leg field, if clinically indicated) radiation therapy or to receive a single dose of carboplatin (concentration-versus-time or area-under-the-curve [AUC] × 7) after radical inguinal orchiectomy study participants were followed up for a median of 6.5 years.[18,21] The RFS rate at 5 years was 94.7% in the carboplatin arm and 96.0% in the radiation therapy arm (1.3% difference; 90% CI, 0.7%–3.5%; hazard ratio [HR], 1.25 [nonsignificant trend in favor of radiation therapy]; 90% CI, 0.83–1.89). The one death from seminoma occurred in the radiation therapy arm. There was a reduced number of contralateral testicular germ cell tumors in the carboplatin arm: 2 versus 15 (HR, 0.22; 95% CI, 0.05–0.95; P = .03).[21][Level of evidence A1] In this trial, AUC dosing was based on radioisotope measurement of glomerular filtration rate; dosing based on calculations of creatinine clearance is not equivalent, has not been validated in this setting, and is discouraged.
Phase II studies, including several with more than 4 years median follow-up, have consistently reported lower relapse rates (0%–3.3%) when two doses of carboplatin were administered either 3 or 4 weeks apart and dosed either at 400 mg/m2 or at an AUC of 7.[3,4,22-26] Administration of two doses of carboplatin has never been compared with a single dose nor with radiation therapy in a randomized trial.
Stage I nonseminoma is highly curable (>99%). Orchiectomy alone will cure about 70% of patients, but the remaining 30% will relapse and require additional treatment. The relapses are highly curable, and postorchiectomy surveillance is a standard treatment option, but some physicians and patients prefer to reduce the risk of relapse by having the patient undergo either a retroperitoneal lymph node dissection (RPLND) or one or two cycles of chemotherapy. Each of these three approaches has unique advantages and disadvantages, and none has been shown to result in longer survival or superior quality of life.
Treatment options:
Typically, patients are seen monthly during the first year, every 2 months during the second year, every 3 months during the third year, every 4 months during the fourth year, every 6 months during the fifth year, and annually for the subsequent 5 years.[27-29] At each visit, the history is reviewed, a physical examination is given, determination of serum markers are performed, and a chest x-ray is obtained (sometimes at alternating visits). An additional key aspect of surveillance involves abdominal or abdominopelvic CT scans, but the preferred frequency of such scans is controversial.
A randomized controlled trial (MRC-TE08 [NCT00003420]) compared a schedule that used only two scans at 3 months and 12 months with a schedule that used five scans at 3, 6, 9, 12, and 24 months.[30] With over 400 randomly assigned patients and a median follow-up of 40 months, all relapsing patients had either good- or intermediate-risk disease, and there were no differences in the stage or extent of disease at relapse between the two arms. No deaths were reported. Nonetheless, some organizations recommend CT scans every 3 to 4 months during the first 3 years of follow-up and continuing but less-frequent CT scans thereafter. While this study would appear to indicate that scans at 3 and 12 months are adequate during the first year, longer follow-up will be needed to assess whether discontinuing scans after 12 months is safe.[30][Level of evidence A1] With regard to chest imaging, disease recurrence is rarely detected by chest x-ray alone, so chest x-ray may play little or no role in routine surveillance but is nonetheless included in the mainstream surveillance schedules.[27]
The need for long-term follow-up has not been adequately investigated. Surveillance series with long follow-up times have reported that fewer than 1% of clinical stage I patients relapse after 5 years.[31,32] Late relapses often occur in the retroperitoneum when they do occur. Therefore, some schedules discontinue CT scans after 12 months, while others recommend at least annual scans for 10 years.
The option of a radical inguinal orchiectomy followed by a regular and frequent surveillance schedule should be considered only if:
A nerve-sparing RPLND that preserves ejaculation in virtually every patient has been described in clinical stage I patients and appears to be as effective as the standard RPLND.[34-36] Surgery should be followed by monthly determination of serum markers and chest x-rays for the first year and every-other-month determinations for the second year.[27]
Men undergoing RPLND, who are found to have pathological stage I disease, have a roughly 10% risk of relapsing subsequently, whereas men with pathological stage II disease (i.e., those who are found to have lymph node metastases at RPLND) have as much as a 50% risk of relapse without further treatment.[37] Two cycles of post-RPLND chemotherapy using either bleomycin, etoposide, and cisplatin (BEP) or etoposide plus cisplatin (EP) lowers the risk of relapse in men with pathological stage II disease to about 1%.[38,39] Most patients in studies of RPLND underwent the operation at a center of excellence with a urological surgeon who had performed hundreds of such operations. The ability of less-experienced urologists to achieve similar results is unknown.
