Liver cancer surgery

At this time, surgery, either with resection (removal of the tumor) or a liver transplant, offers the only reasonable chance to cure liver cancer. If all known cancer in the liver is successfully removed, you will have the best outlook.

Partial hepatectomy

Surgery to remove part of the liver is called partial hepatectomy. This operation is only attempted if the person is healthy enough for surgery and all of the tumor can be removed while leaving enough healthy liver behind. Unfortunately, most liver cancers cannot be completely removed. Often the cancer is in too many different parts of the liver, is too large, or has spread beyond the liver.

Imaging tests, such as CT or MRI with angiography are done first to see if the cancer can be removed completely. Still, sometimes during surgery the cancer is found to be too large or spread too far to be removed, and the surgery has to be cancelled.

More than 4 out of 5 people in the United States with liver cancer also have cirrhosis. In someone with severe cirrhosis, removing even a small amount of liver tissue at the edges of a cancer might not leave enough liver behind to perform essential functions. People with cirrhosis are eligible for surgery only if the cancer is small and they still have a reasonable amount of liver function left. Doctors often assess this function by assigning a Child-Pugh score (see the section “How is liver cancer staged?”), which is a measure of cirrhosis based on certain lab tests and symptoms. Patients in class A are most likely to have enough liver function to have surgery. Patients in class B are less likely to be able to have surgery. Surgery is not typically an option for patients in class C.

Possible risks and side effects: Liver resection is a major, serious operation that should only be done by skilled and experienced surgeons. Because people with liver cancer usually have liver problems besides the cancer, surgeons have to remove enough of the liver to try to get all of the cancer, yet leave enough behind for the liver to function adequately.

A lot of blood passes through the liver, and bleeding after surgery is a major concern. On top of this, the liver normally makes substances that help the blood clot. Damage to the liver (both before the surgery and during the surgery itself) can add to potential bleeding problems.

Other possible problems are similar to those seen with other major surgeries and can include infections, complications from anesthesia, blood clots, and pneumonia.

Another concern is that because the remaining liver still has the underlying disease that led to the cancer, sometimes a new liver cancer can develop afterward.

Liver transplant

When it is available, a liver transplant may be the best option for some people with small liver cancers. At this time, liver transplants can be an option for those with tumors that cannot be removed with surgery, either because of the location of the tumors or because the liver is too diseased for the patient to withstand removing part of it. In general, it is used to treat patients with small tumors (either 1 tumor smaller than 5 cm across or 2 to 3 tumors no larger than 3 cm) that have not invaded nearby blood vessels. It can also rarely be an option for patients with resectable cancers (cancers that can be removed completely).

According to the Organ Procurement and Transplantation Network, about 1,200 liver transplants were done in people with cancer in the liver in the United States in 2011, the last year for which numbers are available. In most cases, the patients had liver cancer but some had bile duct cancer.

With a transplant, not only is the risk of a second new liver cancer significantly reduced, but the new liver will function normally.

Unfortunately, the opportunities for liver transplants are limited. Only about 6,000 livers are available for transplant each year, and most of these are used for patients with diseases other than liver cancer. Increased awareness about the importance of organ donation is an essential public health goal that could make this treatment available to more patients with liver cancer and other serious liver diseases.

Most livers for transplants come from people who have just died. But in recent years, a small number of patients have received part of a liver from a living donor (usually a close relative) for transplant. The liver can regenerate some of its lost function over time if part of it is removed. Still, the surgery does carry some risks for the donor. Less than 250 living donor transplants are done in the United States each year. Only a small number of them are for patients with liver cancer.

People needing a transplant must wait until a liver is available, which can take too long for some people with liver cancer. In many cases a person may get other treatments, such as embolization or ablation (described in following sections), while waiting for a liver transplant. Or doctors may suggest surgery or other treatments first and then a transplant if the cancer comes back.

Possible risks and side effects: Like partial hepatectomy, a liver transplant is a major operation with serious risks (bleeding, infection, blood clots, complications from anesthesia, etc.). But there are some additional risks after this surgery.

