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With providers practicing in 50 specialties at 13 convenient locations, it’s easy to find the right healthcare team at Carle.

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Medical Services

Carle Foundation Hospital

Based in Urbana, Ill., the Carle Foundation Hospital is a 413-bed regional care hospital that has achieved Magnet® designation. It is the area's only Level 1 Trauma Center.

611 W. Park Street, Urbana, IL 61802   |   (217) 383-3311

Carle Hoopeston Regional Health Center

Carle Hoopeston Regional Health Center is comprised of a 24-bed critical access hospital and medical clinic based in Hoopeston, Illinois.

701 E. Orange Street, Hoopeston, IL 60942   |   (217) 283-5531

Carle Richland Memorial Hospital

Located in Olney, Ill., Carle Richland Memorial Hospital is a 134-bed hospital with nearly 600 employees serving portions of eight counties in southeastern Illinois.

800 East Locust St, Olney, IL 62459   |   (618) 395-2131

Convenient Care vs. ED

Carle Convenient Care offers same-day treatment for minor illnesses and injuries through walk-in appointments.

Not sure where to go? Click here for a list of conditions appropriate for the emergency department

Philanthropy

Philanthropy gives hope to patients and helps take health care in our community to a whole new level.

Classes & Events

Carle offers free community events open to members of the public. Select a category to view the calendar of upcoming events.

Treatment Options

At Carle Cancer Center, the latest state-of-the-art treatments and technologies are available to our patients. It is important to remember that different cancers require different treatments based on a variety of factors. For this reason, your treatment plan will be designed to meet the needs and requirements of your specific form of cancer.

Physicians will create an individualized treatment plan for each patient. Treatment plans depend upon:

  • Exact location of tumor
  • Stage of cancer
  • Patient's age
  • General health of patient

Patients and physicians will confer to carefully consider treatment options, while considering how the treatment might change a patient's appearance, speech ability, and eating and breathing. There is much to consider, and each step will be carefully analyzed for the best interest of the patient. Treatment options may include surgery, chemotherapy and/or radiation therapy.


Prostate Cancer

Surgery

Radical (open) prostatectomy
A radical prostatectomy is the surgical removal of the entire prostate and seminal vesicles. Lymph nodes in the pelvic area may also be removed. This operation has the risk of interfering with sexual function. Nerve-sparing surgery, when possible, increases the chance that a man can maintain his sexual function after surgery by avoiding surgical damage to the nerves that allow erections and orgasm to occur. Orgasm can occur even if some nerves are cut since these are two separate processes. Urinary incontinence is also a possible side effect of radical prostatectomy. To help resume normal sexual function, men can receive drugs, penile implants, or injections. Sometimes, another surgery can fix urinary incontinence.
Robotic or laparoscopic prostatectomy
This type of surgery is possibly much less invasive than a radical (open) prostatectomy and may shorten recovery time. A camera and instruments are inserted through small, keyhole incisions in the patient's abdomen. The surgeon then directs the robotic instruments to remove the prostate gland and surrounding tissue. In general, robotic prostatectomy causes less bleeding and less pain, but the sexual and urinary side effects can be similar to a radical (open) prostatectomy. This procedure has not been available for as long as radical (open) prostatectomy, so longer-term follow-up information, including permanent cure rates, are not yet certain. Talk with your doctor about whether your treatment center offers this procedure and how it compares with the results of the conventional radical (open) prostatectomy.
Cryosurgery
Cryosurgery (also called cryotherapy or cryoablation) is the freezing of cancer cells with a metal probe inserted through a small incision in the area between the rectum and the scrotum, the skin sac that contains the testicles. Cryosurgery may be useful for early-stage cancer and for men who cannot have a radical prostatectomy. However, it has not been compared with radical prostatectomy or radiation therapy, so doctors do not know if this would be a better treatment option. A common side effect of cryosurgery is impotence, so this approach is not recommended for men who desire to preserve their sexual function. Another side effect may be the development of fistulae (holes between the prostate and the bowel), although this appears to be much less common with newer cryosurgery techniques.
Transurethral resection of the prostate (TURP)
TURP is most often used to relieve symptoms of a urinary blockage, not to treat prostate cancer. In this procedure, with the patient under a full anesthesia (medication to block the awareness of pain), a surgeon inserts a cystoscope (a narrow tube with a cutting device) into the urethra and then into the prostate to remove prostate tissue.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping their ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy for prostate cancer is given intravenously (injected into a vein), and it may help patients with advanced or castration-resistant prostate cancer. A medical oncologist, a doctor who specializes in treating cancer with medication, usually prescribes chemotherapy.