In patients with pathological stage I disease after RPLND, the presence of lymphatic or venous invasion or a predominance of embryonal carcinoma in the primary tumor appears to predict for relapse.[40-42] In a large, Testicular Cancer Intergroup Study, the relapse rate among men with pathological stage I disease was 19% in those with vascular invasion versus 6% in those without vascular invasion. One study reported that the relapse rate for men with pathological stage I disease was 21.2% (18 of 85 men relapsed), if their tumors were predominantly embryonal carcinoma and 29% if there was a predominance of embryonal carcinoma plus lymphovascular invasion versus 3% (5 of 141 men relapsed), if there was not a predominance of embryonal carcinoma.[40,41]
Among pathological stage II patients, the relapse rate was 32% among men with embryonal carcinoma-predominant tumors compared with 15.6% in the other stage II patients. The risk of metastatic disease (i.e., either pathological stage II disease or relapsed pathological stage I disease) in men with tumors showing a predominance of embryonal carcinoma plus lymphovascular invasion was 62% compared with 16% in men with neither risk factor.
These data have shown that high-risk patients undergoing RPLND have a substantial risk of subsequently receiving chemotherapy. Data from one institution have shown that about one-half of men with stage I pure embryonal carcinoma undergoing RPLND will subsequently receive cisplatin-based chemotherapy.[43]
Retroperitoneal dissection of lymph nodes is not helpful in the management of children, and potential morbidity of the surgery is not justified by the information obtained.[33] In men who have undergone RPLND, chemotherapy is employed immediately on first evidence of recurrence.
A randomized controlled trial compared a single cycle of BEP chemotherapy with RPLND in 382 patients. The 2-year recurrence-free survival rates were 99.5% with chemotherapy versus 91.9% with RPLND (absolute difference, 7.6%; 95% CI, 3.1%–12.1%). There were no treatment-related or cancer-specific deaths in either arm of the study.[44]
A Swedish and Norwegian study reported results of a risk-adapted therapy protocol in which patients with nonseminomas with lymphovascular invasion underwent postorchiectomy chemotherapy with one or two cycles of BEP chemotherapy, while those without lymphovascular invasion underwent either surveillance or a single cycle of BEP.[45] The study included 745 patients and, with a median follow-up of 4.7 years and 2-year follow-up of 89% of patients, there were no deaths from testicular cancer, although one patient died of a stroke immediately after completing chemotherapy for relapsed disease. OS was 98.9% and cause-specific survival was 99.9%. Both of these studies were conducted at community-based hospitals and demonstrated that postorchiectomy chemotherapy could be delivered at a regional or national level without depending on centers of excellence.
Several phase II studies and case series reporting results after two cycles of BEP in patients with intermediate- or high-risk disease have identified relapse rates ranging from 0% to 4% (average, 2.4%).[46] Less than 1% of patients in these series died of testicular cancer. When compared with RPLND or surveillance, chemotherapy produces the lower relapse rate and a comparable disease-specific survival rate. However, it is unknown whether a brief course of chemotherapy results in late toxic effects or an increased risk of late relapse. Longer follow-up is awaited.
There is no consensus about the optimal management of men with stage I nonseminomas, but each of the three strategies above produces a disease-specific survival rate of about 99%. Some clinicians have advocated a risk-adapted approach such that patients with low-risk disease undergo surveillance, while others undergo either RPLND or chemotherapy. The goal of this approach is to minimize the side effects of treatment, but risk-adapted therapy has never been demonstrated to result in better outcomes. Some experts prefer a surveillance strategy generally so as to minimize unnecessary treatment. Others prefer RPLND to obtain more accurate staging, to reduce the risk of needing chemotherapy (and, therefore, chemotherapy's side effects and toxicity) and to, theoretically, reduce the risk of late relapse. At the same time, many experts reject RPLND as insufficiently effective at lowering relapse rates and prefer chemotherapy. Surveillance and chemotherapy have been tested at the regional and national level with excellent results, however, the limited data concerning RPLND in patients with regional disease have shown higher than expected in-field relapse rates but no deaths.[44,45]
With regard to risk stratification, data suggest that relapse rates are higher in patients with histological evidence of lymphatic or venous invasion or a predominance of embryonal carcinoma.[12,31,40,41,47] Tumors that consist of mature teratoma appear to have a lower relapse rate.[48]
Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.
