Episode 11: Testicular Cancer Treatment: Making an Informed Diagnosis

This video interview for Oncology Decoded distills a rich conversation between oncologists Manojkumar Bupathi, MD, MS, Benjamin Garmezy, MD, and Nabil Adra, MD, focusing on key decision points in managing testicular cancer.

The standard workup for patients with testicular cancer includes CT scans of the chest, abdomen, and pelvis to determine disease extent. It emphasizes the importance of tumor markers, AFP and hCG, noting their utility and a key piece of information: their half-lives. This knowledge helps to confirm whether the markers are declining as expected after initial surgery.

Navigating Treatment Regimens: A core segment addresses the treatment options for good-risk metastatic disease: either 3 cycles of bleomycin, etoposide, and cisplatin (BEP) or 4 cycles of etoposide plus cisplatin. The experts discuss the pros and cons of each.

• BEP x 3: Preferred by the experts to minimize long-term neurotoxicity and ototoxicity, a common adverse effect of the additional cycle of platinum therapy in the EP regimen. They noted that with proper patient selection (considering age, renal function, and lung health), the risk of bleomycin toxicity is low.
• EP x 4: A valid alternative for patients where bleomycin is contraindicated.

The discussion also clarified that for intermediate and poor-risk disease, more intensive regimens like BEP for 4 cycles or vinblastine, ifosfamide, and cisplatin are necessary.

The Role of Surgery: The video outlines the strategic use of surgery for stage II disease. For patients with small-volume stage II seminoma or non-seminoma, a retroperitoneal lymph node dissection (RPLND) is often preferred over chemotherapy. The experts explain that this approach is aimed at sparing patients from chemotherapy adverse effects, as a proper RPLND is curative in a significant number of cases.

High-Dose Chemotherapy and Relapse: The video addresses the critical topic of disease relapse. It outlines that for patients who progress on frontline chemotherapy, the standard of care is moving towards high-dose chemotherapy with stem cell transplant. The experts cite institutional data showing high cure rates in this setting, mentioning the ongoing phase 3 TIGER trial (NCT02375204), which is evaluating this approach head-to-head against standard-dose salvage chemotherapy.

Key Takeaways and Notable Trials:

• Tumor Markers: AFP levels under 25 ng/mL are considered normal. Be cautious of mild hCG elevations, as they can be caused by marijuana use or cross-reactivity with luteinizing hormone.
• Chemotherapy Monitoring: Monitoring tumor markers with every cycle of chemotherapy is crucial, as a rise may indicate a need to change the treatment plan.
• BEP vs. EP: The choice depends on a patient's comorbidities, but BEP for 3 cycles is a highly effective, less toxic regimen for appropriate patients.
• Community Care: The experts underscored the importance of early consultation with a specialized center, especially for surgery or relapsed disease, to ensure the best possible outcomes for these patients.

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.