There are several standard drugs used for prostate cancer, and a number of new drugs are currently being studied in clinical trials. In general, standard chemotherapy begins with docetaxel combined with a steroid called prednisone. This combination has been shown to help men with advanced prostate cancer live longer than another chemotherapy drug, mitoxantrone (Novantrone), which is most useful for controlling pain from the cancer. The FDA has also approved the drugs mitoxantrone, docetaxel, and cabazitaxel (Jevtana) for use in specific situations, such as prostate cancer that is resistant to hormone therapy. Cabazitaxel is similar to docetaxel, but research studies have shown it can be effective for prostate cancer that is resistant to docetaxel.

In general, the side effects of chemotherapy depend on the individual, the type of chemotherapy received, the dose used, and the length of treatment, but they can include fatigue, sores in the mouth and throat, diarrhea, nausea and vomiting, constipation, blood disorders, nervous system effects, changes in thinking and memory, sexual and reproductive issues, appetite loss, pain, and hair loss. The side effects of chemotherapy usually go away once treatment has finished. However, some side effects may continue, come back, or develop later. Ask your doctor which side-effects you may experience, based on your treatment plan. Your health care team will work with you to manage or prevent many of these side effects.

Radiation Therapy

External-beam radiation therapy
External-beam radiation therapy focuses a beam of radiation on the area with the cancer. Some cancer centers use conformal radiation therapy (CRT), in which computers help precisely map the location and shape of the cancer. CRT reduces radiation damage to healthy tissues and organs around the tumor by directing the radiation therapy beam from different directions to focus the dose on the tumor. External-beam radiation therapy is usually given with a high-energy x-ray beam. It can also be given with proton therapy (also called proton beam therapy), which uses protons rather than x-rays. At high energy, protons can destroy cancer cells.
Intensity-modulated radiation therapy (IMRT)
IMRT is a type of external-beam radiation therapy that uses CT scans to form a 3D picture of the prostate before treatment. A computer uses this information about the size, shape, and location of the prostate cancer to determine how much radiation is needed to destroy it. With IMRT, high doses of radiation can be directed at the prostate without increasing the risk of damaging nearby organs.
Proton therapy
Proton therapy (also called proton beam therapy) is a type of external-beam radiation therapy that uses protons rather than x-rays. At high energy, protons can destroy cancer cells. Current research has not shown that proton therapy provides any more benefit to patients with prostate cancer than traditional radiation therapy.
Brachytherapy
Brachytherapy is the insertion of radioactive sources directly into the prostate. These sources (called seeds) give off radiation just around the area in which they are inserted and may be used for hours (high-dose rate) or for weeks (low-dose rate). Low-dose rate seeds are left in the prostate permanently, even after all the radioactive material has been used up. For a man with a high-risk cancer, brachytherapy is usually combined with other treatments.

Radiation therapy may cause immediate side effects such as diarrhea or other problems with bowel function, such as diarrhea, gas, bleeding, and loss of control of bowel movements; increased urinary urge or frequency; fatigue; impotence (erectile dysfunction); and rectal discomfort, burning, or pain. Most of these side effects usually go away after treatment, but erectile dysfunction is usually permanent. Many side effects of radiation therapy may not show up until months or years after treatment.

Hormone Therapy

Because prostate cancer growth is driven by male sex hormones called androgens, lowering levels of these hormones can help slow the growth of the cancer. Hormone treatment is also called androgen ablation or androgen-deprivation therapy. The most common androgen is testosterone. Testosterone levels in the body can be lowered either surgically, with surgical castration (removal of the testicles), or with drugs that turn off the function of the testicles (medical castration, see below).

Hormone therapy is used to treat prostate cancer in different situations, including cancer that has come back after surgery and radiation therapy (recurrent prostate cancer) or cancer that has spread throughout the body at any time (metastatic prostate cancer).