Stage II seminoma is divided into bulky and nonbulky disease for treatment planning and expression of prognosis. Bulky disease is generally defined as tumors larger than 5 cm on a computed tomography (CT) scan (i.e., stage IIC disease). Nonbulky disease can be further subdivided into stage IIA, meaning no lymph node mass larger than 2 cm, and stage IIB, meaning a lymph node mass between 2 cm and 5 cm.
Nonbulky stage II disease has a cure rate of about 90% to 95% with radiation therapy alone at doses of 30 Gy to 36 Gy.[1-4] Most patients with relapsed disease can be cured with chemotherapy. Cure rates are slightly higher for patients with stage IIA disease than for those with IIB disease, but the figures are within the range given above. Risk factors for relapse include multiple enlarged nodes.
Results for patients with stage IIC disease have been less favorable. For example, one institution reported that among patients with stage IIC disease, 9 of 16 (56%) had a relapse following radiation therapy, compared with only 1 of 23 patients (4%) treated with chemotherapy.[3] A pooled analysis of earlier studies reported a 65% relapse-free survival (RFS) rate for men receiving radiation therapy for bulky stage II seminoma.[5] Unfortunately, only sparse contemporary data are available on the use of radiation therapy to treat bulky stage II seminomas, and there are no randomized trials comparing radiation therapy with chemotherapy in this population. Combination chemotherapy with cisplatin is effective therapy in patients with bulky stage II seminomas and has become the most widely accepted treatment option.[6,7]
Residual radiological abnormalities are common at the completion of chemotherapy. Many abnormalities gradually regress during a period of months. Some clinicians advocate empiric attempts to resect residual masses 3 cm or larger, while others advocate close surveillance, with intervention only if the residual mass increases in size. Postchemotherapy radiation therapy is no longer favored, in part because of a retrospective study of a consecutive series of 174 patients with seminoma and postchemotherapy residual disease seen at ten treatment centers. The study reported that empiric radiation was not associated with any medically significant improvement in progression-free survival after completion of platinum-based combination chemotherapy.[4][Level of evidence C2]
In some series, surgical resection of specific masses has yielded a significant number of patients with residual seminoma who require additional therapy.[5] Nevertheless, other reports indicate that the size of the residual mass does not correlate well with active residual disease, most residual masses do not grow, and frequent marker and CT scan evaluation is a viable option even when the residual mass is 3 cm or larger.[6]
A more recent approach has been to obtain a fluorine F 18-fludeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) scan following chemotherapy. A study of 56 patients reported that positron emission tomography (PET) scans correctly identified eight of ten patients with residual seminoma with no false positives among the 46 patients with benign masses.[8] In this study, PET scans were 100% accurate in patients with residual masses greater than 3 cm in greatest diameter whereas residual malignant masses less than 3 cm were only detected in one of three men. This study provides support for observing men with residual 18F-FDG PET-negative masses greater than 3 cm and for performing a biopsy or resection of any 18F-FDG PET-positive mass.
Treatment options for patients with nonbulky tumors:
Treatment options for patients with bulky tumors:
Stage II nonseminoma is highly curable (>95%). Men with stage II disease and persistently elevated serum tumor markers are generally treated as having stage III disease and receive chemotherapy. For men with normal markers after orchiectomy, nonseminomas are divided into stages IIA, IIB, and IIC for treatment purposes. In general, stage IIA patients undergo RPLND to confirm the staging. As many as 40% of clinical stage IIA patients will have benign findings at RPLND and will be restaged as having pathological stage I disease.[13] RPLND can thus prevent a significant number of patients with clinical stage IIA disease from receiving unnecessary chemotherapy.
