Cancer Health Center

Testicular cancer is broadly divided into seminoma and nonseminoma for treatment planning because seminomatous types of testicular cancer are more sensitive to radiation therapy and chemotherapy and are less prone to distant metastases. Moreover, nonseminomas may include teratomatous elements, which tend to be resistant to chemotherapy and often require surgery for cure. By definition, pure seminomas do not contain elements of teratoma. Therefore, surgery plays a larger role in the management of nonseminomas than in the management of seminomas. Nonseminomatous testicular tumors include:

• Embryonal carcinomas.
• Yolk sac tumors.
• Choriocarcinomas.
• Teratomas.
• Mixed germ cell tumors.

An international germ cell tumor prognostic classification has been developed based on a retrospective analysis of 5,202 patients with metastatic nonseminomatous and 660 patients with metastatic seminomatous germ cell tumors.[1] All patients received treatment with cisplatin- or carboplatin-containing therapy as their first chemotherapy course. The prognostic classification, shown below, was agreed on in 1997 by all major clinical trial groups worldwide. It should be used for reporting clinical trial results of patients with germ cell tumors.

A meta-analysis of treatment outcomes for patients with advanced nonseminoma suggested that 5-year survival rates have improved for those patients with a poor prognosis during the period of 1989 to 2004.[2] In addition to improved therapy, the improvement seen in these survival rates could be the result of publication bias, changes in patient selection in reported clinical trials, or more sensitive staging methods that could migrate less-advanced stages to more-advanced stage categories (i.e., stage migration).

Good Prognosis

Nonseminoma:

• Testis/retroperitoneal primary, and
• No nonpulmonary visceral metastases, and
• Good markers-all of:
  • Alpha-fetoprotein (AFP) less than 1,000 ng/mL, and
  • Human chorionic gonadotropin (hCG) less than 5,000 IU/mL (1,000 ng/mL), and
  • Lactate dehydrogenase (LDH) less than 1.5 × the upper limit of normal

  56%-61% of nonseminomas

  5-year progression-free survival (PFS) is 89%; 5-year survival is 92%-94%

Seminoma:

• Any primary site, and
• No nonpulmonary visceral metastases, and
• Normal AFP, any hCG, any LDH

  90% of seminomas

  5-year PFS is 82%; 5-year survival is 86%

Intermediate Prognosis

Nonseminoma:

• Testis/retroperitoneal primary, and
• No nonpulmonary visceral metastases, and
• Intermediate markers-any of:
  • AFP 1,000 ng/mL or more and 10,000 ng/mL or less, or
  • hCG 5,000 IU/L or more and 50,000 IU/L or less, or
  • LDH 1.5 or more × N* and less than 10 × N*

  13%-28% of nonseminomas

  5-year PFS is 75%; 5-year survival is 80%-83%

  *N indicates the upper limit of normal for the LDH assay.

Seminoma:

• Any primary site, and
• Nonpulmonary visceral metastases, and
• Normal AFP, any hCG, any LDH

  10% of seminomas

  5-year PFS is 67%; 5-year survival is 72%

Poor Prognosis