Treatment
Surgery – orchidectomy
The first step is nearly always to remove the affected testicle and this needs to be done to stage the cancer before further treatment is planned. The operation is always carried out within a few days. It is done through a small cut in the groin. Prosthesis (silicone testicle-shaped implant) may be put in the scrotum at the same time or this can be done later. Physical recovery takes about a week.
Long term side effects from the surgery are rare if the other testicle is normal. This may not always be the case; someone who has had cancer in one testicle is more likely than an unaffected man to get cancer in the remaining testicle. Fertility, the production of testosterone and potency are not affected by the loss of one testicle. Fertility may be affected by subsequent chemo and radiotherapy treatment. Some men might bank sperm for later use at this point. If the other testicle is not working or absent, testosterone replacement therapy will be needed to maintain libido and potency, the man will be infertile.
Examination of the testicle and tumour in conjunction with information on spread of disease from the Computerised Tomography (CT) scan will give important information on:
- The type of the tumour
- The stage of the tumour
This information will dictate the best treatment.
The next steps in testicular cancer treatment are:
Once the testicle is removed the type of testicular cancer is known. The most important information is whether the cancer is a seminoma or a non-seminoma. The staging investigation results such as CT scan of lymph nodes in the abdomen, chest and lungs will show whether there are secondary tumours in these areas and what further treatment is needed. Many men will go on to have chemotherapy and or radiotherapy treatment after they have had their testicle removed. The likely treatment and outcome by stage of disease is outlined below:
Stage 1 testicular cancer
Seminoma
Removal of the testicle and either:
- No further treatment
- For some men radiotherapy to the lymph nodes on the back wall of the abdominal cavity
or
- For some men a single dose of the chemotherapy drug carboplatin
These treatments reduce the risk of recurrent disease from 20% to 4%.
Non-seminoma
Removal of the testicle, often but not always followed by:
- Two cycles of chemotherapy 3 weeks apart.
In this group ‘low risk’ means a 10-15% chance of recurrent disease and ‘high risk’ means a 50% chance of recurrent disease. Two cycles of chemotherapy reduce the recurrence rate to 4% for both ‘high risk’ and ‘low risk’ disease.
Stage 2 testicular cancer
Seminoma
Removal of the testicle followed by one of the following:
- radiotherapy to the lymph nodes on the back wall of the abdominal cavity
- two cycles of chemotherapy
Non-seminoma
Removal of the testicle is usually carried out first followed by -:
- two cycles of chemotherapy
Chemotherapy may be given before surgery if the disease is more advanced
Stage 3 and 4 Testicular cancer
The disease is more advanced at this stage; men at this stage are divided into three categories for treatment based on ‘prognostic factors’ such as levels of tumour markers and where the disease has spread to. Chemotherapy treatment may be given before the testicle is removed.
- Good prognosis group – this is the majority of men with advanced testicular cancer. Chemotherapy treatment using three drugs called bleomycin, etoposide and cis-platin is given, this combination is commonly called ‘BEP’ chemotherapy. It is given for 3 cycles 3 weeks apart. Over all success rate is 85% with 10-15% of men requiring more treatment than this to get the disease under control.
- Intermediate prognosis group – this group also receive ‘BEP’ chemotherapy but need four cycles instead of three. Some men may need more intensive treatment with more drugs for a longer period from the beginning. Over all including those who had extra treatments on top of BEP chemotherapy, cure rates for this group are 70-80%.
- Poor prognosis group: the chance of getting rid of cancer completely with 4 cycles of BEP chemotherapy in this group is 48%. Many of these men will be offered more intensive treatment from the beginning. This is likely to mean more side effects during and after treatment. Treatment may include high dose chemotherapy and bone marrow transplant. Further surgery in addition to removal of the testicle may be required to remove deposits of tumour elsewhere in the body. Radiotherapy treatment may be used for example to the head for brain metastases.
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Amended April 2008
