What is stage I nonseminoma testicular cancer?
Testicular cancer is a disease involving the uncontrolled growth of cells
on or inside the testicles, or testes.
There are two main types
of testicular cancer: seminoma and nonseminoma germ-cell tumors (also called
NSGCTs). Unlike seminomas, nonseminomas tend to be very resistant to radiation
therapy. Nonseminoma cells are also more likely to travel through the
bloodstream to the lungs, liver, bones, and brain.
Stage I cancers
are those that are believed to be confined to the testes, though in some cases
they may have spread to the lymph nodes of the lower back (retroperitoneum) but
cannot be detected.
Both seminomas and nonseminomas are highly
curable, especially when they are diagnosed and treated early. When compared to
other forms of cancer, even those testicular cancers that have spread beyond
the testes to other parts of the body have a very high cure rate.
What are the treatment choices for stage I nonseminoma germ-cell tumors?
Following orchiectomy, stage I nonseminoma germ-cell
tumors (NSGCTs) are usually treated with additional surgery, chemotherapy, or
watchful waiting. NSGCTs are rarely treated with radiation therapy.
Retroperitoneal lymph node dissection (RPLND) is surgery to remove lymph nodes that may be
cancerous from the lower back and pelvis. During the early phases of stage I
nonseminoma testicular cancer, it can be very difficult to tell whether these
lymph nodes are cancerous without surgically removing them first. In the past,
RPLND was associated with high rates of infertility. Modern "nerve-sparing" and
laparoscopic surgical techniques have lowered the
chances of becoming infertile following RPLND.
Chemotherapy. Chemotherapy is the use of very powerful
medicines to kill cancer cells. The most common chemotherapy used to treat
nonseminoma testicular cancer is called cisplatin combination therapy and
involves the use of several different medicines. This treatment varies in
intensity and is often used for men whose cancer has spread beyond the
lymph nodes or other organs.
Watchful waiting means you are being monitored closely by your
doctor but are not receiving active treatment such as surgery or chemotherapy.
Men who choose watchful waiting for stage I nonseminomas usually have monthly
physical exams, chest X-rays, and blood tests for the first year as well as one
CT scan every 3 months. If no recurrent cancer is
found, the number of physical exams and blood and imaging tests will gradually
decrease to about one a year after 5 years following orchiectomy.2 This follow-up work can be hard for some men to do.
What are the risks of RPLND?
RPLND is a surgical
procedure and carries all the risks of any major surgery, including:
- Reactions to
RPLND can cause retrograde ejaculation, which can make
you infertile. This can happen as a result of nerve damage caused by the
surgery. With retrograde ejaculation, the semen flows from the prostate gland
into the bladder rather than out through the penis.
retrograde ejaculation typically do not have erection problems or difficulty
Laparoscopic and other "nerve-sparing" techniques now used in many RPLND surgeries
have greatly lowered the risk of retrograde ejaculation following RPLND.
Studies show that 95% of men who have nerve-sparing RPLND have normal
ejaculation after surgery.2 Nerve-sparing RPLND
surgery may be more difficult or impossible for men who have previously had
chemotherapy treatment for cancer. Talk to your doctor about whether
nerve-sparing surgery is possible for you.
Other risks associated
with RPLND include:
- Postoperative pain.
ascites, a condition in which digestive fluids collect inside the abdominal
(belly) cavity. This may lead to abdominal pain and difficulty
- Lymphedema, which is a collection of
fluid that causes swelling (edema) in the arms and legs. This type of edema
occurs when the amount of lymph fluid in a person's arm or leg exceeds the
body's ability to remove it, and the fluid then collects in the tissues of the
- Excessive bleeding (hemorrhage).
- Pulmonary embolism, which is a sudden blockage of
arterial blood flow within the lung.
What are the risks of chemotherapy?
affects rapidly growing cells in your body. Besides cancer cells, this includes
blood cells, hair cells, and the cells that line your digestive tract. Common
short-term side effects include nausea and vomiting, hair thinning or hair
loss, mouth sores, diarrhea, and an increased chance of bleeding and infection.
Many men do not have problems with these side effects. Other men have a great
deal of difficulty. If you have problems, your doctor can use other medicines
to help relieve some of these side effects.
chemotherapy for the treatment of testicular cancer has also been associated
with serious long-term side effects. These side effects are uncommon. They
high blood pressure, increased
cholesterol levels, kidney, heart, and lung damage,
and also an increased risk of secondary cancers including
melanoma.1 (But these
long-term side effects have been linked to higher doses of chemotherapy than
are usually used for stage I testicular cancers.) Before beginning treatment,
talk to your doctor about any concerns you may have about the long-term side
effects of chemotherapy.
Chemotherapy for treatment of testicular
cancer has been linked to permanent infertility in some men. Most men diagnosed
with testicular cancer are younger than 35, so fertility issues are often
important in determining which treatment they receive. Most chemotherapy does
not permanently affect healthy sperm counts, but many doctors recommend sperm
banking prior to any treatment for testicular cancer for those men who may wish
to have children. Talk to your doctor about any fertility concerns you have.
What are the risks of watchful waiting?
of men (1 out of 4) who choose watchful waiting instead of RPLND following
orchiectomy will have their cancer return and will need chemotherapy.1 Watchful waiting is a reasonable choice for many men with
stage I nonseminoma testicular cancer. But watchful waiting depends on diligent
follow-up care by you and your doctor.
In most cases of careful
watchful waiting, recurrent cancer is confined to lymph nodes in the lower back
and pelvis. This can usually be successfully treated when the testing schedule
has been closely followed and the cancer is discovered when it first appears.
Cancer that appears in the retroperitoneal lymph nodes during
watchful waiting may require more aggressive therapy than if RPLND or
chemotherapy had been done right after orchiectomy.