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After testicular cancer has been diagnosed and the extent of the cancer spread has been determined, the doctor agrees with the patient which treatment steps are to be carried out.

NOTE: Ask  your doctor to get a second opinion from a testicular cancer specialist for the treatment of your disease from the Internet-based project “Second Opinion Testicular Tumors”

Treatment methods that can be used to treat testicular cancer are:

  • Surgery (Orchiectomy / Retroperitoneal Lymphadenectomy)
  • radiotherapy
  • chemotherapy or
  • Combinations of these forms of therapy.

The aim of the treatment is to completely remove or destroy the tissue affected by cancer and thus cure the disease.

Surgery
The first step in the treatment of testicular cancer is usually the surgical removal of the tumor-affected testicle (orchiectomy). Only in the case of advanced tumors can the removal of the diseased testicles be postponed and chemotherapy carried out first.

Which further treatment measures follow the orchiectomy depends in particular on the type of tumor (seminoma or non-seminoma) and how far the disease has progressed at the time of diagnosis.

Further treatment of seminoma

For patients in whom no lymph node involvement or spread to other organs is found (N0M0),   three treatment options are available after the operation :

In the  case of wait-and-see behavior  (so-called wait-and-see strategy or surveillance strategy), no further therapy is carried out. This is favored in the USA and now also in Europe for seminoma in CS1. To explain: It is known that despite inconspicuous diagnostics, about 20 percent of affected patients have the smallest affected lymph nodes in the back of the abdomen. In these 20 percent, there will be a relapse if no further therapy is carried out after the operation. Since the chances of recovery are not limited compared to immediate treatment if the growing findings are discovered in good time, a patient can decide to proceed in this way. However, the checks must be carried out very carefully and at regular intervals.

If a patient elects immediate treatment to reduce the 20 percent recurrence, there are two options: either  radiation therapy  in the back of the abdomen along the abdominal aorta, or  chemotherapy  with a well-tolerated drug. The irradiation takes place five days a week and is completed after two weeks. Chemotherapy  is given  once or twice. It can be performed on an outpatient basis.

The chances of recovery from all three options are almost 100 percent. In order to be able to decide on one of the options, a detailed discussion should take place with the treating specialist. Radiation  in clinical stage 1 seminoma (limited to the testicles) has been heavily criticized . A study from 2010 (Horwich, ASCO 2010) showed that after 18 years, some patients can expect malignant second tumors. The increase was strongest for poorly curable pancreas, stomach and bladder tumors. Radiation is only recommended for this indication in special situations.

If there are lymph node metastases up to a maximum transverse diameter of 5 cm (N1-N2) in the posterior abdominal cavity, chemotherapy is carried out as in the case of more extensive lymph node involvement (N3) or metastases in other organs (M+).

Further treatment of non-seminomas

Even in the case of non-seminomomas with no indication of resettlement, there is the possibility of  wait-and-see behavior  (wait-and-see strategy or surveillance strategy). The risk of a relapse can be estimated using prognostic factors. The risk is particularly high if tumor cells have already invaded the testicular vessels (vascular invasion) when the removed tumor-bearing testicle is viewed under the microscope. In this case, no wait-and-see strategy should be implemented since the risk of metastases is around 50%.

Available preventative treatments include removal of specific regions of lymph nodes in the back of the abdomen (diagnostic retroperitoneal  lymphadenectomy ) or  two-  or three-drug chemotherapy . The treatment lasts six weeks and is carried out on an inpatient basis, with the patient only being in the hospital on certain days within the total period of six weeks. If blood vessels are affected, chemotherapy as a systemic therapy is the safest procedure. Studies have shown that application of a single cycle is very effective when there are no visible metastases but vascular invasion of the primary tumor can be seen under the microscope (stage pT2).

Chemotherapy is now recommended for patients with existing lymph node metastases and/or metastases in other organs. In the case of lymph nodes up to 2 cm in the back of the abdomen and negative tumor markers in the blood, surgical removal can be useful, or if necessary, a check and surgical removal or chemotherapy first if the secondary tumors enlarge. The number of chemotherapy cycles depends on the extent of the lymph node involvement, the type of organ affected and the level of the tumor markers. Tumor foci larger than 1 cm that are still in the body after the end of chemotherapy must be surgically removed.

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The individual therapy methods are presented in more detail below.

