C44. Complex treatment of testis tumors
Management
All patients with suspected testicular cancer on ultrasound and physical examination should undergo surgical exploration. If surgery and intraoperative frozen histology sections cannot rule out malignancy, orchidectomy is performed. This allows for histological examination and complete staging and risk stratification. However, at no point should the urologic surgeon incise the tumour itself, for risk of seeding. A testicular prosthesis can be placed at the same time. If there is sign of retroperitoneal lymph node involvement (most commonly the para-aortic lymph nodes), retroperitoneal lymph node dissection (RPLND) is indicated.
Localised disease with no high-risk features can usually be followed with active surveillance after surgery, but if there is intermediate or high-risk, adjuvant chemotherapy is recommended. In locally advanced disease, adjuvant radiotherapy or chemotherapy is indicated. For metastatic disease, adjuvant chemotherapy is indicated.
Organ sparing surgery
Organ sparing surgery, i.e. the resection of a tumour instead of complete orchidectomy, may be an option if the cancer affects both testicles or the patient only has one testicle and it is affected. The goal is to maintain the endocrine function of the testicles. Adjuvant radiotherapy is always indicated.
Biopsy of contralateral testicle
During orchidectomy, we may perform a biopsy of the contralateral (healthy-looking) testicle. This is to look for GCNIS (cancer in situ). This biopsy is indicated if the cancer is a germ cell tumour or there are risk factors of GCNIS, such as cryptorchidism or an atrophic testicle.
Chemotherapy
Chemotherapy is indicated if there is metastatic disease. It's usually a combination of cisplatin, etoposide, and bleomycin.
Radiotherapy
Seminomas are very radiosensitive, whereas non-seminomas are only moderately radiosensitive. For this reason, radiotherapy is mostly only used for seminomas. Radiotherapy is less and less used nowadays in favour of chemotherapy.