Non-Seminoma: Stage II
Patients with stage II non-seminoma have cancer that involves the testicle and the retroperitoneal lymph nodes and is curable in over 90% of cases
A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.
The following is a general overview of the treatment of stage II testicular non-seminoma. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.
Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news in order to learn about new treatments and the results of clinical trials.
There are several treatment options for patients with stage II non-seminoma based on the extent of the disease at diagnosis. All include surgical removal of the cancer with orchiectomy and pelvic lymph node dissection or adjuvant therapy.
Lymph Node Dissection and Surveillance
Because surgical removal of the cancer cures the majority of patients and chemotherapy can cure most patients whose cancer returns following surgery, a surgical orchiectomy and retroperitoneal lymph node dissection followed by close surveillance is the standard treatment. Surveillance consists of monthly checkups, physical examination, chest x-ray, and cancer marker tests (AFP, BHCG and LDH) with CT scans every 2 months. This option of surgery and careful surveillance, reserving chemotherapy to only treat cancer recurrences, is usually advised for patients who have fewer than 6 lymph nodes involved with cancer at retroperitoneal lymph node dissection, none of which are greater than 2 centimeters (about one inch) in diameter and cancer that is without evidence of venous or lymphatic invasion. Such patients have a cancer recurrence rate of approximately 20-30% if treated with surgery alone and most are curable with standard combination chemotherapy containing Platinol® when recurrence occurs. By utilizing this approach, the majority of patients are cured and 70-80% of patients will not require chemotherapy.
Lymph Node Dissection and Adjuvant Chemotherapy
It is important to understand that some patients with non-seminoma already have small amounts of cancer that have spread beyond what was removed surgically and cannot be detected with any of the currently available tests. Undetectable areas of cancer are referred to as micrometastases. The presence of micrometastases causes cancer recurrence following treatment with surgery alone. An effective treatment is needed to cleanse the body of micrometastases in order to improve a patient’s potential for cure. The delivery of cancer treatment following local treatment with surgery is referred to as adjuvant therapy and may include chemotherapy or radiation therapy.
Following orchiectomy and lymph node dissection, some patients will experience cancer recurrence if they are not treated with adjuvant therapy. By routinely administering adjuvant chemotherapy after surgery, the chance of cancer recurrence can almost be completely eliminated. The choice of receiving adjuvant chemotherapy is influenced by the risk of cancer recurrence and the preferences of the patient concerning surveillance.
Tumors larger than 2 centimeters, involvement of more than 6 lymph nodes with cancer and evidence of vascular invasion of the primary tumor are all associated with an increased risk of cancer recurrence. The relapse rate after retroperitoneal lymph node dissection has been reported to be approximately 60% in patients who had microscopic evidence of vascular invasion in the primary tumor. Patients whose tumor markers do not return to normal following the removal of retroperitoneal lymph nodes are also at a high risk for cancer recurrence. These patients may elect to be treated with adjuvant chemotherapy to reduce their risk of recurrence.
The results of a large clinical trial comparing adjuvant chemotherapy to surveillance demonstrated that 2 courses of Platinol®-based chemotherapy (either Platinol®, Velban®, bleomycin (PVB) or Velban®, bleomycin, cyclophosphamide, Platinol® (VAB VI)) prevented cancer recurrences in more than 95% of patients with stage II non-seminoma. There was a 49% recurrence rate in patients assigned to surveillance; however, almost all of these patients could be effectively treated with chemotherapy at the time of relapse. This study suggests that although adjuvant therapy will almost always prevent recurrences, the alternative approach of surveillance with chemotherapy only for patients who relapse results in an equivalent overall cure rate.
Neoadjuvant Chemotherapy with Delayed Surgery for Large Volume Disease
Neoadjuvant therapy consists of chemotherapy or radiation therapy that is administered prior to surgery with the intent of shrinking the cancer so that it is easier to remove. Some patients have large cancers and it may be difficult to remove the entire cancer with surgery. Treatment with neoadjuvant chemotherapy may decrease the size of the cancer, thereby allowing for easier and more complete removal with surgery. Standard chemotherapy regimens include bleomycin, etoposide and Platinol® (BEP) for 3 courses or a regimen of etoposide and Platinol® for 4 courses.
If patients do not achieve a complete response from neoadjuvant chemotherapy, surgical removal of residual cancer is performed. The timing of such surgery requires clinical judgment, but typically occurs after 3 or 4 cycles of combination chemotherapy and normalization of tumor markers. The chance of finding residual cancer after chemotherapy is dependent on the histology of the primary tumor. Patients whose primary tumor contained teratomatous elements have a higher probability of having residual teratoma or carcinoma in the lymph nodes than do patients whose primary tumor contains only embryonal cancer. However, one study has reported that regardless of initial histology, there is a significant risk of residual teratoma or carcinoma in residual masses after chemotherapy. Therefore, some physicians think that neither the size of the initial cancer nor the degree of shrinkage accurately identifies patients likely to have residual teratoma or carcinoma. This has led some physicians to recommend surgery with resection of all residual masses apparent on CT scans in patients who have normal cancer markers after responding to chemotherapy. If patients have persistent non-seminomatous germ cell malignant cancer in the surgically removed mass, additional chemotherapy is required.
Chemotherapy Before Orchiectomy for Life-Threatening Disease
In some cases, cancer has spread to other areas of the body and has become life threatening. In these instances, chemotherapy is initiated prior to orchiectomy. When this is done, orchiectomy after chemotherapy is advisable in order to remove the primary cancer. This is because there is a blood-testes barrier to chemotherapy. There are two places in the body where chemotherapy cannot penetrate, the brain and the testes. The blood-testes barrier prevents chemotherapy from reaching the testicle, thereby resulting in a high incidence of residual cancer in the testicle after completion of a full course of chemotherapy. In other words, all cancer outside the testes can be eliminated with a full course of chemotherapy, but there could still be cancer in the testes.
The standard chemotherapy regimens based on controlled studies consist of 3 cycles of bleomycin, etoposide and Platinol® (BEP) or 4 cycles of etoposide and Platinol® using a 5-day etoposide schedule.
Adjuvant Therapy and No Lymph Node Dissection for Low Volume Disease
In some clinical trials, primary chemotherapy has been administered to patients with small volume cancers in an effort to avoid lymph node dissection. Although clinical trials directly comparing lymph node dissection to chemotherapy have not been performed, it appears that primary chemotherapy, when compared to primary retroperitoneal node dissection, produces similar cure rates in patients with clinical stage II non-seminoma.
Questions to Ask Your Physician:
- Based on my situation, what is the best treatment option?
- What are the risks of delaying treatment compared to getting adjuvant chemotherapy?
- What are the risks of lymph node dissection?
Strategies to Improve Treatment
The progress that has been made in the treatment of testicular cancer has resulted from improved development of chemotherapy and radiation treatments in patients with more advanced stages of cancer and participation in clinical trials. Future progress in the treatment of testicular cancer will result from continued participation in appropriate clinical trials. The main issues for treatment of stage II non-seminoma involve studies to determine the optimal timing for intervention with chemotherapy and the role of retroperitoneal node dissection.
Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed. For more information, go to Supportive Care.