Germ Cell Tumors of the Testis Treatment

Inguinal exploration with cross-clamping of the spermatic cord vasculature and delivery of the testis into the field is the mainstay of exploration for a possible testis tumor. If cancer cannot be excluded by examination of the testis, radical orchiectomy is warranted. Scrotal approaches and open testicular biopsies should be avoided. Further therapy depends on the histologic characteristics of the tumor as well as the clinical stage.

A. Low-Stage Seminoma (I, II-A)
Seminoma is exquisitely radiosensitive. Ninety-five percent of all stage I seminomas are cured with radical orchiectomy and retroperitoneal irradiation (usually 2500-3000 cGy). This low dose of radiation is usually well tolerated, with minimal, if any, gastrointestinal side effects.

Low-volume retroperitoneal disease also can be treated effectively with retroperitoneal irradiation with an average 5-year survival rate of 87%. Prophylactic mediastinal radiation is no longer employed because this may cause considerable myelosuppression and thus compromise the patient's ability to receive chemotherapy if required. Chemotherapy should be used as salvage therapy for patients who relapse following irradiation.

B. High-Stage Seminoma (II-B, III)
Patients with bulky seminoma and any seminoma associated with an elevated AFP should receive primary chemotherapy. Seminomas are also sensitive to platinum-based regimens, as are their NSGCT counterparts. Some of the successful regimens include cisplatin, etoposide, and bleomycin (PEB); vinblastine, cyclophosphamide, dactinomycin, bleomycin, and cisplatin (VAB-6); and cisplatin and etoposide. All seminomas receive low-risk chemotherapy regimens, which currently consist of cisplatin and etoposide (4 cycles) or 3 cycles of PEB.

Ninety percent of patients with stage III disease achieve a complete response with chemotherapy. Residual retroperitoneal masses following chemotherapy are often fibrosis (90%) unless the mass is well circumscribed and in excess of 3 cm, under which circumstances approximately 40% of patients harbor residual seminoma. In such cases surgical excision is warranted.

C. Low-Stage Nonseminomatous Germ Cell Tumors
Standard treatment for stage A disease in the United States has included retroperitoneal lymph node dissection (RPLND). However, because three-fourths of patients with clinical stage A disease are cured by orchiectomy alone and the morbidity of RPLND is not negligible, other alternatives have been explored. These options include surveillance and modified RPLND.

Surveillance in stage A NSGCT was proposed because, as mentioned previously, 75% of patients with clinical stage A disease have, in fact, pathologic stage A disease. In addition, infertility related to disruption of sympathetic nerve fibers is common following RPLND. Clinical staging has been markedly improved in the presence of CT scanning and LAG. And finally, effective chemotherapy regimens have been developed for relapse. Patients are considered candidates for surveillance if the tumor is an NSGCT confined within the tunica albuginea, the tumor does not demonstrate vascular invasion, tumor markers normalize after orchiectomy, radiographic imaging shows no evidence of disease (chest x-ray [CXR], CT), and the patient is considered reliable.