i or stage ii and to reduce the risk that malignant testicular cancer cells that may have metastasized to lymph nodes in the lower abdomen. this surgery is called retroperitoneal lymph node dissection (rplnd). however, this approach, while standard in many places, especially the united states, is out of favor due to costs and the high level of expertise required to perform successful surgery. sperm banking is frequently carried out prior to the procedure (as with chemotherapy), as there is a risk that rplnd may damage the nerves involved in ejaculation, causing ejaculation to occur internally into the bladder rather than externally. many patients are instead choosing surveillance, where no further surgery is performed unless tests indicate that the cancer has returned. this approach maintains a high cure rate because of the growing accuracy of surveillance techniques. adjuvant treatment since testicular cancers can spread, patients are usually offered adjuvant treatment - in the form of chemotherapy or radiotherapy - to kill any cancerous cells that may exist outside of the affected testicle. the type of adjuvant therapy depends largely on the histology of the tumor (i.e., the size and shape of its cells under the microscope) and the stage of progression at the time of surgery (i.e., how far cells have 'escaped' from the testicle, invaded the surrounding tissue, or spread to the rest of the body). if the cancer is not particularly advanced, patients may be offered careful surveillance by periodic ct scans and blood tests, in place of adjuvant treatment. before 1970, survival rates from testicular cancer were low. since the introduction of adjuvant chemotherapy, chiefly platinum-based drugs like cisplatin and carboplatin, the outlook has improved substantially. although 7000 to 8000 new cases of testicular cancer occur in the united states yearly, only 400 men are expected to die of the disease. in the uk, a similar trend has emerged: since improvements in treatment, survival rates have risen rapidly to cure rates of over 95%. radiation therapy radiation may be used to treat stage ii seminoma cancers, or as adjuvant (preventative) therapy in the case of stage i seminomas, to minimize the likelihood that tiny, non-detectable tumors exist and will spread (in the inguinal and para-aortic lymph nodes). radiation is ineffective against and is therefore never used as a primary therapy for non-seminoma. non-seminoma chemotherapy is the standard treatment for non-seminoma when the cancer has spread to other parts of the body (that is, stage 2b or 3). the standard chemotherapy protocol is three, or sometimes four, rounds of bleomycin-etoposide-cisplatin (bep). bep as a first-line treatment was first reported by professor michael peckham in 1983. the landmark trial published in 1987 which established bep as the optimum treatment was conducted by dr. lawrence einhorn at indiana university. an alternative, equally effective treatment involves the use of four cycles of etoposide-cisplatin (ep). lymph node surgery may also be performed after chemotherapy to remove masses left behind (stage 2b or more advanced), particularly in the cases of large non-seminomas. seminoma as an adjuvant treatment, use of chemotherapy as an alternative to radiation therapy in the treatment of seminoma is increasing, because radiation therapy appears to have more significant long-term side effects (for example, internal scarring, increased risks of secondary malignancies, etc.). two doses, or occasionally a single dose of carboplatin, typically delivered three weeks apart, is proving to be a successful adjuvant treatment, with recurrence rates in the same ranges as those of radiotherapy. the concept of carboplatin as a single-dose therapy was developed by tim oliver, professor of medical oncology at barts and the london school of medicine and dentistry. however, very long-term data on the efficacy of adjuvant carboplatin in this setting do not exist. since seminoma can recur decades after the primary tumor is removed, patients receiving adjuvant chemotherapy should remain vigilant and not assume they are cured 5 years after treatment. prognosis treatment of testicular cancer is one of the success stories of modern medicine, with sustained response to treatment in more than 90% of cases, regardless of stage. in 2011 overall cure rates of more than 95% were reported, and 80% for metastatic disease—the best response by any solid tumor, with improved survival being attributed primarily to effective chemotherapy. by 2013 more than 96 per cent of the 2,300 men diagnosed each year in the u.k. were deemed cured, a rise by almost a third since the 1970s, the improvement attributed substantially to the chemotherapy drug cisplatin. in the united states, when the disease is treated while it is still localized, more than 99% of people survive 5 years. surveillance for