Recent research has shown that hormone therapy can help lengthen lives when used with radiation therapy for a prostate cancer that is more likely to recur. For some men, hormone therapy will be used first to shrink a tumor before radiation therapy or surgery. In some men with prostate cancer that has spread locally, called locally advanced or high-risk prostate cancer, hormone therapy is given before, during, and after radiation therapy for three years. Hormone therapy should also be considered for men who have prostate cancer that has spread to the lymph nodes (found after radical prostatectomy) as adjuvant therapy. It may also be given for up to three years for men with intermediate-risk or high-risk cancer.

Traditionally, hormone therapy was used until it stopped controlling the cancer. Then the cancer was called castration-resistant (meaning that the hormone therapy has stopped working), and other treatment options were considered. Recently, researchers have begun studying intermittent hormone therapy, which is hormone therapy that is given for specific periods of time and then stopped temporarily according to a schedule. Giving hormones in this way appears to lower the side effects of this therapy, but it has not been shown to be effective for all stages of prostate cancer. Types of hormone therapy include:

  • Bilateral orchiectomy
  • LHRH agonists
  • LHRH antagonist
  • Anti-androgens
  • Combined androgen blockade
  • CYP17 inhibitors

Kidney Cancer

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. If the cancer has not spread beyond the kidneys, surgery to remove the tumor, part or all of the kidney, and possibly nearby tissue and lymph nodes, may be the only treatment necessary. The types of surgery used for kidney cancer include the following procedures:

Radical nephrectomy
Surgery to remove the tumor, the entire kidney, and surrounding tissue is called a radical nephrectomy. If nearby tissue and surrounding lymph nodes are also affected by the disease, a radical nephrectomy and lymph node dissection is performed. During a lymph node dissection, the lymph nodes affected by the cancer are removed. If the cancer has spread to the adrenal gland or nearby blood vessels, the surgeon may remove the adrenal gland during a procedure called an adrenalectomy and parts of the blood vessels.
Partial nephrectomy
A partial nephrectomy is the surgical removal of a tumor while preserving kidney function and lowering the risk of kidney disease after surgery, called hyperfiltration injury. It is used most often for a small tumor, even when the other kidney is functioning normally.
Laparoscopic and robotic surgery
During laparoscopic surgery, the surgeon makes several small incisions rather than the one larger incision in the abdomen used during a traditional surgical procedure. The surgeon then inserts telescoping equipment into these small, keyhole incisions to remove the kidney completely or perform a partial nephrectomy. Sometimes, the surgeon may use robotic instruments to perform the operation. This surgery may take longer, but it is less painful afterward and patients recover more quickly. It is important to discuss the potential benefits and risks of these types of surgery with the surgical team.
Radiofrequency ablation
Radiofrequency ablation (RFA) is the use of a needle inserted into the tumor to destroy the cancer with an electrical current. The procedure is performed by a radiologist or urologist. The patient is sedated and given local anesthesia to numb the area.
Cryoablation
Cryoablation, also called cryotherapy or cryosurgery, is the freezing of cancer cells with a metal probe inserted through a small incision. The metal probe is placed into the cancerous tissue using a CT scan and ultrasound for guidance. The procedure requires general anesthesia for several hours. The U.S. Food and Drug Administration (FDA) approved this treatment for kidney cancer, but more research studies are needed to determine how effective this treatment is in the long term.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells' ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication.

Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally). A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

While chemotherapy is useful for treating most types of cancer, kidney cancer is often resistant to chemotherapy. However, researchers continue to study new drugs and new combinations of drugs. For some patients, the combination of gemcitabine (Gemzar) and capecitabine (Xeloda) or fluorouracil (5-FU, Adrucil) will temporarily shrink a tumor.

It is important to remember that transitional cell carcinoma, also called urothelial carcinoma, and Wilms tumor are much more likely to be successfully treated with chemotherapy. The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist.

Radiation therapy is not considered to be effective as a primary treatment for kidney cancer. It is used alone only rarely to treat kidney cancer because of the high rate of damage that it causes to the healthy kidney. It is used only if a patient cannot have surgery and, even then, usually only on areas where the cancer has spread and not the primary kidney tumor. Most often, radiation therapy is used after the cancer has spread to help ease symptoms, such as bone pain or swelling in the brain.

The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. For kidney cancer, internal radiation therapy is given using a hollow needle to insert radioactive seeds directly into a tumor. Another type of radiation therapy is stereotactic radiosurgery, which is designed to direct the radiation therapy to a specific area without damaging nearby tissue. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Internal radiation therapy may cause some bleeding, infection, and risk of injury to nearby tissue. Most side effects go away soon after treatment is finished.