People who get a liver transplant have to be given drugs to help suppress their immune systems to prevent their bodies from rejecting the new organ. These drugs have their own risks and side effects, especially the risk of getting serious infections. By suppressing the immune system, these drugs might also allow any remaining liver cancer to grow even faster than before. Some of the drugs used to prevent rejection can also cause high blood pressure, high cholesterol, diabetes, can weaken the bones and kidneys, and can even lead to a new cancer.

After a liver transplant, regular blood tests are important to check for signs of the body rejecting the new liver. Sometimes liver biopsies are also taken to see if rejection is occurring and if changes are needed in the anti-rejection medicines.

Survival rates for liver cancer

Survival rates are often used by doctors as a standard way of discussing a person's prognosis (outlook). Some patients might want to know the survival statistics for people in similar situations, while others may not find the numbers helpful, or may even not want to know them. If you do not want to read about the survival statistics for liver cancer, skip to the next section.

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Of course, many of these people live much longer than 5 years. Five-year relative survival rates, such as the numbers below, assume that some people will die of other causes and compare the observed survival with that expected for people without the cancer. This is a more accurate way to describe the prognosis for patients with a particular type and stage of cancer.

To get 5-year survival rates, doctors have to look at people who were treated at least 5 years ago. Although the numbers below are among the most current we have available, improvements in treatment since then may result in a more favorable outcome for people now being diagnosed with liver cancer.

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they cannot predict what will happen in any particular person's case. Knowing the type and the stage of a person's cancer is important in estimating their outlook. But many other factors may also affect a person's outcome, such as a person's overall health (especially whether or not they have cirrhosis), the treatment received, and how well the cancer responds to treatment. Even when taking these other factors into account, survival rates are rough estimates at best. Your doctor can tell you how and if the numbers below apply to you.

The numbers below come from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, and are based on patients who were diagnosed with liver cancer (hepatocellular type) between 2003 and 2009.

The SEER database does not divide liver cancer survival rates by AJCC TNM stages. Instead, it groups cancer cases into summary stages:

• Localized means the cancer is still confined to the liver, and includes stages I, II, and some stage III cancers. This includes a wide range of cancers, some of which are easier to treat than others.
• Regional means the cancer has grown into nearby organs or has spread to nearby lymph nodes, and includes stages IIIC and IVA cancers.
• Distant means that the cancer has spread to distant organs or tissues and is the same as stage IVB.

Stage	5-year Relative Survival Rate
Localized	28%
Regional	7%
Distant	2%

For all stages combined, the relative 5-year survival rate from liver cancer is about 15%. Part of the reason for this low survival rate is that most patients with liver cancer also have other liver problems such as cirrhosis, which itself can be fatal.

In general, survival rates are higher for people who can have surgery to remove their cancer, regardless of the stage. For example, studies have shown that patients with small, resectable tumors who do not have cirrhosis or other serious health problems are likely to do well if their cancers are removed. Their overall 5-year survival is over 50%. For people with early-stage liver cancers who are able to have a liver transplant, the 5-year survival rate is in the range of 60% to 70%.

What is hepatitis?

Q: What is hepatitis?

A: Hepatitis is an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E. These five types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread. In particular, types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis and cancer.

Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C and D usually occur as a result of parenteral contact with infected body fluids. Common modes of transmission for these viruses include receipt of contaminated blood or blood products, invasive medical procedures using contaminated equipment and for hepatitis B transmission from mother to baby at birth, from family member to child, and also by sexual contact.

Acute infection may occur with limited or no symptoms, or may include symptoms such as jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.

Q: What are the different hepatitis viruses?

A: Scientists have identified five unique hepatitis viruses, identified by the letters A, B, C, D, and E. While all cause liver disease, they vary in important ways.

Hepatitis A virus (HAV) is present in the faeces of infected persons and is most often transmitted through consumption of contaminated water or food. Certain sex practices can also spread HAV. Infections are in many cases mild, with most people making a full recovery and remaining immune from further HAV infections. However, HAV infections can also be severe and life threatening. Most people in areas of the world with poor sanitation have been infected with this virus. Safe and effective vaccines are available to prevent HAV.