Testicle removal (orchiectomy)

Orchiectomy is basically the first step in treatment when testicular cancer is present. The affected testicle is exposed from the groin. As a rule, the operating doctor can tell by eye whether the tumor is malignant or not. If this is unclear in rare cases, a piece of tissue is removed and examined under the microscope during the operation. If the suspicion of testicular cancer is confirmed, the diseased testicle is removed together with the epididymis and spermatic cord. This procedure is called an orchiectomy. The operation is relatively simple and safe.

During the operation, a tissue sample can also be obtained from the healthy testicle (biopsy) to determine whether the preliminary stage of a testicular tumor (testicular intraepithelial neoplasia, TIN) has already developed here. If such a precancerous stage is found, this testicle is treated with radiation therapy. However, the result of the radiation is that the formation of semen and thus the fertility of the patient are permanently suspended. If you want to have children, there is an alternative option of waiting and only treating the child when a malignant tumor develops. This can sometimes take years.

Consequences of orchiectomy
The removal of a single testicle (semicastration) has no effect on  sexuality  and potency, nor on the ability to father children. The healthy testicle on the opposite side takes over the function of the removed testicle.

However, in 50 percent of testicular tumor patients, the formation of sperm in the healthy testicles is also restricted for reasons that are not yet known. It therefore makes sense to have the quality of the semen tested using a semen sample from the remaining testicle after the removal of the tumor-affected testicle, ie before further treatment measures. If there is actually limited sperm formation, there is the possibility of obtaining and freezing sperm for later artificial insemination. This is important because subsequent treatment measures can lead to further damage, even if only temporary, even if 2-3 cycles of chemotherapy are administered.

If desired for cosmetic reasons, a testicular prosthesis that looks and feels like a healthy testicle can be used to replace the removed testicle (see also special features).

Lymph node removal (retroperitoneal lymphadenectomy)

During this operation, lymph nodes in the back of the abdomen are removed. The extent of the intervention depends on the stage of the tumor. If the lymph nodes are unremarkable in the computer tomogram (N0), only a modified field is operated on, ie lymph nodes are only removed in certain lymph node areas. If lymph node involvement is detected (N1-2), the surgical field is expanded. In any case, the doctors try to protect nerve fibers in the surgical area, which are important for ejaculation. Special surgical techniques have been developed for this purpose.

Consequences of lymph node
removal Retroperitoneal lymphadenectomy can affect nerves that are important for ejaculation. If this is the case, the semen is no longer thrown out through the urethra during orgasm, but is transported backwards (retrograde) into the bladder (retrograde ejaculation). The patient’s ability to fertilize naturally is thereby lost. However, the semen can be extracted from the urine and used for artificial insemination.

In most cases, normal ejaculation can be maintained due to the nerve-sparing surgery that is possible in the early stages of the disease and the limited surgical field. The potency, i.e. the ability of the limb to stiffen, the emotional life and the ability to have an orgasm are retained in any case.

Radiotherapy

In  radiation therapy  , cancer cells are destroyed using radioactive radiation. It can be used to treat seminoma. The prerequisite, however, is that the tumor is in an early stage, ie that there are no or only small lymph node metastases and no organ metastases have yet formed (N0-2).

The area on the rear abdominal wall to the left and right of the abdominal aorta is irradiated. This should prevent the development of lymph node metastases (N0) or completely destroy existing metastases (N1-2). If lymph node metastases have already been detected in this area (N1-2), the pelvic region on the affected side is also irradiated along the large pelvic vessels. Radiation is usually done on an outpatient basis. It is important to weigh the potential long-term consequences of radiation therapy against the morbidity of alternative therapy methods. Radiation therapy for clinical stage 1 seminoma (limited to the testicles), for example, has come under strong criticism because a study showed that after 18 years, 14% of patients had to reckon with malignant secondary tumors.

Radiation therapy is also the method of choice if early form cancer (TIN) has been detected in the biopsy of the opposite testicle.

Side effects of radiation therapy
During radiation therapy, temporary disorders in the gastrointestinal tract, nausea, loss of appetite, vomiting, diarrhea, physical weakness, exhaustion, increased susceptibility to infections, hair loss and inflammation of the urinary bladder and skin can occur. These symptoms can be treated with medication and will subside once treatment has ended.

