2. Management

This section is heavily based on the ESMO guidelines released in 2010 [1]

Initial management

Orchidectomy is indicated in nearly all cases. This gives a pathological diagnosis as well provides staging information. Tumour markers are performed prior to orchidectomy and then followed after the treatment. Further management is dependent on clinical stage.

Stage IA (T1 N0 M0 S0)

Stage IA patients, who have a localised testicular tumour with no lymphovascular invasion or involvement of the spermatic cord/tunica vaginalis, have a low risk of relapse (under 20%). Management is dependent on the geographical location of the patient's doctor as well as their wishes:

  • In the USA, retroperitoneal lymph node dissection is regarded as the standard of care for patients who are not suitable for surveillance
  • In Europe, chemotherapy is the treatment of choice for patients not suitable for surveillance
  • Surveillance is usually recommended, as long as tumour markers can be followed and imaging is available

Patients should be followed up regularly, regardless of treatment choice (see the Outcomes topic).

Stage IB (T2-4 N0 M0 S0)

Stage IB patients are at elevated risk of recurrence (over 50%) and chemotherapy is usually recommended:

  • Chemotherapy involves two cycles of PEB (cisplatin/etoposide/bleomycin)
  • Surveillance can be used and patients are still cured in the majority of cases at relapse
  • Again, if both options are unavailable/refused then nerve sparing retroperitoneal lymph node dissection can be considered

Patients should be followed up regularly as above.

Stage IIA/IIB disease (TAny N1-2 M0 S0-1)

Treatment depends on the size of lymph nodes and the levels of tumour markers, as well as patient choice.
For Stage IIA disease with normal tumour markers after orchidectomy:

  • Consider 6 weekly follow up with imaging and follow up until masses have progressed or disappeared
    • If disease progresses treat with PEBx3 (below)
  • Alternatively, perform retroperitoneal lymph node dissection with nerve sparing

For Stage IIA disease with elevated tumour markers, or any Stage IIB disease:

  • Treat with chemotherapy, options of:
    • PEB x3
    • Cisplatin/Etoposide (PE) x4 for patients who may not tolerate bleomycin

If residual tumour is present on follow up, and over 1 cm in size, it should be resected.
For either treatment, follow up should be performed regularly (see Outcomes

Advanced Disease - IIC, IIIA, IIIB, IIIC (TAny N3 AND/OR M1 AND/OR S2+)

Stage IIC and IIIA disease must always be treated with chemotherapy:

  • PEB x3 OR PE x4

Overall survival for patients in this category is still about 90%.

Stage IIIB disease (with moderately elevated markers) should receive an additional cycle of chemotherapy:

  • PEB x4, or alternatively
  • Cisplatin/Etoposide/Ifosfamide x4 if bleomycin not thought to be safe

5 year survival for these patients is about 80%

Stage IIIC disease, with non-pulmonary visceral metastases or markedly elevated tumour markers, is treated with the same schedule as IIIB disease. Survival is about 60% at five years.

The next stage in management is determined by the outcome of the initial chemotherapy, and is the same for all advanced stages:

  • If markers have fallen to normal levels, and there is no residual disease:
  • If markers have fallen to normal, but residual disease is present (and operable):
    • Resect residual lesions
    • If the tumour has been completely resected, and viable tumour was under 10% (or teratoma) then further follow up is indicated
    • If the tumour was incompletely resected, or if margins are unclear, or if over 10% of the mass was viable tumour, consolidation chemotherapy with etoposide/ifosfamide/cisplatin is indicated
  • If markers have remained elevated, and residual disease is seen (and operable):
    • Monthly follow up with repeat CT and markers
    • If markers are elevating, then consolidation chemotherapy with PIE
    • If markers are stable or falling then resect the lesions
  • If residual disease is extensive or inoperable, but markers have normalised then:
    • Consider consolidation chemotherapy
    • Consider high dose, experimental chemotherapy
  • If there is continued marker elevation and disease is inoperable:
    • High dose experimental chemotherapy (eg. gemcitabine/paclitaxel)

Role of Radiotherapy in Non-Seminomatous Germ Cell Tumours

Radiotherapy as two roles in non-seminomatous germ cell tumours:

  • In patients with brain metastases (IIIC disease) then whole brain radiotherapy can be curative when combined with systemic therapy to the other disease
  • In patients with incurable disease, radiotherapy can provide palliation for troublesome lesions

Links

Bibliography
1. Schmoll et al. Testicular non-seminoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology (2010) vol. 21 Suppl 5 pp. v147-54