Bladder Cancer

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. There are different types of surgery for bladder cancer, and the most beneficial option usually depends on the stage and grade of the disease. Surgical options to treat bladder cancer include:

Transurethral bladder tumor resection (TURBT)

This procedure is used for diagnosis and staging, as well as treatment. During TURBT, a surgeon inserts a cystoscope (see the Diagnosis section) through the urethra into the bladder and removes the tumor using a tool with a small wire loop or using a laser or fulguration (high-energy electricity). The patient is given medication to block the awareness of pain, known as an anesthetic.

For patients with non-muscle-invasive bladder cancer, TURBT may be able to eliminate the cancer. However, the doctor may recommend additional treatments to prevent cancer recurrence, such as intravesical (into the bladder) chemotherapy or immunotherapy (see below). For patients with muscle-invasive bladder cancer, additional treatments involving surgery to remove the bladder or, less commonly, radiation therapy are necessary.

Cystectomy

A radical cystectomy is the removal of the whole bladder and possibly nearby tissues and organs. For men, the prostate and urethra also may be removed. For women, the uterus, fallopian tubes, ovaries, and part of the vagina also may be removed. In addition, lymph nodes in the pelvis are removed for both men and women. This is called a pelvic lymph node dissection. A thorough pelvic lymph node dissection is the most accurate way to find cancer that has spread to the lymph nodes. Rarely, for some specific cancers, it may appropriate to remove only part of the bladder, which is called partial cystectomy.

During a laparoscopic or robotic cystectomy, the surgeon makes several small incisions (cuts) instead of the one larger incision used for traditional surgery. The surgeon then uses telescoping equipment with or without robotic assistance to remove the bladder. The surgeon must make an incision to remove the bladder and surrounding tissue. This type of operation requires a surgeon who is very experienced in minimally invasive surgery. Several studies are still in progress to determine whether laparoscopic or robotic cystectomy is as safe as the standard surgery and whether it is able to eliminate bladder cancer as successfully as standard surgery.

Urinary diversion

If the bladder is removed, the doctor will create a new way to pass urine out of the body by using a section of the small intestine or colon to divert urine to a stoma or ostomy (an opening) on the outside of the body. The patient will need to wear a bag attached to the stoma to collect and drain urine.

Increasingly, surgeons can use part of the small or large intestine to make a urinary reservoir, which is a storage pouch that sits inside the body. With these procedures, the patient does not need a urinary bag and can have a better quality of life. For some patients, the surgeon is able to connect the pouch to the urethra, creating what is called a neobladder, so the patient can pass urine out of the body normally. However, the patient may need to insert a thin tube called a catheter if urine does not empty through the neobladder. Also, patients with a neobladder will no longer have the urge to urinate and will need to learn to urinate on a consistent schedule.

For other patients, the pouch is connected to the skin on the abdomen or umbilicus through a small stoma, which creates a type of continent urinary reservoir. This means urine will stay in the reservoir until the patient drains the pouch and no urinary pad is needed. The pouch is drained by inserting a catheter through the small stoma and then removing the catheter.

Living without the bladder can affect a patient's quality of life. Finding ways to keep all, or part, of the bladder is an important treatment goal, as long as the patient's prognosis isn't affected. For some patients with muscle-invasive bladder cancer, certain treatment plans involving chemotherapy and radiation therapy (see below) may be used as an alternative to removing the bladder.

The side effects of bladder cancer surgery depend on the procedure. Patients should talk with their doctor in detail to understand exactly what side effects may occur, including urinary and sexual side effects, and how they can be managed. In general, side effects may include:

  • Delayed healing
  • Infection
  • Mild bleeding and discomfort after surgery
  • Infections or urine leaks after cystectomy or a urinary diversion. If a neobladder has been created, a patient may sometimes be unable to urinate or completely empty the bladder.
  • Men may be unable to have an erection, called impotence, after cystectomy. Sometimes, a nerve-sparing cystectomy can be performed. When this is done successfully, men may be able to have a normal erection.
  • Damage to the nerves in the pelvis and loss of sexual feeling and orgasm for both men and women. Often, these problems can be fixed.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells' ability to grow and divide. A chemotherapy regimen typically consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

There are two types of chemotherapy that may be used to treat bladder cancer. The type the doctor recommends and when it is given depends on the stage of the cancer. Patients should talk with their doctor about chemotherapy before surgery.