Hepatitis B virus (HBV) is transmitted through exposure to infective blood, semen, and other body fluids. HBV can be transmitted from infected mothers to infants at the time of birth or from family member to infant in early childhood. Transmission may also occur through transfusions of HBV-contaminated blood and blood products, contaminated injections during medical procedures, and through injection drug use. HBV also poses a risk to healthcare workers who sustain accidental needle stick injuries while caring for infected-HBV patients. A safe and effective vaccine is available to prevent HBV.

Hepatitis C virus (HCV) is mostly also transmitted through exposure to infective blood. This may happen through transfusions of HCV-contaminated blood and blood products, contaminated injections during medical procedures, and through injection drug use. Sexual transmission is also possible, but is much less common. There is no vaccine for HCV.

Hepatitis D virus (HDV) infections occur only in those who are infected with HBV. The dual infection of HDV and HBV can result in a more serious disease and worse outcome. Safe and effective hepatitis B vaccines provide protection from HDV infection.

Hepatitis E virus (HEV), like HAV, is mostly transmitted through consumption of contaminated water or food. HEV is a common cause of hepatitis outbreaks in developing parts of the world and is increasingly recognized as an important cause of disease in developed countries. Safe and effective vaccines to prevent HEV infection have been developed but are not widely available.

What is the treatment for brain cancer?

A treatment plan is individualized for each brain cancer patient. The treatment plan is constructed by the doctors who specialize in brain cancer, and treatments vary widely depending on the cancer type, brain location, tumor size, patient age, and patient's general health status. A major part of the plan is also determined by the patient's wishes. Patients should discuss treatment options with their health-care providers.

Surgery, radiation therapy, and chemotherapy are the major treatment categories for most brain cancers. Individual treatment plans often include a combination of these treatments. Surgical therapy attempts to remove all of the tumor cells by cutting the tumor away from normal brain tissue. This surgery is often termed invasive surgery to distinguish it from noninvasive radiosurgery or radiation therapy described below.

Radiation therapy attempts to destroy tumor cells by using high-energy radiation focused onto the tumor to destroy the tumor cells' ability to function and replicate. Radiosurgery is a nonsurgical procedure that delivers a single high dose of precisely targeted radiation using highly focused gamma-ray or X-ray beams that converge on the specific area or areas of the brain where the tumor or other abnormality is located, minimizing the amount of radiation to healthy brain tissue. Equipment used to do radiosurgery varies in its radiation source; a gamma knife uses focused gamma rays, and a linear accelerator uses photons, while heavy-charged particle radiosurgery uses a proton beam.

Chemotherapy attempts to destroy tumor cells using chemicals (drugs) that are designed to destroy specific types of cancer cells. There are many chemical agents used; specific drug therapies are numerous, and each regimen is usually designed for the specific type of brain cancer and individualized for each patient. For example, bevacizumab (Avastin) is a drug approved for treatment of glioblastomas. Chemotherapy can be administered intrathecally (by a spinal tap or through a surgically placed permanent reservoir under the scalp attached through a sterile tubing placed into the fluid-containing chambers in the brain), by IV administration, and biodegradable chemically impregnated polymers. All treatments attempt to spare normal brain cells.

Other treatment options may include hyperthermia (heat treatments), immunotherapy (immune cells directed to kill certain cancer cell types), or steroids to reduce inflammation and brain swelling. These may be added on to other treatment plans.

Clinical trials (treatment plans designed by scientists and physicians to try new chemicals or treatment methods on patients) can be another way for patients to obtain treatment specifically for their cancer cell type. Clinical trials are part of the research efforts to produce better treatments for all disease types. Stem cell treatments for brain and brain stem cancers and other conditions may be available, because research with patients is ongoing using these potential therapies. The best treatment for brain cancer is designed by the team of cancer specialists in conjunction with the wishes of the patient.

What are the symptoms and signs of brain cancer?

