1. Aetna considers high-dose chemotherapy (HDC) with autologous bone marrow or peripheral stem cell transplant medically necessary for the treatment of persons with testicular cancer who do not attain a complete remission after an initial course of standard-dose chemotherapy, i.e., those with refractory (less than 50 % reduction in tumor burden) testicular cancer or those exhibiting a partial response (at least a 50 % reduction in tumor burden).

    

2. Aetna considers HDC with autologous bone marrow or peripheral stem cell transplant as consolidation therapy medically necessary for persons with testicular cancer who relapse after an initial course of standard-dose chemotherapy.

    

3. Aetna considers HDC with tandem autologous bone marrow or peripheral stem cell transplant medically necessary for persons with testicular cancer who have relapsed.

    

4. Aetna considers HDC with autologous bone marrow or peripheral stem cell transplant experimental and investigational as initial treatment (i.e., instead of an initial course of standard-dose chemotherapy with Food and Drug Administration-approved drugs) of persons with testicular cancer because the effectiveness of this approach has not been established.

    

5. Aetna considers HDC with allogeneic bone marrow or peripheral stem cell transplant experimental and investigational for the treatment of persons with testicular cancer because its effectiveness for this indication has not been established.

See also CPB 0352 - Tumor Markers, and CPB 0532 - Scrotal Ultrasonography.

Testicular cancer, a highly treatable, commonly curable cancer, accounts for only 1 % of all male malignancy.  It usually develops in young and middle-age men in the 20- to 40- year old age group.  Testicular cancer is one type of germ cell tumors, which can be classified according to their histology, stage, prognosis, or response to chemotherapy.  Histology includes seminoma, embryonal carcinoma, teratoma, choriocarcinoma, yolk sac tumor, and mixed germ cell tumors.  Seminomas are the most common and can be subdivided into typical, spermatocytic, and anaplastic varieties.  All other types of germ cell tumors may be collectively referred to as non-seminomatous germ cell tumors.  Seminoma accounts for 40 % of all germ cell tumors, while non-seminoma germ cell tumors account for 60 %.  Testicular palpation is useful in differentiating the type of tumor involved.  Seminomas are usually felt throughout the entire testicle, whereas non-seminomas tend to be small hard masses.

Differentiation between seminoma and non-seminoma germ cell tumors is important because the staging, evaluation and management in the two are different.  Seminomas are generally characterized by an indolent clinical course, and are more sensitive to radiation therapy than non-seminomas for patients with early-stage disease.  Furthermore, seminomas frequently exhibit a predictable pattern of metastatic spread via the regional lymphatics to the retroperitoneal nodes of the abdomen and/or to the mediastinal and supraclavicular lymph nodes before gaining access to other visceral structures.  In contrast, patients with non-seminomas are generally radio-resistant, with pulmonary and other hematogenous metastases more common than for patients with seminomas.

Once the histologic diagnosis is made, the patient must be staged.  The stage of the disease is dependent on the location (extent) of the tumor:

• Stage I is limited to the testis, epididymis, or spermatic cord
• Stage II is limited to retroperitoneal (regional) lymph nodes
• Stage III is disease outside the retroperitoneum, involving supradiaphragmatic nodal sites or viscera.

Ultrasonography as well as laboratory tests are used to confirm the diagnosis and stage of disease.  In addition to blood cell counts and urine analysis, there are 2 serum tumor markers present in testicular cancer, (i) human chorionic gonadotropin (HCG) and (ii) alpha-fetal protein (AFP).  Studies have reported that 40 % of patients diagnosed with disseminated non-seminomas will have an elevated AFP, 75 % will have an elevated HCG, and 85 % will have one or both markers elevated.  In contrast, these markers are only present in 10 % of patients with seminoma, although 50 % of patients with stage III seminomas will have elevated HCG levels.  Staging is also confirmed by laparotomy and CT scan.

For patients with Stage I disease, radiation therapy (for seminomas) or retroperitoneal lymph node resection (for non-seminomas) has been shown to result in cure rates of greater than 90 %.  Additionally, for patients with Stage I non-seminomas, surveillance (after orchiectomy) is another generally accepted alternative.  For patients with Stage II, Stage III disease or extragonadal site of origin, treatment with cisplatin-based chemotherapy has been shown to be very effective in achieving a complete remission.  The results of treatment of non-seminomatous germ cell tumors have been improved significantly by cisplatin-containing chemotherapy regimens.  The literature indicates that first-line therapy generally entails 3 to 4 cycles of the combination regimen of cisplatin, bleomycin, and etoposide.  Under established guidelines, patients whose tumors are resistant to cisplatin may proceed to regimens containing carboplatin.  Chemotherapy is often followed by surgery to remove residual masses.  Regimens used for relapsed disease include cisplatin plus ifosfamide, combined with either etoposide or vinblastine (salvage therapy).

Salvage therapy has been shown to induce long-term complete responses in about 25 % of patients with disease that has persisted or recurred following other cisplatin-based regimens.  Patients who have had an initial complete response to first-line chemotherapy and those without extensive disease have the most favorable outcome.  However, the literature states that few, if any, patients with recurrent non-seminomatous germ cell tumors of extragonadal origin achieve long-term disease-free survival using vinblastine, ifosfamide, and cisplatin if their disease recurred after they received an initial regimen containing etoposide and cisplatin.  High-dose chemotherapy with autologous bone marrow transplantation (ABMT) has been used with some success in the setting of refractory disease.  Durable complete remissions may be attainable in 10 to 20 % of patients with disease resistant to standard cisplatin-based regimens who are treated with high-dose carboplatin and etoposide with ABMT.

A review by Ayash et al (2001) stated that patients with relapsed/refractory testicular cancer benefit most from ABMT if they have platinum-sensitive disease in first relapse.  Patients who do poorly despite ABMT have a mediastinal primary site, true cisplatin-refractory disease, disease progression before ABMT, and/or markedly elevated beta-HCG at ABMT.  New treatment modalities are needed for the latter group.  This observation is in accordance with the view of Flechon and associates (2001) that new strategies are needed to improve the survival rate of poor prognosis germ cell tumor patients.