Intravesical chemotherapy
Intravesical (local) chemotherapy is usually given by a urologist. During this type of therapy, drugs are delivered into the bladder through a catheter that has been inserted through the urethra. Local treatment only destroys superficial tumor cells that come in contact with the solution. It cannot reach tumor cells in the bladder wall or tumor cells that have spread to other organs. Mitomycin (Mitozytrex, Mutamycin) and thiotepa (multiple brand names) are the drugs used most often for intravesical chemotherapy. Other drugs that are used include doxorubicin (Adriamycin), gemcitabine (Gemzar), and valrubicin (Valstar).
Systemic chemotherapy
Systemic (whole body) chemotherapy is usually prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

A combination of drugs, called MVAC, has been used as the standard treatment for bladder cancer for many years. MVAC uses four drugs: methotrexate (multiple brand names), vinblastine (Velban, Velsar), doxorubicin, and cisplatin (Platinol). When it is given before surgery, MVAC can extend life and cure patients. For patients with bladder cancer that has spread, known as metastatic disease, this combination can shrink the cancer and potentially prolong life. In addition, depending on the disease setting, MVAC can help delay bladder cancer recurrence. However, it has severe side effects.

The combination of gemcitabine plus cisplatin is also used and has comparable anticancer effects to MVAC for patients with metastatic disease but with somewhat fewer side effects.

Many of systemic chemotherapies continue to be tested in clinical trials to help determine which drugs, or which drug combinations, work best to treat bladder cancer. Usually a combination of drugs works better than one drug alone. Researchers are also studying when it is best to use chemotherapy, either before or after surgery.

Side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

Radiation Therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. When radiation therapy is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.

Radiation therapy is usually not used by itself as a primary treatment for bladder cancer, but it may be given in combination with chemotherapy. However, some patients who cannot receive chemotherapy might receive radiation therapy alone. The combination of radiation therapy and chemotherapy may be used to treat cancer that is located only in the bladder for the following reasons:

  • To destroy any remaining tumor after TURBT while sparing the bladder
  • To relieve symptoms caused by a tumor, such as pain, bleeding, or blockage
  • To treat a metastasis located in one area, such as the brain or bone

Side effects from radiation therapy may include fatigue, mild skin reactions, and loose bowel movements. For bladder cancer, side effects most commonly occur in the pelvic or abdominal area and may include bladder irritation with the need to pass urine frequently during the treatment period and bleeding from the bladder or rectum. Most side effects go away soon after treatment is finished.


Testicular Cancer

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. There are different types of surgery used to treat testicular cancer, each is described further below. If a decision is made to perform an orchiectomy, a sample of blood will be collected before surgery to test for levels of serum tumor markers because they are often helpful in planning treatment and follow-up care.

Radical inguinal orchiectomy

Treatment of testicular cancer usually starts with surgery to remove the testicle with cancer, called radical inguinal orchiectomy. This is done through an incision in the groin along the beltline. It is used to diagnose and treat both early-stage and later-stage seminomas and non-seminomas. For later-stage cancer, a radical inguinal orchiectomy may, occasionally, be delayed until after treatment with chemotherapy is finished.

The removal of one testicle typically does not affect a man's testosterone level if he still has the other testicle, and it is a normal size. If a man's testosterone level is reduced, symptoms may include depression or other mood changes, fatigue, decreased sex drive, inability to achieve a normal erection, especially in the morning, and hot flashes, as well as loss of muscle and bone mass in the long term. Orchiectomy is unlikely to make a man unable to father a biological child because the remaining testicle will still produce sperm. However, about 25% of men with testicular cancer are infertile even before being diagnosed with cancer. It appears that the cancer itself may cause some men to become infertile. Sperm counts may improve after the testicle with cancer is removed.

A man may develop cancer in both testicles either at the same time or at different times. However, this is rare, occurring in about 2% of men with testicular cancer. If the removal of both testicles, called a bilateral orchiectomy, is performed, the man will no longer produce sperm or testosterone and will not be able to biologically produce children. If the doctor recommends removing the testicle in a man with one testicle, semen is usually analyzed twice before surgery to check if the man's sperm are fully functioning. If the sperm are functional, then sperm banking is usually recommended, so that he will be able to have children later if he wishes. In addition, for men who have had both testicles removed, testosterone hormone replacement therapy will be needed.

