Treatments for non-seminoma

The following are treatment options for the stages of non-seminoma testicular cancer. Treatment options can depend on the stage, the prognosis group (based on the International Germ Cell Cancer Consensus Group (IGCCCG) classification system) and the treatments that were used to treat the original cancer if it comes back (relapses). Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.

Surgery is the main treatment for stage 1 non-seminoma. The type of surgery done is called a radical inguinal orchiectomy (an orchiectomy). This surgery removes the testicle and spermatic cord through a small opening in the groin. It’s usually done as part of the diagnosis. Surgery, followed by active surveillance, is the only treatment that most men with stage 1 non-seminoma need.

Some men with stage 1 non-seminoma may also have a retroperitoneal lymph node dissection (RPLND). This surgery removes lymph nodes from the back of the abdomen (called the retroperitoneum). Lymph nodes are usually removed from the same side of the body where the tumour was removed. Testicular cancer usually spreads to these lymph nodes, so removing them can lower the risk of the cancer coming back (relapse). An RPLND is often done for men who have a high risk of relapse. Chemotherapy can be given after an RPLND if cancer cells are found in the lymph nodes that were removed.

Active surveillance is the preferred treatment after surgery for stage 1 non-seminoma. It involves regular and frequent follow-up to look for signs and symptoms that the cancer has come back. Tests done during a visit include a physical exam, blood tests to check tumour marker levels and imaging tests.

If the cancer comes back, it usually happens within 18 months after surgery. Treatment is given when the cancer comes back.

Chemotherapy may be offered after surgery for stage 1 non-seminoma if you can’t complete the regular and frequent follow-up of active surveillance or you prefer to have treatment after surgery. It can also be given after surgery if there are high levels of tumour markers in the blood. Chemotherapy is given through a needle in a vein (intravenously). You may be offered this chemotherapy combination:

• BEP – bleomycin, etoposide (Vepesid) and cisplatin

Surgery is part of the treatment for stage 2 non-seminoma. The type of surgery done is called an orchiectomy.

A retroperitoneal lymph node dissection (RPLND) may be offered after an orchiectomy. An RPLND is surgery to remove the lymph nodes in the back of the abdomen. Lymph nodes may be removed from the same side of the body where the tumour was removed or on both sides of the abdomen. An RPLND may be done for stage 2A or 2B non-seminoma when tumour marker levels are normal after an orchiectomy.

If a mass bigger than 1 cm in diameter remains after an orchiectomy and chemotherapy (called residual disease), more surgery may be done to remove the mass. This is postchemotherapy surgery. The surgery is usually a bilateral RPLND, which removes lymph nodes from the back of the abdomen on both sides of the body.

Chemotherapy may be offered after surgery for stage 2 non-seminoma. It will be offered if the tumour marker levels stay elevated after an orchiectomy or if the tumour has a good prognosis based on the IGCCCG classification system. Chemotherapy is given through a needle in a vein. You may be offered one of the following chemotherapy combinations:

• BEP – bleomycin, etoposide and cisplatin
• EP – etoposide and cisplatin
• VIP – etoposide, ifosfamide (Ifex) and cisplatin

EP and VIP are used when bleomycin affects the lungs or there is a high risk that it will cause lung damage.

Men who have tumours in the good prognosis group are offered BEP or EP.

Men who have tumours in the intermediate prognosis group are offered BEP or VIP.

If doctors find that lymph nodes removed during an RPLND have cancer cells in them, chemotherapy with BEP or EP can be given.

Active surveillance is usually offered after an orchiectomy for stage 2A non-seminoma if the tumour marker levels are normal. It involves regular and frequent follow-up to see if lymph nodes at the back of the abdomen are getting bigger. Tests done during a follow-up visit include a physical exam, blood tests to check tumour marker levels and imaging tests.

If the retroperitoneal lymph nodes are growing and tumour marker levels are still normal, your doctors will do an RPLND.

