Observation or Lymph Node Removal: Two Common Options for Testicular Cancer
The first step in treating testicular cancer is removal of the affected testicle through a 2-3 inch incision in the lower groin. Special blood tests (tumor markers) are also drawn at this time. Once the diagnosis is confirmed by the pathologist, additional testing would include a CT scan of the abdomen and repeat blood testing if the original tumor markers were abnormal. The next step is determining if the cancer has spread. Typically, testicular cancer will spread to the lymph nodes in the back of the abdominal cavity (also called the retroperitoneum). If a large amount of disease is found in this area (or any amount in another area), chemotherapy would be the best treatment. Any remaining disease would then be removed surgically. When a small amount of lymph node enlargement in the retroperitoneum is detected, surgical removal (retroperitoneal lymph node dissection or RPLND) is usually recommended.
Here’s where the debate over treatment begins. In cases where the CT scan is normal, a significant portion of patients can still have a small amount of disease in these lymph nodes. As a result, it can be difficult to decide between intense observation, surgical removal, or chemotherapy. A big factor in this decision is the type of cancer cells (often more than one type) found in the removed testicle. Some types (embryonal cell, choriocarcinoma) are more aggressive, thereby increasing the chance of spread if observation persists for too long. Another type (teratoma) does not respond to chemotherapy and is best treated by removal when the lymph node involvement is small. Pure (no other cell type) seminoma interestingly is the only type of cancer that responds to radiation. In these cases, radiation is often recommended to treat retroperitoneal lymph nodes that appear normal on a CT scan.
The biggest advantage to observation over time is avoiding major surgery and any associated potential side effects (particularly when no disease is found in these lymph nodes). The major downside to observation is the intensity of follow-up which often includes monthly CT scans. In addition, when a cancer recurs, the resulting treatment is usually much more involved than if treated when the CT scan was normal. However, the ultimate cure rate with either choice is very similar (>95%).
Traditionally, RPLND is performed through a large abdominal incision but can also be completed with a laparoscopic approach. However, side effects or complications can still occur. The obvious advantages to undergoing RPLND for normal-appearing lymph nodes are knowing the status of the disease, decreasing the intensity of the follow-up, and eliminating disease present in these lymph nodes. Following RPLND, if cancer cells are present in the lymph nodes, chemotherapy is usually given as an additional precaution to treat disease that may have spread further. However, the amount of chemotherapy is usually much less than for recurrences detected later.
More recently, chemotherapy has been proposed as an alternative to observation or major surgery for patients with normal-appearing lymph nodes on CT scan. Although data are still being collected, the cure rates seem similar. However, since most patients with testicular cancer are young, long-term side effects can be a concern. These side effects include risk of secondary cancers such as leukemia, cardiovascular disease, lung disease, and impaired fertility. In patients with persistently abnormal tumor markers following testicular removal, chemotherapy is always the best next option.
The information surrounding this controversial decision between observation and aggressive treatment is daunting. This decision is influenced by pathology findings in the testicle, tumor markers, ability to adhere to strict follow-up protocols, and personal preference. Of course, there is no substitute to detailed discussions with experienced physicians.