Men can choose to have an artificial or prosthetic testicle implanted in the scrotum that has a weight and texture that is somewhat similar to a normal testicle but not exactly the same. Some men find that a prosthetic testicle is uncomfortable. Each man is encouraged to talk with his doctor about the best timing of this implantation. Some men prefer to wait until after the active treatment period is over to give this option full consideration.

Retroperitoneal lymph node dissection (RPLND)
This is surgery to remove the retroperitoneal lymph nodes that lie at the back of the abdomen. RPLND may be considered for men with clinical stage I and IIA non-seminomas and men with retroperitoneal masses that remain after finishing chemotherapy for late-stage disease. In men with non-seminomas, any masses larger than 1 cm that remain after chemotherapy are removed if it is possible, but for men with pure seminomas, masses smaller than 3 cm are usually left in place and monitored for changes with CT scans. RPLND is usually performed as an open operation with an incision down the middle of the abdomen. Doctors are studying the use of laparoscopic RPLND, which uses several smaller incisions instead of the one large incision, but that approach still being studied, requires a surgeon skilled in the procedure, and may not be as effective.
RPLND for stage I and IIA non-seminomas

About 30% of patients with clinical stage I non-seminoma who have an RPLND are found to have lymph nodes with cancer; in other words, the surgery shows that they have stage II disease. For men with clinical stage I disease, the risk of recurrence can be lowered with RPLND. In these situations, RPLND is done as a treatment that reduces the risk of recurrence, in addition to being used to stage the cancer. This makes it possible to determine which men are most likely to need chemotherapy after RPLND. Doctors are now able to better determine which stage I tumors are at a higher risk of having spread to the lymph nodes or beyond, based on the results of the pathology tests performed on the tumor in the testicle after it is removed. Decisions about whether to have an RPLND may be based on the patient's risk factors. Active surveillance (see below) for patients with low-risk disease and chemotherapy for patients with high-risk disease may be recommended for some, but RPLND is a reasonable treatment option when a patient can see a urologist with extensive experience with RPLND. If an RPLND is chosen for stage I non-seminoma, it is usually done within six weeks after orchiectomy.

If 5 or fewer lymph nodes have cancer but none are larger than 2 cm (pN1), this surgery alone is successful for 80% to 90% of men, while about 10% to 20% of men will have a recurrence. If more lymph nodes have cancer (pN2 or pN3), surgery alone is successful for about 50% of patients, while the other 50% will have a recurrence. The advantage of the RPLND is that it can cure most patients with small lymph node metastases, provide a more accurate assessment of the extent of disease, and avoid the need for frequent CT scans of the abdomen during follow-up care. It also reduces the chance that a man with early-stage (stage I) testicular cancer will be given unnecessary chemotherapy.

Just as RPLND may show cancer in lymph nodes that appeared normal on CT scans for men with clinical stage I non-seminomas, surgery may also show that there is no cancer in lymph nodes that were enlarged on a CT scan, called clinical stage II disease. For men with clinical stage IIA testicular non-seminomas, 20% to 40% will actually have pathological stage I cancer, meaning that the cancer has not spread to any lymph nodes. In these situations, the use of RPLND can help many men avoid unneeded chemotherapy.

It is important to remember that the RPLND is a complex surgery requiring experience and skill in order to remove all of the appropriate lymph nodes and to minimize the side effects of the operation. RPLND should only be done by a surgeon who is highly experienced with this operation.

Some patients may experience temporary side effects from RPLND, such as bowel obstruction (blockage) or infection. This procedure should not affect a man's ability to have an erection, orgasm, or sexual intercourse, but it may cause infertility because it can damage the nerves that control ejaculation. Therefore, men are encouraged to bank sperm before RPLND. There are surgical techniques that are usually successful at sparing the nerves involved with ejaculation, and it is recommended that a man discuss this with his surgeon. The main disadvantage of this surgery for stage I non-seminoma is that 70% of patients are cured by removal of the testicle alone; for these men, a RPLND offers no curative benefit, although it does allow the man to avoid the regular CT scans needed with active surveillance, as well as, possibly, peace of mind.