Although there are few early signs, the most common symptoms of brain cancer are weakness, difficulty walking, seizures, and headaches. Other common symptoms are nausea, vomiting, blurry vision, or a change in a person's alertness, mental capacity, memory, speech, or personality. These symptoms can also occur in people who do not have brain cancer, and none of these symptoms alone or in combination can predict that a person has brain cancer. Cancer can occur in any part of the brain (for example, occipital, frontal, parietal, or temporal lobes, brainstem, or meningeal membranes). A few brain cancers may produce few or no symptoms (for example, some meningeal and pituitary gland tumors).

What tests are used to diagnose brain cancer?

The initial test is an interview that includes a medical history and physical examination of the person by a health-care provider. The results of this interaction will determine if other specific tests need to be done.

The most frequently used test to detect brain cancer is a CT scan (computerized tomography). This test resembles a series of X-rays and is not painful, although sometimes a dye needs to be injected into a vein for better images of some internal brain structures. Another test that is gaining popularity because of its high sensitivity for detecting anatomic changes in the brain is MRI (magnetic resonance imaging). This test also resembles a series of X-rays and shows the brain structures in detail better than CT. MRI is not as widely available as CT scanning. If the tests show evidence (tumors or abnormalities in the brain tissue) of brain cancer, then other doctors such as neurosurgeons and neurologists that specialize in treating brain ailments will be consulted to help determine what should be done to treat the patient. Occasionally, a tissue sample (biopsy) may be obtained by surgery or insertion of a needle to help determine the diagnosis. Other tests (white blood cell counts,electrolytes, or examination of cerebrospinal fluid to detect abnormal cells or increased intracranial pressure) may be ordered by the health-care practitioner to help determine the patient's state of health or to detect other health problems.

What causes brain cancer?

Primary brain tumors arise from many types of brain tissue (for example, glial cells, astrocytes, and other brain cell types). Metastatic brain cancer is caused by the spread of cancer cells from a body organ to the brain. However, the causes for the change from normal cells to cancer cells in both metastatic and primary brain tumors are not fully understood. Data gathered by research scientists show that people with certain risk factors are more likely to develop brain cancer.

Individuals with risk factors, such as having a job in an oil refinery, handlers of jet fuel or chemicals like benzene, chemists, embalmers, or rubber-industry workers, show higher rates of brain cancer than the general population. Some families have several members with brain cancer, but heredity as a cause for brain tumors has not been proven. Other risk factors such as smoking, radiation exposure, and viral infection (HIV) have been suggested but not proven to cause brain cancer. There is no good evidence that brain cancer is contagious, caused by head trauma, or caused by cell phone use. Although many lay press and web articles claim that aspartame (artificial sweetener) causes brain cancer, the FDA maintains that it does not cause brain cancer and base their findings on over 100 toxicological and clinical studies regarding the sweetener's safety.

What is metastatic brain cancer?

Cancer cells that develop in a body organ such as the lung (primary cancer tissue type) can spread via direct extention, or through the lymphatic system and/or through the bloodstream to other body organs such as the brain. Tumors formed by such cancer cells that spread (metastasize) to other organs are called metastatic tumors. Metastatic brain cancer is a mass of cells (tumor) that originated in another body organ and has spread into the brain tissue. Metastatic tumors in the brain are more common than primary brain tumors. They are usually named after the tissue or organ where the cancer first developed (for example, metastatic lung orbreast cancer tumors in the brain, which are the most common types found). Occasionally, an abbreviated name may be used that often confuses people; for example, "small cell brain cancer" actually means "small cell lung cancer that has metastasized to the brain." People should not hesitate to ask their doctor about any terms they do not understand.

What is brain cancer?