In contrast, patients with stage IIB and IIC nonseminoma are usually treated with systemic chemotherapy for disseminated disease because these patients have a higher relapse rate after RPLND. One study reported that by limiting RPLND to patients with earlier stage II disease and normal serum tumor markers, 5-year RFS rates increased from 78% to 100% after RPLND, while RFS did not change significantly among stage II patients receiving chemotherapy (100% vs. 98%).[14] However, the question of whether to treat patients with stage II nonseminoma germ cell tumors with RPLND or chemotherapy has never been subjected to a randomized trial.
Treatment options:
This option of surgery and careful follow-up, reserving chemotherapy for relapse, is particularly attractive for patients who have pathological stage I or IIA disease (fewer than six positive nodes at RPLND, none of which are larger than 2 cm in diameter). Such patients appear to have a relapse rate of about 10% if followed without chemotherapy, and most are curable with standard chemotherapy if their disease relapses.[13,15] Presence of lymphatic or venous invasion and the proportion of the primary tumor that is embryonal carcinoma also help to predict which patients may have disease relapse.[16-18] In one study, the relapse rate in men with pathological stage I disease was 3% in men with nonembryonal carcinoma-predominant tumors, 21% in men with embryonal carcinoma-predominant tumors, and 31% in those with embryonal carcinoma-predominant tumors and lymphovascular invasion.[17,18] In children, surgical resection of retroperitoneal nodes is generally not performed. Patients with clinical stage II disease are given chemotherapy.[19]
This option of RPLND plus adjuvant chemotherapy applies to patients who have pathologically confirmed lymph node metastases as a result of RPLND and is most attractive for patients with pathological stage IIB or IIC disease. The results of a large study comparing the first treatment option with the second treatment option were published.[20] Two courses of cisplatin-based chemotherapy (either cisplatin, vinblastine, bleomycin [PVB] or vinblastine, dactinomycin, bleomycin, cyclophosphamide, cisplatin [VAB VI]) prevented a relapse in more than 95% of patients. A 49% relapse rate was seen in patients assigned to observation; however, most of these patients could be effectively treated, and no significant differences were found in overall survival. The study concluded that adjuvant therapy will most often prevent relapse in patients treated with optimal surgery, follow-up, and chemotherapy. However, observation with chemotherapy only for relapse will lead to a similar cure rate.
This option is useful for patients with elevated serum tumor markers and/or clinical stage IIB or IIC disease. The combination of chemotherapy plus resection of residual masses in these patients results in cure in more than 95% of patients.[14,21]
Chemotherapy regimens include:
A randomized study has shown that bleomycin is an essential component of the BEP regimen when only three courses are administered.[25]
Other regimens that appear to produce similar survival outcomes but are no longer considered standard include:
In a randomized comparison of PVB versus BEP, equivalent anticancer activity was seen but with less toxic effects with the use of BEP.[20,28]
If these patients do not achieve a complete response with chemotherapy, surgical removal of residual masses should be performed. The timing of such surgery requires clinical judgment but would occur most often after three or four cycles of combination chemotherapy and normalization or stabilization of serum markers. The presence of persistently elevated markers is not a contraindication to resection of residual masses, but patients with rising markers at the end of chemotherapy are generally treated with salvage chemotherapy. Despite numerous studies, no sufficiently accurate predictors of the histology of residual masses have been validated. Therefore, the standard of care is to resect all residual masses apparent on scans in patients who have normal or stable markers after responding to chemotherapy. The presence of persistent nonseminomatous germ-cell malignant elements in the resected specimen is a poor prognostic sign and is often a trigger for additional chemotherapy. However, men with only microscopic residual cancer have a much more favorable prognosis than men with more substantial residual disease.[29,30] Identifying the patients who benefit from additional chemotherapy is not possible from existing data.
In some cases, chemotherapy is initiated before orchiectomy because of life-threatening metastatic disease. When this is done, orchiectomy after initiation or completion of chemotherapy is advisable to remove the primary tumor. There is a higher incidence (approximately 50%) of residual cancer in the testicle than in remaining radiographically detectable retroperitoneal masses after platinum-based chemotherapy.[31]
Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.
Stage III seminoma and nonseminomas are usually curable but have different criteria for estimating prognosis.
