For most forms of testicular cancer, patients present at an early stage and the tumor happens to be confined at the testicle. When we do what we call a staging evaluation, we look for spread of cancer elsewhere. We often don't find any presence of cancer elsewhere. But, there is a percentage of patients that will present with more extensive disease, meaning that they have had spread to other parts of the body. These could include the abdominal lymph nodes, lymph nodes in the chest, or even spread to the brain.
Testicular cancer spreads in a very predictable manner. The first area of spread happens to be the abdominal lymph nodes. The reason is the testes actually originates prior to both up here in the abdominal area, so all of the lymphatic drainage to the testicle goes directly to the abdominal lymph nodes. So, the first site of spread of testicular cancer is usually the abdominal lymph nodes.
The second site of spread from there goes up to the chest. Then, it can go up higher to the brain. So, it does have a step-wise fashion of spread. Now, in these more advanced cases, often patients will require chemotherapy for treatment of their testicular cancer. In many cases, chemotherapy will cure the disease, then no additional chemotherapy will be required. There are some unfortunate cases of very, very advanced cancers that may not respond as well to chemotherapy. Those patients may go on to require what we call second line chemotherapy agents. The first stage of chemotherapy we call first line treatment. If that fails, we may have to resort to what we call second line therapy.
When second therapy fails, and this is a very small percentage of testicular cancer patients, then we may have to do very, very high dose chemotherapy. High dose chemotherapy can carry many side effects. It can shut down portions of the patient's bone marrow. The bone marrow is a part of the body within the bones that is responsible for producing a lot of the types of blood cells in your body such as clean white blood cells and red blood cells. So, when the bone marrow shuts down due to the use high dose chemotherapy, in those cases it may be necessary for those patients to undergo bone marrow transplantation. Normal, unaffected bone marrow is then transplanted into the patient to provide the function of producing red blood cells and white blood cells. These cells are critical to function of the patient's immune system and carrying oxygen into the body. So, you cannot function without those types of cells, and those patients have to have a way of producing those cells. So, bone marrow transplantation may be required in those rare cases where high dose chemotherapy has to be used.