• New Trends in Treatment
• Testis Cancer Overview

Treatment for GCT depends on tumor type and the extent of tumor growth. In general, there are three stages of tumor progression related to the anatomical sites in which cancer is found (table 2). Stage I cancer is limited to the testicle with no evidence of lymph node involvement. Stage II disease signifies the presence of lymph node involvement at predictable sites known for tumor spread within the abdomen or pelvis (retroperitoneum) and can be evaluated with CT scan. With Stage III, the cancer has spread to areas outside of these usual sites and may involve the lungs, distant lymph nodes, or other organs. Patients with Stage III cancer may have very high tumor marker concentrations on blood tests without evidence of tumor spread seen.

Stage	Tumor	Lymph Nodes	Metastases	Markers
0	Intratubular germ cell neoplasia (cis)	0	0	normal
IA	Limited to tesits, no vascular invasion	0	0	normal
IB	Localle invasive into vascular and/or lymphatic structures, cord, scrotal skin, or tunica albuginea	0	0	normal
IS	Any degree of local tumor growth	0	0	Elevated
IIA	Any degree of local tumor growth	<2 cm	0	Normal or mildly elevated
IIB	Any degree of local tumor growth	>2 cm, <5 cm	0	Normal or mildly elevated
IIC	Any degree of local tumor growth	<5 cm	0	Normal or mildly elevated
IIIA	Any degree of local tumor growth	Any size	Non-regional nodes or pulmonary	Normal or mildly elevated
IIIB	Any degree of local tumor growth	Any size	None, non-regional nodes or pulmonary	LDH 1.5-10xNl HCG 5-50x103 AFP 1-10x103
IIIC	Any degree of local tumor growth	Any size	None, non-regional nodes, pulmonary or visceral	LDH >10xNl HCG > 50x103 AFP > 10x103

As mentioned, seminomatous tumors are extremely sensitive to radiation and chemotherapy with excellent response rates seen after treatment. Stage I seminoma is treated with orchidectomy followed by radiation therapy to areas where tumor spread would be expected (the retroperitoneum). Cure rates with this treatment have been reported as high as 98%. Without radiation therapy, a relapse rate of 15% can be expected. Stage II, low volume disease, is also treated with radiation therapy with slight modification of the treatment method, again with excellent results of 85-95% cure. Stage III, high volume disease requires chemotherapy treatment following orchidectomy and also has good response with 70-80% cure rates (see figure 2 at end of document).

Nonseminomatous tumors do not exhibit good response to radiation treatment and must be managed with chemotherapy and further surgery. Approximately one-third of all patients initially diagnosed with Stage I, non-seminoma will actually have retroperitoneal lymph nodes that contain tumor (Stage II). Surgery is indicated for removal of lymph nodes in the retroperitoneum that are likely to contain cancer cells for both staging and curative treatment. Some sub-stages of disease and cell type can be managed without chemotherapy or surgery but strict long-term surveillance with routine CT scans and chest x-rays is absolutely required (see figure 3 at end of document). Testis cancer spreads predictably along pathways of lymphatic drainage. Left-sided cancers will commonly go to the lymph nodes on the left side of the aorta (para-aortic and preaortic), up to the level of the vein from the left kidney (left renal vein), and rarely cross over to the right side (see figure 1). On the other hand, right-sided tumors often cross over to the left side. Landing areas for right-sided tumors include the right side of the inferior vena cava (precaval) and the area between the aorta and vena cava (interaortal caval).