Patients with disseminated seminomas can be divided into good-risk and intermediate-risk groups based on whether nonpulmonary visceral metastases are present. Patients with good-risk disease (i.e., those with metastases only to lymph nodes and/or lungs) have 5-year progression-free survival (PFS) and overall survival (OS) rates of 82% and 86%, respectively. Patients with intermediate-risk seminoma have 5-year PFS and OS rates of 67% and 72%, respectively.[1]
Patients with disseminated nonseminomas can be divided into good-, intermediate-, and poor-risk groups based on whether nonpulmonary visceral metastases are present, the site of the primary tumor (i.e., mediastinal vs. either gonadal or retroperitoneal), and the level of serum tumor markers.[1]
In the 1997 analysis that established these risk groups, the 5-year OS rates were 92%, 80% and 48% in the good-, intermediate-, and poor-risk groups, respectively. The PFS rates were 89%, 75% and 41% in the good-, intermediate-, and poor-risk groups, respectively. However, a 2006 pooled analysis of chemotherapy trials reported improved outcomes compared with the 1997 paper: survival rates in the good-, intermediate-, and poor-risk groups were 94%, 83%, and 71%, respectively.[2]
Four cycles of bleomycin, etoposide, and cisplatin (BEP) chemotherapy as a standard-of-care treatment option for patients with metastatic testicular germ cell tumors was established by a randomized trial showing that it produced similar outcomes with fewer toxic effects in comparison with cisplatin, vinblastine, and bleomycin (PVB).[3] Two randomized trials comparing four courses of BEP with four courses of etoposide plus ifosfamide plus cisplatin (VIP) showed similar OS and time-to-treatment failure for the two regimens in patients with intermediate- and poor-risk advanced disseminated germ cell tumors who had not received prior chemotherapy.[4-6][Level of evidence A1] Hematologic toxic effects were substantially worse with the VIP regimen. For good-risk patients, two randomized trials compared three versus four cycles of BEP and reported no significant benefit from longer treatment in that population.[7-9]
Numerous attempts have been made to develop a regimen superior to BEP for men with poor-prognosis germ cell tumors but none have been successful. Most recently, four cycles of BEP was compared with two cycles of BEP followed by two cycles of high-dose cyclophosphamide, etoposide, and carboplatin, but there was no difference in survival between the two arms.[10] Earlier trials of higher dose cisplatin or long-term maintenance chemotherapy were similarly disappointing.
For patients with good-risk disease, the goal of clinical trials has been to minimize the toxic effects of treatment without sacrificing the therapeutic effectiveness. As noted above, no difference in outcome was seen when comparing three versus four cycles of BEP chemotherapy. However, attempts to eliminate bleomycin produced more ambiguous and usually disappointing results. A randomized controlled trial comparing three cycles of BEP with three cycles of etoposide and cisplatin (EP) reported lower OS rates (95% vs. 86%, P = .01) in the EP arm.[11] Similarly, when three cycles of BEP was compared with four cycles of EP in a randomized trial in more than 260 patients, there were 6 relapses and 5 deaths in the bleomycin arm compared with 14 relapses and 12 deaths in the EP arm, but these differences were not statistically significant.[12] Several other studies have compared bleomycin-containing regimens to etoposide and cisplatin and in every trial, the trend in survival has favored the bleomycin arm, but the differences have not usually been statistically significant.[13-15] These results have led to some controversy as to whether three cycles of BEP is superior to four cycles of EP.
In most patients, an orchiectomy is performed before starting chemotherapy. If the diagnosis has been made by biopsy of a metastatic site (or on the basis of highly elevated serum tumor markers and radiological imaging consistent with an advanced-stage germ cell tumor) and chemotherapy has been initiated, subsequent orchiectomy is generally performed because chemotherapy may not eradicate the primary tumor. Case reports illustrate that viable tumor has been found on postchemotherapy orchiectomy despite complete response of metastatic lesions.[16]
Some retrospective data suggest that the experience of the treating institution may impact the outcome of patients with stage III nonseminoma. Data from 380 patients treated from 1990 to 1994 on the same study protocol at 49 institutions in the European Organisation for Research and Treatment of Cancer and the Medical Research Council were analyzed.[17] Overall, the 2-year survival rate for the 55 patients treated at institutions that entered fewer than five patients onto the protocol was 62% (95% confidence interval [CI], 48%–75%) versus 77% (95% CI, 72%–81%) in the institutions that entered five or more patients onto the protocol.