Not all brain tumors are alike, even if they arise from the same type of brain tissue. Tumors are assigned a grade depending on how the cells in the tumor appear microscopically. The grade also provides insight as to the cell's growth rate. NCI lists the following grades:Brain cancer is a disease of the brain in which cancer cells (malignant) arise in the brain tissue. Cancer cells grow to form a mass of cancer tissue (tumor) that interferes with brain functions such as muscle control, sensation, memory, and other normal body functions. Tumors composed of cancer cells are called malignant tumors, and those composed of mainly noncancerous cells are called benign tumors. Cancer cells that develop from brain tissue are called primary brain tumors while tumors that spread from other body sites to the brain are termed metastatic or secondary brain tumors. Statistics suggest that brain cancer occurs infrequently and is likely to develop in about 23,000 new people per year with about 13,000 deaths as estimated by the National Cancer Institute (NCI) and American Cancer Society.

• Grade I: The tissue is benign. The cells look nearly like normal brain cells, and they grow slowly.
• Grade II: The tissue is malignant. The cells look less like normal cells than do the cells in a grade I tumor.
• Grade III: The malignant tissue has cells that look very different from normal cells. The abnormal cells are actively growing and have a distinctly abnormal appearance (anaplastic).
• Grade IV: The malignant tissue has cells that look most abnormal and tend to grow quickly.

The most common primary brain tumors are usually named for the brain tissue type from which they originally developed. These are gliomas, meningiomas, pituitary adenomas, vestibular schwannomas, and primitive neuroectodermal tumors (medulloblastomas). Gliomas have several subtypes which include astrocytomas, oligodendrogliomas, ependymomas, and choroid plexus papillomas. When the grades are coupled with the tumor name, it gives doctors a better understanding about the severity of the brain cancer. For example, a grade III (anaplastic) glioma is an aggressive tumor, while an acoustic neuroma is a grade I benign tumor. However, even benign tumors can cause serious problems if they grow big enough to cause increased intracranial pressure or obstruct vascular structures or cerebrospinal fluid flow.

Brain cancers are staged (stage describes the extent of the cancer) according to their cell type and grade because they seldom spread to other organs, while other cancers, such as breast or lung cancer, are staged according to so-called TMN staging which is based on the location and spread of cancer cells. In general, these cancer stages range from 0 to 4, with stage 4 indicating the cancer has spread to another organ (highest stage).

Brain cancer facts

Brain cancer can arise from many different types of brain cells (primary brain cancer) or occur when cancer cells from another part of the body spread (metastasize) to the brain.

Causes of brain cancer are difficult to prove; avoiding compounds linked to cancer production is advised.

Symptoms of brain cancer vary but often include weakness, difficultywalking, seizures, and headaches. Other common symptoms arenausea, vomiting, blurry vision, or a change in a person's alertness, mental capacity, memory, speech, or personality.

Tests for brain cancer involve a history, physical exam, and usually a CT or MRI brain scan; sometimes a brain tissue biopsy is done.

Treatments usually are directed by a team of doctors and are designed for the individual patient; treatments may include surgery, radiotherapy, or chemotherapy, often in combination.

Side effects of treatments range from mild to severe, and patients need to discuss plans with their treatment team members to clearly understand potential side effects and their prognosis (outcomes).

Depending on the brain cancer type and overall health status of the patient, brain cancer frequently has only a fair to poor prognosis; children have a somewhat better prognosis.

What is pancreatitis?

Normally, digestive enzymes secreted by the pancreas do not become active until they reach the small intestine. But when the pancreas is inflamed, the enzymes inside it attack and damage the tissues that produce them.Pancreatitis is inflammation of the pancreas. The pancreas is a large gland behind the stomach and close to the duodenum - the first part of the small intestine. The pancreas secretes digestive juices, or enzymes, into the duodenum through a tube called the pancreatic duct. Pancreatic enzymes join with bile - a liquid produced in the liver and stored in the gallbladder - to digest food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body regulate the glucose it takes from food for energy.

Pancreatitis can be acute or chronic. Either form is serious and can lead to complications. In severe cases, bleeding, infection, and permanent tissue damage may occur.

Both forms of pancreatitis occur more often in men than women.

What are the layers of the bladder?