Although the healthy testicles are protected by a lead chamber when the rear abdominal cavity is irradiated, the treatment can also impair sperm production and thus fertility. If the remaining testicle has to be irradiated due to a precancerous stage (TIN), the direct irradiation treatment leads to permanent infertility. In most cases, however, hormone production in the testicles can be maintained because the cells responsible for testosterone production are very resistant to radiation. A hormone replacement therapy is therefore usually not necessary, the desire for sexual intercourse and potency are maintained. The problem with radiotherapy is the induction of secondary tumors, which increases with the time between radiotherapy (>

chemotherapy

Chemotherapy aims to kill cancer cells throughout the body using drugs that inhibit cell growth (cytostatics). Cytostatics work well against rapidly growing cells, a property that applies particularly to cancer cells.

Chemotherapy is usually used for testicular cancer after the disease has spread throughout the body.

In the case of seminomas, chemotherapy is the method of choice in advanced stages of the disease, i.e. when there are already large lymph node metastases (N3) or metastases have formed in other organs (M1).

In the case of non-seminomas, chemotherapy can be given in the early stages of the disease. In this case, it can be carried out as a supplementary (adjuvant) measure directly after the removal of the testicles (N0) or after the removal of affected abdominal lymph nodes (N1-2). Patients in advanced stages – ie with large lymph node metastases (over 5 cm) or organ metastases (N3, M1) – always receive primarily chemotherapeutic treatment. Lymph node metastases and organ metastases can usually be destroyed by this therapy.

If there was a non-seminoma, the remains of the tumor in the abdomen are then removed, since tumor cells remain alive in about 50 percent of patients despite chemotherapy. About 20 percent of these can still be described as malignant, but the 30 percent of the living cells that no longer show the typical fine-tissue signs of malignancy could grow again and therefore have to be removed. If a seminoma was present, the remains of the tumor after the chemotherapy are initially only observed, since the tissue is usually dead. FDG positron emission tomography should be used to examine whether it is just scar tissue or vital tissue with sugar metabolism. If there is evidence of sugar metabolism, the mass should be surgically removed.

In advanced stages of the tumor, four courses (cycles) of chemotherapy are usually administered. The same drugs are usually used as in the early stages, but they can be changed depending on the extent of the tumor.

A chemotherapy cycle lasts 21 days, with drugs only being given on certain days. In between, the patient can recover at home.

High-dose chemotherapy
The value of high-dose chemotherapy is currently being examined for patients with very advanced disease, eg with metastases in the liver, brain or skeleton (poor prognosis group of the IGCCCG classification). High doses of various cytostatics are used. Since the intensive treatment not only destroys tumor cells, but also the blood-forming bone marrow, blood stem cells are taken from the patient before the high-dose therapy and transferred again after the treatment is complete (blood stem cell transplantation). High-dose chemotherapy is currently only used in special centers as part of studies.

Side effects of chemotherapy
Treatment with cytostatics also affects normal tissue, which regenerates relatively quickly. The mucous membranes of the stomach and intestines, the blood-forming system in the bone marrow and the hair roots are primarily affected. Possible side effects of chemotherapy are therefore nausea, vomiting, diarrhea, hair loss, increased susceptibility to infections and anaemia. Depending on the type and duration of therapy, other side effects can occur, such as a deterioration in hearing, numbness in hands and feet, taste disorders, skin changes and impairment of kidney and lung function. Some of the side effects can be intercepted or alleviated by accompanying measures or medication.

Since the drugs also affect the sperm-producing cells of the testicles, there is a high probability of infertility at this time. However, after a short course of chemotherapy (1 to 2 courses) at normal doses, semen production recovers to baseline quality within two years.

Since damage to the genetic material by the therapy cannot be completely ruled out, the patients should refrain from having offspring in the first two years after the treatment.

Treatment of relapses

In the event of a recurrence of the disease (recurrence), an attempt is made to heal the tumor again, primarily by surgical removal or by renewed chemotherapy, usually with subsequent surgery. Duration and intensity of therapy depend on the extent and localization of the recurrence.

Pain treatment
In advanced stages of cancer, patients often focus on the pain caused by the tumour. They affect their quality of life more than the tumor itself. One of the most important measures in this case is effective pain control. With the drugs and methods available today, tumor pain can be relieved in most cases. The focus is on treatment with painkillers, with morphine for very severe pain. Pain patches are also available. Pain therapy is tailored as individually as possible to the pain situation of the patient.

Cure Prospects
Since the introduction of cisplatin-based chemotherapy, testicular cancer has been one of the most treatable cancers: In the early stages of the disease (N0-N2), 90 to 98 percent of patients can be permanently cured. The results are less favorable in patients with far advanced tumors. But even in these cases, healing rates of up to 70 percent are possible. However, the treatment is then more intensive and associated with more side effects.

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