Testicular Cancer Staging
The staging process involves some assessment of the abdomen, usually a CT scan. Some assessment of the chest which could be a chest x-ray or a chest CT scan, as well as serum markers. There’s probably no other disease where serum markers are as useful as in testicular cancer. One of the markers is the alpha-fetoprotein is elevated in about 50% of the cases. After an orchiectomy is performed, if the person has no residual disease, the alpha-fetoprotein will return to normal. It’s half life is anywhere between 5-7 days. The HCG is elevated in about 60% of tumors. In contrast to the alpha-fetoprotein the half life of HCG is much shorter, with a half life of about 24 hours. One or both of these markers are elevated in about 80% of tumors.
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This is the staging of testicular cancer. Stage I tumors are those tumors that are confined to within the testes, no evidence of metastatic disease and normal markers after orchiectomy. Stage II tumors are those in which there are involved retroperitoneal lymph nodes and the sub-staging of stage II is dependent upon the size of the lymph nodes involved. Stage III tumors are those that involve any other areas beyond the lymph nodes, particularly above the diaphragm.
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Now let’s talk about treatment of different subtypes of testicular cancer. First of all, stage I seminoma. Orchiectomy is performed. The pathologist says this is a pure seminoma. The alpha-fetoprotein has never been elevated. If the alpha-fetoprotein is elevated in the context of a seminoma it is categorically considered a non-seminoma. So for pure seminoma, stage I – that is, radiographically no evidence of disease – markers, HCG, have returned to normal – which can be elevated in about 10% of patients. The standard of care for these patients is infradiaphragmatic radiation in a hockey-stick distribution, to anywhere between 2500 and 3000 rads. Observation is an alternative to infradiaphragmatic radiation, although considering the high cure rate with radiation and low morbidity associated with radiation, it is considered a second alternative to radiation.
For stage II seminomas, that is, involvement of the lymph nodes, the treatment is dependent on the size of the lymph nodes. If the lymph node mass is solitary and is 5 cm or less the standard of care in the United States is radiation in a hockey-stick distribution with a boost of radiation to the lymph node mass of about 1,000 rads. For masses that are greater than 5 cm, chemotherapy is the standard of care.