The bladder consists of three layers of tissue. The innermost layer of the bladder which comes into contact with the urine stored inside the bladder is called the "mucosa" and consists of several layers of specialized cells called "transitional cells," which are almost exclusively found in the urinary system of the body. These same cells also form the inner lining of the ureters, kidneys, and a part of the urethra. These cells form a waterproof lining within these organs to prevent the urine from going into the deeper tissue layers.

The middle layer is a thin lining known as the "lamina propria" and forms the boundary between the inner "mucosa" and the outer muscular layer. This layer has a network of blood vessels and nerves and is an important landmark in terms of the staging of bladder cancer (described in detail below in the bladder cancer staging section).

The outer layer of the bladder comprises of the "detrusor" muscle and is called the "muscularis." This is the thickest layer of the bladder wall. Its main function is to relax slowly as the bladder fills up to provide low-pressure urine storage and then to contract to compress the bladder and expel the urine out during the act of passing urine. Outside these three layers is a variable amount of fat which lines and protects the bladder like a soft cushion and separates it from the surrounding organs such as the rectum and the muscles and bones of the pelvis.

Bladder Cancer Facts

Bladder cancer is one of the common cancers affecting men and women.

The most common symptom isbleeding in the urine (hematuria).

Cigarette smoking is the most significant risk factor with smokers three to four times more likely to get the disease than nonsmokers.

Bladder cancer can be subdivided into superficial and muscle invasive, with the former having much better treatment outcomes than the latter.

The initial treatment for bladder cancer is transurethral resection (TURBT), which removes the tumor from the bladder and provides information regarding stage and grade of the tumor.

Low-grade superficial tumors (Ta) are treated with TURBT followed by an optional instillation of a single dose of a chemotherapy medication in the bladder to reduce recurrence rates. These tumors have high recurrence rates but a very low chance of progression to higher stages.

High-grade T1 tumors have high chances of recurrence and progression and may need additional treatment in the form on BCG or chemotherapy instillation in the bladder. Patients unresponsive to these may be best treated by radical cystectomy.

Radical cystectomy provides the best chances of cure in patients with muscle invasive disease.

Cisplatin-based chemotherapy is used in patients with metastatic disease at presentation or those in which bladder cancer cells are present outside the bladder wall or in lymph nodes during radical cystectomy.

What is the bladder?

The urinary bladder, or the bladder, is a hollow organ present in the pelvis. Most of it lies behind the pubic bone of the pelvis but when full it can extend up into the lower part of the abdomen. Its primary function is to store urine that drains into it from the kidney through tube-like structures called the ureters. The ureters from both the kidneys open into the urinary bladder. The bladder forms a low-pressure reservoir which gradually stretches out as urine fills into it. In males, the prostate gland is located adjacent to the base of the bladder where urethra joins the bladder. From time to time, the muscular wall of the bladder contracts to expel urine through the urinary passage (urethra) into the outside world.

High-dose chemotherapy and stem cell transplant for testicular cancer

In general, testicular cancers respond well to chemotherapy (chemo), but not all cancers are cured. Even though higher doses of chemo might be more effective, they are not given because they could severely damage the bone marrow, which is where new blood cells are formed. This could lead to life-threatening infections, bleeding, and other problems because of low blood cell counts.

A stem cell transplant allows doctors to use higher doses of chemo. Blood-forming stem cells are collected from the bloodstream in the weeks before treatment using a special machine. In the past the stem cells were taken from the bone marrow, but this is done less often now. The stem cells are frozen, and then the patient receives high-doses of chemo.

After the chemo the patient gets his stem cells back again. This is called a transplant, but it does not involve surgery – the cells are infused into a vein much like a blood transfusion. The stem cells settle in the bone marrow and start making new blood cells over the next few weeks.

For testicular cancer, stem cell transplant is most often used to treat cancers that have come back after treatment with chemo. Current studies are exploring whether a stem cell transplant may be valuable in treating some patients with advanced germ cell cancers as part of their first treatment.

A stem cell transplant is a complex treatment that can cause life-threatening side effects because of the high doses of chemotherapy used. Be sure you understand the possible benefits and risks. If the doctors think you might benefit from a transplant, it should be done at a hospital where the staff has experience with the procedure and with managing the recovery phase.