Similarly, a population-based study of testis cancer in Japan in the 1990s reported a significant association between survival and the number of testis cancer patients treated. The relative 5-year survival rate was 98.8% at high-volume hospitals compared with 79.7% at low-volume hospitals. After adjusting for stage and age, the hazard ratio for death in a high-volume hospital was 0.11 (95% CI, 0.025–0.495).[18] Several other studies have reported similar findings.[19-21] As in any nonrandomized study design, patient selection factors and factors leading patients to choose treatment at one center versus another can make interpretation of these results difficult.
Many patients with poor-risk, nonseminomatous testicular germ cell tumors who have a serum beta-human chorionic gonadotropin (beta-hCG) level higher than 50,000 IU/mL at the initiation of cisplatin-based therapy (BEP or PVB) will still have an elevated beta-hCG level at the completion of therapy, showing an initial rapid decrease in beta-hCG followed by a plateau.[22] In the absence of other signs of progressing disease, monthly evaluation with initiation of salvage therapy, if and when there is serologic progression, may be appropriate. Many patients, however, will remain disease free without further therapy.[22][Level of evidence C3]
Residual radiological abnormalities are common at the completion of chemotherapy. Such masses are not treated unless they grow or are histopathologically shown to contain viable cancer. In a combined retrospective consecutive series of 174 seminoma patients with postchemotherapy residual disease seen at ten treatment centers, empiric radiation was not associated with any medically significant improvement in PFS after completion of platinum-based combination chemotherapy.[23][Level of evidence C2] In some series, surgical resection of specific masses has yielded a significant number of patients with residual seminoma that require additional therapy.[24] Larger masses are more likely to harbor viable cancer, but there is no size criteria with high sensitivity and specificity. Fluorine F 18-fludeoxyglucose-positron emission tomography (18F-FDG PET) scans have been shown to be helpful in identifying patients who harbor viable cancers, but the false-positive rate is substantial in some series.[25-27] The strength of positron emission tomography (PET) scans in residual seminoma masses is that they have a very high sensitivity and a low false-negative rate. Thus, for men with residual masses for whom resection is being planned, a negative PET scan provides evidence that surgery is not necessary.
Although larger residual masses are more likely to harbor viable seminoma, the size of the residual mass is of limited prognostic value.[24-26] Most residual masses do not grow, and regular marker and computed tomography (CT) scan evaluation is a viable management option for large or small masses.[28] An alternative approach is to operate on larger masses, to resect them when possible, and to perform biopsies of unresectable masses. Postchemotherapy masses are often difficult or impossible to resect because of a dense desmoplastic reaction. Historically, such surgery has been characterized by a high rate of complications or additional procedures such as nephrectomy or arterial or venous grafting.[29]
Residual masses following chemotherapy in men with nonseminomatous germ cell tumors often contain viable cancer or teratoma, and the standard of care is to resect all such masses when possible. However, there are no randomized controlled trials evaluating this issue. Instead, the practice is based on the fact that viable neoplasm is often found at surgery in these patients, and the presumption is that such tumors would progress if not resected. If serum tumor markers are rising, salvage chemotherapy is usually given, but stable or slowly declining tumor markers are not a contraindication to resection of residual masses.
