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CASE STUDY: Treating Early-Stage Metastatic Testicular Cancer with Surgery Alone

The adaptation of an established surgical treatment for metastatic non-seminoma allows most patients with similar stage seminoma to avoid the long-term risks of chemotherapy or radiation therapy.

Testicular cancer is rare, but it is the most common solid cancer in young men, with an average age of diagnosis of 33. Although it is one of the most curable cancers — with a 98% cure rate when diagnosed early — traditional treatments may come at a cost.

Standard testicular cancer treatments like chemotherapy or radiation therapy carry the risk of long-term side effects such as kidney damage, increased odds of cardiovascular disease and secondary cancers, and infertility.

Recently, the results of a multi-institutional clinical trial were published in the Journal of Clinical Oncology, detailing a successful study of treating early metastatic seminoma with surgery alone. The results showed that surgically removing the affected lymph nodes in the retroperitoneum is an effective alternative to chemo and radiation – with fewer long-term side effects.

Exploring surgical approach for early-stage metastatic seminoma

For one California man enrolled in the trial, the thought of infertility was crushing. At the time of his diagnosis in 2015, at age 31, he and his fiancé were planning on having children. 

“I felt devastated by the news that I had cancer, but one of my biggest fears was the potential for infertility," he said. 

He initially had surgery to remove his left testicle. However, a follow-up scan revealed the cancer had spread to his lymph nodes. He consulted more than a dozen doctors about what to do next.

Several other experts recommended Sia Daneshmand, MD, the director of urologic oncology for USC Urology, part of Keck Medicine of USC. At the time, Daneshmand was in the early stages of the clinical trial he had designed, studying the efficacy of using surgery, without chemo or radiation, to treat early-stage metastatic seminoma – one of the two common forms of testicular cancer.

Testicular cancer impacts a “young population with decades of healthy life left in front of them,” Daneshmand said. He was motivated to help these patients avoid the serious risks associated with chemo or radiation and help to enhance their quality of life post-cancer.

His answer came in the form of an established surgery for metastatic non-seminoma – the other form of testicular cancer, which can grow faster than seminomas. In that procedure, the cancerous lymph nodes are surgically removed from behind the abdomen through a 10-centimeter abdominal incision. 

Daneshmand, who is also a member of USC Norris Comprehensive Cancer Center, had explored treating early-stage metastatic seminoma patients with this surgery alone about a decade ago.

“The first four patients I treated were successfully cured,” he said. The positive results led to the larger clinical trial across several institutions patients with stage 2 testicular cancer. 

High success rate for surgical clinical trial

The California man was one of the first patients to join the trial.

“There's an approach I have called the midline extraperitoneal approach, where we don't enter the abdominal cavity,” said Daneshmand, who served as the trial’s lead investigator. “We keep the intestines within the sac called the peritoneum and go behind it to remove the lymph nodes.”

According to Daneshmand, this strategy allows most patients to go home the day after surgery.

“It makes it a very attractive option because it gets them back on their feet quickly with a low complication rate,” he said.  

It has also been proven to be highly successful. Of the 55 people who participated in the clinical trial, 8 in 10 were cured without needing further therapy. 

The remainder of patients in the trial were successfully cured with chemotherapy or additional procedures for a 100% total survival rate. Most cancer recurrences happened within two years of surgery. 

“For the majority of patients to be cured with a single surgery was certainly a big win,” said Daneshmand. Given the results, the updated national treatment guidelines for testicular cancer now include surgery as an treatment option for early metastatic seminoma.

The California patient was among the 80% cured from surgery alone. Eight years later, he remains cancer-free — and he and his wife are welcoming their first child.