many patients with stage i cancer, adjuvant (preventative) therapy following surgery may not be appropriate and patients will undergo surveillance instead. the form this surveillance takes, e.g. the type and frequency of investigations and the length time it should continue, will depend on the type of cancer (non-seminoma or seminoma), but the aim is to avoid unnecessary treatments in the many patients who are cured by their surgery, and ensure that any relapses with metastases (secondary cancers) are detected early and cured. this approach ensures that chemotherapy and or radiotherapy is only given to the patients that need it. the number of patients ultimately cured is the same using surveillance as post-operative "adjuvant" treatments, but the patients have to be prepared to follow a prolonged series of visits and tests. for both non-seminomas and seminomas, surveillance tests generally include physical examination, blood tests for tumor markers, chest x-rays and ct scanning. however, the requirements of a surveillance program differ according to the type of disease since, for seminoma patients, relapses can occur later, and blood tests are not as good at indicating relapse. ct scans are performed on the abdomen (and sometimes the pelvis) and also the chest in some hospitals. chest x-rays are increasingly preferred for the lungs as they give sufficient detail combined with a lower false-positive rate and significantly smaller radiation dose than ct. the frequency of ct scans during surveillance should ensure that relapses are detected at an early stage while minimizing the radiation exposure. for patients treated for stage i non-seminoma, a randomized trial (medical research council te08) showed that, when combined with the standard surveillance tests described above, 2 ct scans at 3 and 12 months were as good as 5 over 2 years in detecting relapse at an early stage. for patients treated for stage i seminoma who choose surveillance rather than undergoing adjuvant therapy, there have been no randomized trials to determine the optimum frequency of scans and visits, and the schedules vary very widely across the world, and within individual countries. in the uk there is an ongoing clinical trial called trisst. this is assessing how often scans should take place and whether magnetic resonance imaging (mri) can be used instead of ct scans. mri is being investigated because it does not expose the patient to radiation and so, if it is shown to be as good at detecting relapses, it may be preferable to ct. for more advanced stages of testicular cancer, and for those cases in which radiation therapy or chemotherapy was administered, the extent of monitoring (tests) after treatment will vary on the basis of the circumstances, but normally should be done for five years in uncomplicated cases and for longer in those with higher risks of relapse. fertility a man with one remaining testis may maintain fertile. however, sperm banking may be appropriate for men who still plan to have children, since fertility may be adversely affected by chemotherapy and/or radiotherapy. a man who loses both testicles will be infertile after the procedure, though he may elect to bank viable, cancer-free sperm prior to the procedure. epidemiology globally testicular cancer resulted in 8,300 deaths in 2013 up from 7,000 deaths in 1990. testicular cancer has the highest prevalence in the u.s. and europe, and is uncommon in asia and africa. worldwide incidence has doubled since the 1960s, with the highest rates of prevalence in scandinavia, germany, and new zealand. although testicular cancer is most common among men aged 15–40 years, it has three peaks: infancy through the age of four as teratomas and yolk sac tumors, ages 25–40 years as post-pubertal seminomas and non-seminomas, and from age 60 as spermatocytic tumors. germ cell tumors of the testis are the most common cancer in young men between the ages of 15 and 35 years. united states in the united states, about 8,900 cases are diagnosed a year. the risk of testicular cancer in white men is approximately 4-5 times the risk in black men, and more than three times that of asian american men. the risk of testicular cancer in latinos and american indians is between that of white and asian men. the cause of these differences is unknown. united kingdom in the uk, approximately 2,000 people are diagnosed a year. over a lifetime, the risk is roughly 1 in 200 (0.5%). it is the 16th most common cancer in men. it accounts for less than 1% of cancer deaths in men (around 60 men died in 2012). other animals testicular tumors occur also in other animals. in horses, these include interstitial cell tumors and teratomas. typically, the former are found in older stallions (affected stallions may become extremely vicious, suggesting excessive production of androgen), and the latter are found in young horses and are large.