Testicular Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Stage I Testicular Cancer
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
Stage I seminoma has a cure rate of greater than 95% regardless of whether or not postorchiectomy adjuvant therapy is given.
Standard treatment options:
Radical inguinal orchiectomy with no retroperitoneal node radiation therapy followed by periodic determination of serum markers, chest x-rays, and computed tomographic (CT) scans of the abdomen and pelvis (surveillance). These studies are typically performed every 4 months for the first 3 years, then every 6 months for 3 years, and then annually for an additional 4 years.
Results of multiple clinical series, including more than 1,200 patients with stage I seminoma managed by postorchiectomy surveillance, have been reported.[1,2,3,4,5,6,7,8] 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. Independent risk factors for relapse include tumor size greater than 4 cm and invasion of the rete testis. The 5-year risk of relapse is about 10% without either risk factor, 16% with one risk factor, and 32% with both risk factors.
Radical inguinal orchiectomy followed by either one or two doses of carboplatin adjuvant therapy.
In a large randomized controlled equivalency trial comparing para-aortic (or dog-leg field, if clinically indicated) radiation to a single dose of carboplatin (concentration-versus-time curve [AUC] × 7) after radical inguinal orchiectomy, relapse-free survival (RFS) and overall survival (OS) rates were equivalent after a median follow-up of 4 years.[Level of evidence: 1iiA] Three-year RFS was 94.8% with carboplatin versus 95.9% with radiation therapy. 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.[2,3,11,12,13,14,15] Administration of two doses of carboplatin has never been compared to a single dose nor to radiation therapy in a randomized trial.
Removal of the testicle via radical inguinal orchiectomy followed by radiation therapy is an approach that is associated with a 5-year relapse-free survival of 95% to 96% and a 5-year disease-specific survival in excess of 99% in multiple large series and randomized controlled trials.[16,17,18,19,20,21,22]
Two treatment fields are commonly 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 of para-aortic radiation therapy alone versus para-aortic radiation therapy with an added ipsilateral iliac lymph node field. Three-year RFS rates were virtually identical (96% vs. 96.6%) as were OS rates (99.3% vs. 100%). 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), radiation to 20 Gy over 10 daily fractions was clinically equivalent to 30 Gy over 15 fractions after a median follow-up of 61 months in both RFS and OS. Patient-reported lethargy and ability to perform normal work were better in the lower-dose regimen.[Level of evidence: 1iiA]