If the retroperitoneal lymph nodes are growing and tumour marker levels are getting higher, you will be offered chemotherapy.

Surgery is a main treatment for stage 3 non-seminoma. The first type of surgery done is called an orchiectomy. In some cases, chemotherapy is given before an orchiectomy when the cancer has spread over a large area of the abdomen and you have many symptoms.

Chemotherapy is a standard treatment for stage 3 non-seminoma. It is usually given after an orchiectomy. Chemotherapy may also be used before surgery if the cancer had already spread and doctors confirmed it was non-seminoma by doing a biopsy. Chemotherapy is given through a needle in a vein. You may be offered one of the following chemotherapy combinations:

• BEP – bleomycin, etoposide and cisplatin
• VIP – etoposide, ifosfamide and cisplatin
• EP – etoposide and cisplatin

EP and VIP are used when bleomycin affects the lungs or there is a high risk that it will cause lung damage.

The combination of chemotherapy drugs used depends on the tumour’s prognosis, which is based on the IGCCCG classification system.

Men who have tumours in the good prognosis group are offered BEP or EP.

Men who have tumours in the intermediate prognosis group are offered BEP or VIP.

After chemotherapy, the healthcare team will follow up to look for any cancer that remains (called residual disease) and check tumour marker levels. Any residual lesions larger than 1 cm will be removed by surgery. An RPLND can be part of that surgery. Surgery to remove cancer that is outside of the retroperitoneum, such as in the lungs or mediastinum, may be done in some cases.

If the tumour has spread to the brain, chemotherapy using VIP is usually offered.

After chemotherapy, the healthcare team will follow up with imaging tests to look for any cancer that remains and signs that the cancer has come back.

Relapsed non-seminoma means that the cancer has come back after it has been treated. The following are treatment options for relapsed non-seminoma.

Chemotherapy is the main treatment for relapsed non-seminoma. The combination of chemotherapy drugs given will depend on the treatments that were used to treat the original cancer.

Men who didn’t have chemotherapy after surgery to treat the original cancer will be offered BEP for relapsed non-seminoma.

Men who were given an RPLND to treat the cancer the first time will be offered BEP, EP or VIP for relapsed non-seminoma.

Men who were given BEP or EP the first time may be given another chemotherapy drug combination (called salvage chemotherapy) through a needle in a vein. You may be offered one of the following combinations:

• TIP – paclitaxel, ifosfamide and cisplatin
• VIP – etoposide, ifosfamide and cisplatin
• VeIP – vinblastine, ifosfamide and cisplatin

High-dose chemotherapy with carboplatin and etoposide may be used if testicular cancer comes back after it is treated with standard-dose chemotherapy or salvage chemotherapy. After high-dose chemotherapy, a stem cell transplant is done to replace the stem cells that are damaged or destroyed by high-dose chemotherapy. The stem cell transplant uses stem cells from your own blood (called autologous peripheral blood stem cell transplant).

Chemotherapy can also be used as palliative therapy for cancer that comes back after having most other treatments. Palliative therapy is given to relieve symptoms rather than to treat the cancer itself. Palliative chemotherapy that may be used for non-seminoma includes:

• etoposide given by mouth (orally)
• gemcitabine with oxaliplatin or paclitaxel given through a needle in a vein

Surgery may be done after salvage chemotherapy or high-dose chemotherapy with a stem cell transplant. An RPLND may be done if the cancer comes back in the retroperitoneum after active surveillance or previous chemotherapy for stage 1 non-seminoma. Surgery may also be done to remove a non-seminoma if it comes back more than 2 years after the original cancer was treated.

You may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments don’t work anymore, they’re not likely to improve your condition or they may cause side effects that are hard to cope with. There may also be other reasons why you can’t have or don’t want cancer treatment.

Talk to your healthcare team. They can help you choose care and treatment for advanced cancer.

Talk to your doctor about clinical trials open to men with testicular cancer in Canada. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.