Testicular Cancer
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A new clinical study shows that surgery alone is just as effective, yet safer than chemotherapy or radiation treatments in the long-term, for patients with early-stage seminoma, a type of testicular cancer. Seminoma is a slow-growing form of testicular cancer that, if untreated, usually spreads to lymph nodes in an area behind the abdomen lining called the retroperitoneum. Seminomas represent about 30% of testicular cancers. For decades the conventional treatment for Stage 2A and 2B seminoma has been chemotherapy and/or radiation. While effective, they expose patients to the risk of heart damage, neuropathies, hearing loss, and the possibility of treatment-related cancer development in the long term.

In a trial from the University of Southern California, researchers wanted to see if surgery alone could provide the same or better cure rates without the side effects of chemotherapy and radiation. “My thinking was why are we treating early-stage seminomas, which tend to be somewhat more indolent, with the same chemo regimen that we would for far more advanced disease,” said lead study investigator Sia Daneshmand, MD, a urologic oncologist at USC.

Standard practice is to perform retroperitoneal lymph node dissection (RPLND) to remove and test lymph nodes in patients with non-seminoma Stage 2 disease. For this reason, Daneshmand thought it might also be a good option for seminomas of the same stage. RPLND has not traditionally been considered a viable stand-alone treatment for Stage 2A or 2B early metastatic seminoma. But after performing a few small case studies with just a few patients, Daneshmand could see that the approach was successful and initiated the larger Phase II trial.

Results of that multi-institutional clinical trial recently published in the Journal of Clinical Oncology show that surgically removing the affected lymph nodes in the retroperitoneum is an effective alternative to chemotherapy and radiation with fewer long-term side effects.

The study enrolled 55 patients across 12 institutions to investigate if surgery could replace chemotherapy and radiation as an effective treatment, thereby sparing patients the long-term risks associated with the two traditional therapies.

Study participants had previously undergone surgery to remove the testicle(s) where the original cancer occurred, and their cancer had progressed no further than to the retroperitoneum. Once enrolled, the patients underwent RPLND.

Daneshmand and his colleagues found that 81% of the patients demonstrated a two-year recurrence-free survival rate. The 20% who did experience recurrence of the cancer were successfully treated with either chemotherapy or additional surgery for an overall survival rate of 100%.

“That’s the key, that we can actually do this surgery, wait, and not give any additional therapy because we are seeing an 80% cure rate without exposing patients to long-term risk of side effects,” said Daneshmand. “And the ones who aren’t immediately cured can be salvaged with chemotherapy. And we show that we can go from 9 weeks of chemotherapy to a surgery which is about 3-4 hours and the patients are usually home the next day.”

In this study, the researchers also observed that 12% to 15% of patients diagnosed with Stage 2A or 2B seminoma had negative lymph nodes. “This surgery-only approach will spare those patients from chemo and radiation when they don’t even have disease in the retroperitoneum,” he adds.

Daneshmand mentions that the modern RPLND surgery he performs is a new technique. Called a midline extraperitoneal approach, the surgery keeps the intestines in the peritoneum. “This way, we can get to the back of the abdomen like we normally do but without bringing the intestines out,” he describes. Because testicular cancer management is highly nuanced, especially for early metastatic seminomas, Daneshmand recommends that treatment be sought only at centers of excellence or in consultation with centers of excellence. “Studies show that the outcomes are better for the patient with fewer side effects and better survival,” he said.

Altogether seminomas are a less common form of testicular cancer, and the Stage 2 early metastatic types are even more uncommon. “This study shows that we can change the standard treatment for these cancers where now people are getting chemotherapy and radiation where they could just have surgery,” said Daneshmand.

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