Current concepts in clinical therapeutics: testicular cancer

The incidence and epidemiology, pathophysiology, diagnosis and staging, and therapy of testicular cancer are reviewed. Although relatively rare, testicular cancer is an important disease because it is the first disseminated solid tumor occurring in adults for which truly effective therapy has been developed. More than 90% of testicular neoplasms are of germ-cell origin; about 40% of cases involve pure seminoma, 15%-20% are pure embryonal carcinoma, and the rest are of mixed types. Clinically, the major distinction is between pure seminoma and other types because of therapeutic differences. Most men with testicular neoplasms initially complain of a painless testicular mass. Surgical exploration follows, with orchiectomy and complete excision of the spermatic cord if a neoplasm is documented. Seminoma is a highly radiosensitive tumor, and overall cure rates now approach 95%-98%. Combination therapy with cisplatin has been effective in treating patients with extensive disease. Nonseminomatous testicular cancer patients who do not have metastases are treated with a traditional orchiectomy and retroperitoneal lymph-node dissection; about 10% of patients will relapse and must be treated with antineoplastic agents. Patients with disseminated disease require systemic treatment with cisplatin-based combination drug therapy. Reduction of toxicity and identification of patients who can be spared extensive treatment are the current thrusts of research; efficacy is excellent for several regimens. Major advances have been made over the last two decades in curing patients with testicular cancer.