Beyond the BEP: A Deep Dive into Testicular Cancer Management

In this episode of Oncology Decoded, hosts Manojkumar Bupathi, MD, MS, and Benjamin Garmezy, MD, spoke with Nabil Adra, MD, about testicular cancer care. The discussion gave a comprehensive overview of managing germ cell tumors, offering practical pearls for community oncologists.

The conversation opened with the initial approach to a patient presenting with a testicular mass. The doctors emphasize the importance of a thorough workup, including a CT scan of the chest, abdomen, and pelvis, and the use of tumor markers: AFP and hCG. Adra noted that while AFP and hCG are elevated in about 60% of cases, it’s crucial to understand their half-lives—about 5 to 7 days for AFP and 1 to 2 days for hCG—to properly assess their decline post-orchiectomy. He clarified that an AFP level under 25 ng/mL is considered normal and that mild elevations in hCG can be linked to marijuana use or cross-reactivity with luteinizing hormone, which should be investigated before initiating chemotherapy. The panel also touches on the use of lactate dehydrogenase as a prognostic marker, cautioning against using it as the sole basis for starting treatment.

A central part of the discussion revolves around the bleomycin, etoposide, cisplatin (BEP) vs etoposide and cisplatin chemotherapy regimens for good-risk disease. Adra explained the rationale behind the preference for BEP for 3 cycles at his institution, arguing that it avoids the long-term toxicities of neuropathy and ototoxicity associated with a fourth cycle of platinum therapy, a concern with the EP for 4 cycles. He stressed that with careful patient selection—avoiding bleomycin in patients over 50, with renal dysfunction, or pre-existing lung disease—the risk of pulmonary toxicity is minimal. He also influenced Garmezy’s practice by highlighting the importance of monitoring tumor markers with every cycle of chemotherapy, noting that a rising marker could signal a need to pivot to second-line therapy.

The conversation shifted to the role of surgery in stage II disease. For patients with non-bulky (less than 3 cm) stage II seminoma or non-seminoma, the panel discusses the preference for a retroperitoneal lymph node dissection (RPLND) over upfront chemotherapy or radiation to spare patients from long-term side effects. Adra highlighted that a proper RPLND at an experienced center can be curative in 80% of cases. The doctors stressed the importance of referring patients to surgeons with extensive experience in these complex procedures.

Finally, the hosts and guest tackled the management of relapsed/refractory disease. They discussed the 3 main options: salvage surgery, standard-dose chemotherapy, or high-dose chemotherapy with stem cell transplant. Adra shared that his institutional preference is for high-dose chemotherapy due to published data showing high cure rates, mentioning the ongoing phase 3 TIGER trial (NCT02375204), which is directly comparing standard-dose paclitaxel, ifosfamide, and cisplatin with high-dose chemotherapy. The episode concluded with a key pearl on managing patients with a high burden of pulmonary metastases, where a "cycle 0" of EP is sometimes used before starting a full course of vinblastine, ifosfamide, and cisplatin to mitigate the risk of hemoptysis.

Bupathi, is executive cochair of the Genitourinary Cancer Research Executive Committee at Sarah Cannon Research Institute (SCRI) and medical oncologist with Rocky Mountain Cancer Centers specializing in solid tumors and genitourinary cancers; Garmezy, is associate director of genitourinary research and executive cochair of the Genitourinary Cancer Research Executive Committee at SCRI and medical oncologist at SCRI Oncology Partners specializing in genitourinary cancers, and Adra is associate professor of Clinical Medicine and Clinical Urology, service line leader in medical oncology, medical director of Indiana University Health Simon Cancer Center, and program leader-genitourinary.