Treatment & Follow Up

SO YOU’RE SICK AS BALLS IT TURNS OUT.

SO THERE’S A PARTY GOING ON IN MY TESTICLES… AND EVERYONE’S INVITED?

Imagine a house party… you have a few friends over, you have a few laugh’s, maybe order some pizza, everything is great. This is a normal healthy party (or a healthy testicle). But then suddenly… a bunch people you don’t know just start showing up uninvited, and they keep coming and coming until the house is full and the party starts spilling into the neighborhood until it’s total mayhem. In short, there’s a party in your testicles, and everyone is invited!

SO HOW DO YOU
STOP A RUNAWAY
PARTY IN YOUR
TESTICLES?

You have to call in the big guns. BUT every party is different, so each is going to need their own tailored approach. Therapy for testicular cancer is tailored to the type of testicular cancer, blood tumor marker levels, results from CT scans, and overall progression of the disease. Here are some general guidelines on treatment:
  • For patients with testicular cancer that has not spread to any other part of the body, surgery to take out the testicle (radical orchiectomy: definition below) usually cures the patient. Sometimes chemotherapy or radiation is used to reduce the risk of the cancer coming back.
  • Chemotherapy or radiation is used if the patient relapses or the testicular cancer returns in another body part.
  • For patients with testicular cancer that has spread outside of the testicle, a combination of chemotherapy, radiation or surgery may be used to potentially cure the patient. However, chemotherapy alone is a common procedure for those who are being treated for testicular cancer.
  • Once there is no sign of testicular cancer inside the body, careful follow-up and surveillance is performed through CT scans and blood work to watch for a possible relapse.

LET’S CHECK OUT THESE DIFFERENT THERAPIES IN A LITTLE MORE DETAIL.

SURGERY

This is the term used to describe the surgery to remove a cancerous testicle. Newly diagnosed patients are immediately scheduled to remove the entire testicle that contains the primary testicular tumor, reducing the chance of the cancer spreading. The surgery is typically performed through the inguinal canal, which is located in the lower lateral abdomen right below the beltline. The procedure takes up to an hour under general anesthesia and the patient will be required to stay in the hospital overnight. After the procedure, swelling and bruising around the incision site are normal. Patients are recommended to avoid activity for several days, particularly lifting any heavy objects (10+ pounds) for at least a week, until the incision site has healed.

Biopsies of tumors to confirm the presence of testicular cancer are typically not performed, since the majority of testicular masses are cancerous. Also, only one functional testicle is needed to maintain fertility, testosterone production and sexual performance. This means that the removal of one testicle typically does not negatively impact the patient’s health. Patients may ask to obtain an implant or prosthesis to replace the cancerous testicle during the radical orchiectomy or sometime after the initial surgery. These implants exist in multiple sizes and types, such as saline filled, silicone gel and soft solid implants. The implants do not serve a functional purpose and are purely for cosmetic purposes. Pros and Cons should be evaluated with your surgeon before deciding to obtain a testicular implant.

Retroperitoneal Lymph Node Dissections (RPLNDs) are mainly performed in patients with non-seminomas. The oncology team will determine if this procedure is needed. Not all patients require this treatment. The most common lymph nodes to be affected by testicular cancer are those in the retroperitoneal area, which is in the abdominal cavity behind the peritoneum. Lymph nodes need to be monitored carefully through CT scans to determine whether or not the cancer has spread. Lymph nodes that appear to be larger than 1cm on CT scans are considered to be enlarged. The lymph nodes are located at the back of the abdominal cavity; the intestines are pushed to the side during the duration of the procedure:

Here are the lymph nodes that may be enlarged if the cancer has spread:

An RPLND is performed under general anesthesia for several hours and the patient will require to stay in the hospital for a few days after the operation has been completed. An incision is made in the midline of the abdomen, where the bowels are pushed aside. The full extent of the surgery varies depending on the severity of the disease, however, lymph nodes surrounding the testicles are always removed and examined to determine the presence of any remaining cancer cells. Some risks associated with RPLND are:

  • Infection and extensive bleeding
  • Damage to abdominal organs, particularly the intestines, kidneys, spleen and pancreas
  • Nerve damage may occur, which may lead to retrograde ejaculation. If this occurs, semen will enter the bladder instead of going through the urethra during ejaculation.
  • Pain in and around the incision area

Chemotherapy may either be given before a RPLND or after. If it is given before, the procedure will aid to determine whether the cancer has spread to adjacent nodes, which will determine the need for further treatment. Additionally, if chemotherapy is given prior to the RPLND, the lymph nodes will be observed using CT scans first. If the lymph nodes are still enlarged or begin growing in size, a RPLND will be performed to remove them. The remaining lymph node mass that is removed may contain live cancerous cells, dead tissue (necrotic), scar tissue (fibrotic) and a noncancerous tissue type called mature teratoma.

Metastasectomy is the surgical removal of metastases, which are secondary cancerous growths that have spread from the primary testicular tumor. This procedure is commonly performed in patients with leftover masses after chemotherapy in the mediastinum and the lungs. This procedure is critical to ensure that no residual cancer is left inside the body.

