| Ch 12 | Page 11 / 13 | |
| Multidiscliplinary approach |
Example of a therapeutic protocol | |
The following example illustrates a typical multidisciplinary approach showing the various actors involved throughout the therapeutic decision.
Testicular cancer is relatively rare but is highly representative of the importance of a multidisciplinary approach.
Testis cancer can be simply described as follows.
Two types of testis cancers exist: seminoma and non-seminoma (for which various histologies exist).
Assaying the tumour marker (AFP and HCG) is of great importance for non-seminoma forms after unilateral castration in order to distinguish between benign and severe cases.
If the tumour is strictly limited to the testis without spreading, unilateral castration is sufficient.
If the tumour invades beyond the testis, then complementary treatment is required.
The surgical procedure is always necessary since the testes are a kind of sanctuary within which chemotherapy cannot penetrate. The setting of a testicular prosthesis limits the (generally reduced) psychological impact of unilateral castration, which has no consequence on fertility and sexual potency.
As long as the tumour is limited to proximal nodes (lumbo-aortic nodes), radiotherapy, with a relatively low dose of 30 Gy, is very efficient for seminoma. This radiotherapy does not induce major toxicity.
For nonseminoma invading beyond testis, assays of tumour markers and abdominal scans guide therapy. If there is any persisting doubt that the tumour extends beyond the testis, then chemotherapy should be prescribed.
In the case of remote evolution, for nonseminoma testicular cancer, chemotherapy can be either simple (4 cures with Etoposide and Platinol) or stronger (when tumour markers are very high or in the case of very large tumour masses).
After chemotherapy, the persistence of node lesions should lead to surgical excision in order to avoid further evolution stemming from these tumour residues. The surgeon should take great care in the proximity of ejaculation nerves which are situated just behind the lumbo-aortic nodes. Absence of ejaculation would lead to sterility (or should be corrected by epididymis in vitro withdrawal).
For metastatic or relapsing seminoma, chemotherapy is instituted as for nonseminoma.
Unfortunately, retrospective studies of medical records, particularly for patients who died from their disease show that (with the exception of immediately severe cases with brain metastases or very large masses) most treatment failures are due to poor patient follow-up, irregular and non-rigorous chemotherapy, insufficient explanation or guidance of often young and rebellious patients.
Treating these patients requires well trained teams in order to obtain the almost 100% recovery rate for limited diseases.
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