Case series of men undergoing postchemotherapy resections have reported that roughly 10% will have viable germ cell cancer, 45% will have teratomas, and 45% will have no viable tumors.[30] Numerous attempts have been made to identify the patients who need surgery and the patients who can be safely observed. Variables predictive of finding only necrosis or fibrosis at surgery include the following:[31]
However, only a small proportion of men have favorable enough features to have less than a 10% chance of having viable neoplasm in their residual masses, and thus the utility of current models has been questioned.[24,32]
When multiple sites of residual disease are present, all residual masses are generally resected. If it is not surgically feasible, resection is generally not performed. Some patients may have discordant pathological findings (e.g., fibrosis/necrosis, teratoma, or carcinoma) in residual masses in the abdomen versus the chest. Some medical centers perform simultaneous retroperitoneal and thoracic operations to remove residual masses,[28,33] but most do not. Although the agreement among the histologies of residual masses found after chemotherapy above the diaphragm versus those found below the diaphragm is only moderate (kappa statistic, 0.42), some evidence exists that if retroperitoneal resection is performed first, results can be used to guide decisions about whether to perform a thoracotomy.[34]
In a multi-institutional case series of surgery to remove postchemotherapy residual masses in 159 patients, necrosis only was found at thoracotomy in about 90% of patients who had necrosis only in their retroperitoneal masses. The figure was about 95% if the original testicular primary tumor had contained no teratomatous elements. Conversely, the histology of residual masses at thoracotomy did not predict nearly as well the histology of retroperitoneal masses.[34] Nonetheless, some centers continue to support resection of all residual masses, even if necrosis is found in the retroperitoneum.[35]
The presence of persistent malignant elements in the resected specimen is considered by some clinicians to be an indication for additional chemotherapy.[36] However, there are no prospective trials investigating the benefit of such treatment. In some cases, chemotherapy is initiated before the orchiectomy because of life-threatening metastatic disease. When this is done, orchiectomy after initiation or completion of chemotherapy is advisable to remove the primary tumor. A physiological blood-testis barrier seems to appear, and there is a higher incidence (approximately 50%) of residual cancer in the testicle than in remaining radiographically detectable retroperitoneal masses after platinum-based chemotherapy.[16] Some investigators have suggested that in children, 90% of whom have yolk sac tumors, radiation therapy should be given to residual masses after chemotherapy rather than surgery.[37]
Treatment options for initial treatment for nonseminoma patients with good-risk disease:
Chemotherapy combinations include:
Treatment options for initial treatment for nonseminoma patients with intermediate- and poor-risk disease:
Management of residual masses following chemotherapy for patients with seminoma
Management of residual masses following chemotherapy for patients with nonseminoma
Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.
Deciding on further treatment depends on many factors, including the specific cancer, previous treatment, site of recurrence, and individual patient considerations. Salvage regimens consisting of ifosfamide, cisplatin, and either etoposide or vinblastine can induce long-term complete responses in about 25% of patients with disease that has persisted or recurred following other cisplatin-based regimens. Patients who have had an initial complete response to first-line chemotherapy and those without extensive disease have the most favorable outcomes.[1,2] This regimen is now the standard initial salvage regimen.[2,3] Few, if any, patients with recurrent nonseminomatous germ cell tumors of extragonadal origin, however, achieve long-term disease-free survival (DFS) using vinblastine, ifosfamide, and cisplatin if their disease recurred after they received an initial regimen containing etoposide and cisplatin.[2][Level of evidence C2]
High-dose chemotherapy with autologous marrow transplant has also been used in uncontrolled case series in patients with recurrent disease.[4-11] However, a randomized controlled trial comparing conventional doses of salvage chemotherapy with high-dose chemotherapy with autologous marrow rescue showed more toxic effects and treatment-related deaths in the high-dose arm without any improvement in response rate or overall survival.[12][Level of evidence A1] In some highly selected patients with chemorefractory disease confined to a single site, surgical resection may yield long-term DFS.[13,14] One case series suggested that a maintenance regimen of daily oral etoposide (taken 21 days out of 28 days) may benefit patients who achieve a complete remission after salvage therapy.[15]
A special case of late relapse may include patients who relapse more than 2 years after achieving complete remission; this population represents less than 5% of patients who are in complete remission after 2 years. Results with chemotherapy are poor in this patient subset, and surgical treatment appears to be superior, if technically feasible.[16] Teratoma may be amenable to surgery at relapse, and teratoma also has a better prognosis than carcinoma after late relapse. Teratoma is a relatively resistant histological subtype, so chemotherapy may not be appropriate.
Clinical trials are appropriate and should be considered whenever possible, including phase I and phase II studies for those patients who do not achieve a complete remission with induction therapy, or for those who do not achieve a complete remission following etoposide and cisplatin for their initial relapse, or for patients who have a second relapse.[17]
Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
General Information About Testicular Cancer
Updated statistics with estimated new cases and deaths for 2024 (cited American Cancer Society as reference 1).
This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® Cancer Information for Health Professionals pages.
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of testicular cancer. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.
This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Testicular Cancer Treatment are:
Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary].”
The preferred citation for this PDQ summary is:
PDQ® Adult Treatment Editorial Board. PDQ Testicular Cancer Treatment. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/types/testicular/hp/testicular-treatment-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389220]
Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.
Based on the strength of the available evidence, treatment options may be described as either “standard” or “under clinical evaluation.” These classifications should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.
More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website’s Email Us.