• New Trends in Treatment
• Testis Cancer Overview

Current research has focused on minimizing some of the associated problems encountered in the successful treatment of testis cancer. One of the areas of greatest interest has been to determine which patients with stage I, nonseminomatous GCT require treatment and which can be managed under surveillance protocols. Surveillance in properly selected individuals could provide complete cure in approximately 70% of patients after orchidectomy alone without the risks of chemotherapy or radical surgery. A recent study by Sharir et al., looked closely at the best means of detecting tumor spread in a group of 170 patients being followed by surveillance. As expected, almost 30% had disease progression within 2 years after initial diagnosis and were treated. The most important tools for diagnosing these patients included history, physical examination, tumor markers and CT scanning at regularly performed intervals starting 2 months after initial orchiectomy. Even with this extremely close follow-up, 1 patient died of cancer.

Factors associated with a high risk of spread have been identified in grade I, nonseminomatous tumors. These include the presence of embryonal carcinoma, and microscopic vascular or lymphatic invasion. A study of high-risk, stage I patients receiving orchidectomy and an abbreviated 2 cycle course of adjuvant, cisplatin based chemotherapy revealed excellent disease-free survival while avoiding the use of RPLND. Of 58 patients, fifty-six were rendered disease-free with this treatment. No deaths occurred, 1 patient had a teratoma at 22 months and 1 patient suffered from a contralateral tumor 7.5 years after treatment. High-grade toxicity was noted among less than 10% of subjects in the study and long-term sequelae of treatment were reported as minimal.

Significant numbers of men with testis cancer have problems with infertility. Fertility for these individuals can be influenced by cryptorchidsm, intraepithelial neoplasia of the opposite testis, production of anti-sperm antibodies, and disturbances in the hormones responsible for sperm production. Investigations into the effect of testis tumors on sperm quality have highlighted some important considerations regarding fertility options in these patients. Recent studies have shown that overall sperm quality is poor in patients with testis cancer prior to treatment. , Following orchidectomy, sperm concentrations appear to decrease further with significant concomitant increases in levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH).4 These substances, called gonadotropins, are responsible for stimulating sperm and testosterone production, respectively. Studies such as these suggest that pre-treatment cryopreservation of sperm should be considered for all patients with testis cancer.

Advances in surgical approaches to RPLND have significantly decreased the complications from this procedure. The developments of nerve sparing surgery and modified template dissections have limited the previously encountered problems of retrograde ejaculation following this operation. A recent trend toward more minimally invasive, laparoscopic surgery has prompted some centers to explore the use of this technique for RPLND. One group reported on its experience with post-chemotherapy laparoscopic RPLND in 24 patients with stage IIB tumors. All patients had normal ejaculatory function preserved and were disease-free at an average follow-up of 2 years. Other outcomes, including complications (though mild) and operative time, were arguably not as favorable when compared to current open techniques and reflect the considerable challenge of this type of surgery. With further development and experience with the technique, laparoscopic RPLND may become the standard for future surgical management of low volume retroperitoneal disease.

Advanced Care
Significant advances in our understanding of GCT have improved treatments and outcomes for patients with testis cancer. Helical CT scan imaging has allowed better identification of minimally advanced disease and permitted surveillance for appropriately selected patients. Reliable tumor marker testing and special histological staining techniques have also aided in diagnosis and stratification of patients for treatment options. Better chemotherapeutic regimens have limited associated morbidity from these medications. Finally, state-of-the-art surgical techniques with nerve sparing surgery have significantly reduced the complications from this life-saving procedure. The team of doctors that make up the Urologic Oncology program at New York Presbyterian Hospital, and our affiliate Memorial Sloan-Kettering Hospital, is active in testis cancer research and treatment.

Testis cancer is a highly curable disease entity when treated appropriately. For unknown reasons, testis cancer is becoming more prevalent in the U.S. and elsewhere. Just as self-examination for breast cancer is taught to young women, testicular self-examination should be encouraged among young men. Advanced medical techniques in diagnosis and treatment exist which effectively address this form of cancer with low risk of complications. As with many forms of cancer, early detection and treatment can significantly enhance prognosis.

Physicians:

Neil Bander, M.D. Dept of Urology, New York-Presbyterian Hospital 212-746-5460

Mendel Shemtov, M.D. Dept of Urology, New York-Presbyterian Hospital 212-746-5449

David Nanus, M.D. Dept of Oncology, New York-Presbyterian Hospital 212-746-2920