Also, despite the surgery, about 10% of testicular cancers recur even if the lymph nodes were not found to have cancer. If the RPLND finds that the lymph nodes have cancer, then a decision needs to be made whether to give two courses of chemotherapy (see below) to decrease the chance of recurrence to about 1%. However, active surveillance is also an option, beginning treatment with chemotherapy only if the cancer recurs. This is because this type of cancer has a greater than 95% chance of being cured with three cycles of chemotherapy if the recurrence is diagnosed early through regular monitoring.

RPLND to remove residual tumors after chemotherapy
RPLND performed after chemotherapy is a more complex surgery and is more likely to cause infertility from being unable to ejaculate and other side effects. However, the surgical removal of any masses larger than 1 cm that remain after chemotherapy for non-seminomas is believed to be an essential part of treating the disease when such it can be safely done. About 35% to 40% of men going through such surgery will have a mass that contains teratoma or about 10% to 15% will have one of the other germ cell cancers. The other 40% to 50% of men will have no mass. Some treatment centers will perform an RPLND after chemotherapy in men who had enlarged retroperitoneal lymph nodes before chemotherapy even if the lymph nodes return to normal size (less than 1 cm) after chemotherapy. Some treatment centers may not recommend RPLND if a CT scan taken after chemotherapy is normal. For men found to have teratoma, no additional treatment is given after RPLND. For men found to have one of the other germ cell tumors (seminoma, embryonal carcinoma, yolk sac tumor, or choriocarcinoma), additional chemotherapy is generally recommended after RPLND.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells' ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication.

Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally). A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

The following drugs are used for testicular cancer, usually in the combinations listed further below.

  • Bleomycin (Blenoxane)
  • Carboplatin (Paraplatin)
  • Cisplatin (Platinol)
  • Etoposide (Toposar, VePesid)
  • Ifosfamide (Ifex)
  • Paclitaxel (Taxol)
  • Vinblastine (Velban)
  • Vinorelbine (Navelbine)

The following chemotherapy regimens may be used for testicular cancer.

  • BEP: bleomycin, etoposide, and cisplatin.
  • EP: etoposide and cisplatin
  • TIP: paclitaxel, Ifosfamide, and cisplatin
  • VeIP: vinblastine, ifosfamide, and cisplatin
  • Vinorelbine (Navelbine), etoposide, and cisplatin
  • VIP: etoposide, ifosfamide, and cisplatin

In general, patients with later-stage disease receive more chemotherapy. The appropriate chemotherapy regimen depends on the stage of the cancer and whether it is a seminoma or a non-seminoma. Chemotherapy regimens for specific stages are discussed further below.

Chemotherapy works very well for testicular cancer but can cause side effects and complications. Most of these side effects usually go away once treatment is finished, but some can show up much later. These are called late effects. Balancing the risks and benefits of chemotherapy is an important issue for men with testicular cancer. However, metastatic testicular cancer can generally only be cured with chemotherapy, so for men with metastatic testicular cancer, the benefits of chemotherapy typically outweigh the risks. On the other hand, men with stage I testicular cancer almost never die of the disease regardless of which treatment they receive, so the risks of chemotherapy may outweigh the benefits for these men.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. For testicular cancer, the radiation is generally directed at lymph nodes in the abdomen. Often, the radiation is also targeted at lymph nodes on the same side of the pelvis as the testicle where the cancer started.

Radiation therapy is more effective for treating seminoma than non-seminoma and is used less often than in the past. Active surveillance or, less commonly, carboplatin chemotherapy is used instead of radiation therapy as the preferred treatment of stage I seminomas at many treatment centers because of the risk that radiation therapy may cause other cancers and heart disease. However radiation therapy remains an option for stage I, IIA, and IIB pure seminomas. It is also sometimes used to treat brain metastases from either seminomas or non-seminomas, but testicular cancer rarely spreads to the brain.

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, loose bowel movements, and peptic ulcers. Medications may be helpful to prevent or reduce nausea and vomiting during radiation therapy. Most side effects go away soon after treatment is finished. Radiation therapy may cause problems with sperm production, but this is less common now with newer radiation techniques that can help men to preserve fertility.

Radiation therapy may increase risk of secondary cancers many years after treatment, as well as cardiovascular disease and gastrointestinal disease. Talk with your doctor about your risk of long-term side effects before starting radiation therapy.