CHEMOTHERAPY

Chemotherapy (chemo) is given intravenously to treat the testicular cancer if it has spread. The oncology team will determine if this procedure is needed. Not all patients require this treatment Once injected, chemo travels through the bloodstream and eliminates cancer cells that have spread to lymph nodes or other organs. It can also be used to reduce the risk of the cancer coming back.
Chemotherapy is given in cycles, with each period of treatment followed by rest to ensure adequate recovery (typically 4 days of chemo every 3 weeks). Depending on the severity of the testicular cancer, two to four cycles are given in total. The following drugs can be used to treat testicular cancer:
  • Embryonal
  • Seminoma
  • Malignant Teratoma
  • Yolk Sac
  • Sarcomatoid
  • Choriocarcinoma
Additionally, some chemotherapy drugs may be combined to increase effectiveness of the treatment. The most typical combinations are the following:

BEP: Bleomycin + Etoposide + Cisplatin

EP: Etoposide + Cisplatin

VIP: Etoposide or Vinblastine + Ifosfamide + Cisplatin

Chemotherapy affects all rapidly dividing cells, meaning that healthy hair follicles, bone marrow and the lining of the digestive system are also affected.

Side effects depend on the type of chemotherapy used and may include the following:

  • Hair Loss, nausea, vomiting, diarrhea, loss of appetite and mouth sores (all of which typically resolve themselves after chemo has been completed).
  • Infertility: mostly temporary, while some cases may be permanent, which is why sperm banking should be discussed.
  • Low Blood count (anemia): decreased red blood cells or hemoglobin in the blood, resulting in fatigue.
  • Low Platelet count (thrombocytopenia): decreased blood platelet count. As platelets are necessary for adequate clotting to stop bleeding, thrombocytopenia can result in bruising and extensive bleeding from open cuts.
  • Low White blood cell count (leukopenia): decreased amount of leukocytes the blood. Leukocytes protect the body from infections, so any decrease in these cells can result in an increased susceptibility to infection during chemo treatment.
  • Neutropenia: Low number of neutrophils (immune cells) in blood, further increasing susceptibility to infection. Neutropenic patients who develop a fever (neutropenic fever) while on chemo should immediately go to the emergency.
  • Patients may receive Granulocyte colony-stimulating factor (GCSF), such as Neulasta while on chemo to stimulate the production of blood cells from the bone marrow to promote their ability to function

A HANDY GUIDE TO THE
BASICS OF CHEMO FROM

www.lymphoma.ca

Rare possible side effects from the cancer-treating drugs include:

  • Nerve damage (neuropathy) in patients receiving cisplatin, etoposide, paclitaxel or vinblastine. This is characterized by tingling, numbness or sensitivity of hands and feet.
  • Lung damage leading to shortness of breath in patients receiving bleomycin.
  • Bleeding from bladder (hemorrhagic cystitis) in patients on ifosfamide
  • Hearing loss (ototoxicity) in patients on cisplatin
  • Kidney damage in patients receiving cisplatin and ifosfamide

The majority of symptoms that are encountered during chemotherapy subside after the treatment has finished. If side effects become intolerable or blood cells reach dangerously low levels, chemo may be delayed until the patient recovers prior to receiving the next dose.

RADIATION

Radiation therapy machine

Radiation therapy uses beams of high-energy rays (gamma or x-rays) or small atomic particles (electrons, protons or neutrons) to kill cancer cells. Radiation can be used in testicular cancer treatment to eliminate cancer cells that have spread to adjacent lymph nodes. Radiation is delivered from a machine outside the body, similar to an x-ray procedure. Prior to treatment onset measurements are taken to evaluate the best angles for aiming the radiation beams towards the cancer.

The actual exposure to radiation only takes a few minutes. Seminomas are radiation sensitive, meaning the retroperitoneal abdomen area may be treated with radiation to eliminate any residual cancer cells within the lymph nodes.

Radiation therapy damages cells in the path of the radiation beam, which includes both cancerous and healthy cells. This means that radiation exposure should be limited by shielding other organs as well as the second healthy testicle. Side effects may include fatigue, nausea, diarrhea & changes in skin (redness, blistering and peeling).

FOLLOW UP

Patients who have been cured of their testicular cancer need to be monitored by their oncology team carefully. This may involve patient visits and physical examinations with bloodwork, chest x-rays and CT scans on a frequent basis.

It is important to catch a relapse early, so that it can be treated with a higher chance of curing the cancer. Patients who miss their appointments risk detecting the recurrence at a much later stage, which may lower their chance of curing the cancer.

The Tom Baker Cancer Centre, a sight many testicular cancer patients in Calgary know well

CT SCANS AND BLOOD TESTS

After the patient has been cured of testicular cancer he will be required to go in for CT scans and blood tests for up to five years in four or six month intervals. The chance of relapse in patients with metastatic germ cell tumors is incredibly low after the first two years (check out this research that Oneball funded). After five years of follow up for non-seminoma, the patient is considered cured of cancer with little chance of relapse. For seminoma patients, the follow up is for 10 years. Follow up visits may include:

  • Checking of remaining testicle and scar of initial orchiectomy.
  • Observing the size of local lymph nodes to ensure the cancer has not spread.
  • Obtaining blood serum tumor marker levels.
  • Discussing results of the latest CT scan.