Stem cell transplants often require a lengthy hospital stay and can be very expensive. Even if the transplant is covered by your insurance, your co-pays or other costs could easily amount to tens of thousands of dollars. It is important to find out what your insurer will cover before deciding on a transplant to get an idea of what you might have to pay.

Chemotherapy for testicular cancer

Chemotherapy (chemo) is the use of drugs to treat cancer. The drugs can be swallowed in pill form, or they can be injected by needle into a vein or muscle. To treat testicular cancer, the drugs are usually given into a vein. Chemo is systemic therapy. This means that the drug travels throughout the body to reach and destroy the cancer cells. Chemo is an effective way to destroy any cancer cells that break off from the main tumor and travel to lymph nodes or distant organs.

Chemo is often used to cure testicular cancer when it has spread outside the testicle or to decrease the risk of cancer coming back after the testicle is removed. It is not used to treat cancer that is only in the testicle.

Doctors give chemotherapy in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Chemo cycles generally last about 3 to 4 weeks. The main drugs used to treat testicular cancer are:

• Cisplatin
• Etoposide (VP-16)Bleomycin
• Ifosfamide (Ifex®)
• Paclitaxel (Taxol®)
• Vinblastine

Using 2 or more chemo drugs is often more effective than using any single drug. The chemotherapy regimens most commonly used as the initial treatment for testicular cancer are:

• BEP (or PEB): bleomycin, etoposide, and cisplatin
• EP: etoposide and cisplatin (also known as EP)
• VIP: VP-16 (etoposide) or vinblastine plus ifosfamide and cisplatin

Some doctors use more intensive regimens for patients with high-risk disease, and may suggest a different combination of chemotherapy drugs or even a stem cell transplant (see next section).

If you’d like more information on a drug used in your treatment or a specific drug mentioned in this section, see ourGuide to Cancer Drugs, or call us with the names of the medicines you’re taking.

Possible side effects

Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow (where new blood cells are made), the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemo, which can lead to certain side effects.

The side effects of chemo depend on the type and dose of drugs used and how long they are given. These side effects can include:

• Hair loss
• Mouth sores
• Loss of appetite
• Nausea and vomiting
• Diarrhea
• Increased chance of infections (from having too few white blood cells)
• Easy bruising or bleeding (from having too few blood platelets)
• Fatigue (extreme tiredness, often from having too few red blood cells)

Some of the drugs used to treat testicular cancer can have other side effects. For example:

• Cisplatin and ifosfamide can cause kidney damage. This can be lessened by giving lots of fluids (usually into a vein – IV) before and after these drugs are given.
• Cisplatin, etoposide, paclitaxel, and vinblastine can damage nerves (known as neuropathy). This can lead to hearing loss, numbness or tingling sensations in the hands or feet, and sensitivity to cold or heat. In most cases this goes away once treatment is stopped, but it may last a long time in some people.
• Bleomycin can damage the lungs, causing shortness of breath and trouble with physical activity.
• Ifosfamide can cause the bladder to bleed (called hemorrhagic cystitis). To prevent this, the drug mesna is given along with ifosfamide.

Most side effects are short-term and go away after treatment ends, but some can last a long time and may never go away completely. Report any side effects or changes you notice while getting chemo to your medical team so that you can get prompt treatment for them. There are often ways to prevent or lessen side effects. For example, there are drugs to help prevent or reduce nausea and vomiting. In some cases, the doses of the chemo drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.

Some of the drugs used to treat testicular cancer can cause long-term side effects. These include some of the things mentioned earlier, like hearing loss and kidney or lung damage. Development of a second cancer (like leukemia) is a very serious but rare side effect of chemo, occurring in less than 1% of testicular cancer patients treated with chemo. People who have had chemo for testicular cancer seem to have a higher risk of heart problems later in life. Several studies have also suggested that chemotherapy can sometimes cause high blood cholesterol to develop over time, which may later require treatment.