Diagnosis and Treatment in Testicular Cancers
Unlike other types of cancer, testicular tumors are cancers that constitute 1-1.5% of all malignant tumors in men and are more common in the young population. Recently, its incidence tends to increase, albeit slightly. However, approximately 70% of those diagnosed with testicular cancer are stage 1 disease and they have almost 100% treatment and cure chances. There are cure rates of up to 80-100% even in metastatic disease as a result of the advances in diagnostic methods, the presence of definite tumor markers used in the follow-up of diagnosis and treatment, the development of surgical techniques, and the development of new generation chemotherapy models. Testicular tumors are frequently seen in advanced adolescents and early adulthood. The highest incidence is in young adult males. Some factors pose a risk for the development of the disease.
Risk factors in the development of testicular cancer;
History of undescended testicles
Having Klinefelter syndrome
• Family history of testicular tumor
History of tumor in the other side of the testicle
History of infertility
Testicular cancers are generally divided into two classes. The most common type are germ cell cancers and are seen in 90% of cases. Among these, seminomas are the most common. Seminomas make up 30-35% of germ cell tumors.
1.Germ cell tumors
2.Sex-cord stromal tumors
Leydig cell tumor
Sertoli cell tumors
Granulosa cell tumors
Mixed type tumors
Patient history, physical examination, and testicular ultrasonography are the most valuable methods in diagnosis. Clinically, the presence of a painless, hard, and palpable mass lesion in the testicle is a sufficient finding to suspect a tumor. The first thing to do in such a patient is testicular ultrasonography. Ultrasonography can show the mass lesion in the testicle or other pathologies, if any, in the abdomen.
Another test used in diagnosis is tumor markers. The values of these parameters checked in the blood can be high or normal depending on the type of tumor. Also, these tumor markers have a very important role in post-treatment follow-up and in determining the course of the disease. As for serum tumor markers, hormones in glycoprotein structure called alpha-fetoprotein (AFP), betahumancohorionogonadotropin (B-hCG), and lactate dehydrogenase (LDH) are examined. These hormones are released from the tumor tissue but are not expected to increase in pure seminomas. Limited solid and hard masses in the testicle should be considered as testicular tumors until proven otherwise.
If there is suspicion in the diagnosis of testicular tumor, testicular MR examination can be performed and information about the structure of the mass can be obtained. However, despite all these diagnostic methods, the definitive diagnosis is made by pathological examination. Pathological examination in testicular tumors is done by removing the testicle completely. In other words, procedures such as needle biopsy are not applied for pathology in testicular tumors.
Staging and Classification
Correct staging is required for the correct treatment and follow-up of the disease. For accurate staging, a full-body scan should be done. Measurement of serum tumor markers by abdominal and lung tomography and the characteristics of the mass in the testis should be well known. The TNM classification system is used in staging.
Primary tumor (T)
PTx: Primary tumor not revealed
PT0: No evidence of primary tumor
P: Intubular germ cell neoplasia
PT1: Tumor limited to testis and epididymis, no vascular or lymphatic invasion
• PT2: Tumor has limited vascular or lymphatic invasion into the testis and epididymis or spreads beyond the tunica albuginea with involvement of the tunica vaginalis.
PT3: Tumor has invaded the spermatic cord, with or without vascular/lymphatic invasion
PT4: Tumor has invaded the skin of the scrotum, with or without vascular or lymphatic invasion
Lymph nodes (N)
Nx: No regional lymph node detected
N0: No lymph node metastasis
• N1: Lymph node involvement with the largest size of 2 cm or less or multiple lymph node involvement none of which exceeds 2 cm.
• N2: Single or multiple lymph node involvements larger than 2 cm or less than 5 cm larger than 2 cm or less than 5 cm.
• N3: lymph node involvement greater than 5 cm
Distant metastasis (M)
M0: No evidence of distant metastasis
M1: Distant organ metastasis is present
M1a: non-regional lymph node involvement or lung metastasis
M1b: extrapulmonary metastases
Serum tumor markers (S)
• S0: Normal value markers
• S1: below hCG 5000 and below AFP 1000
S2: between hCG 5000-50000 and AFP 1000-10000
S3: over hCG 50000 and above AFP 10000
Staging is as follows
It is done using the TNM Classification system. Treatment and follow-up program is determined according to the stages. Staging is as follows.
Stage 1: T1-4, N0, M0
Stage1a: T1, N0, M0, SX
Stage1b: T2,3,4, N0, M0, S0
Stage2: any T, N1-3, M0, S1-3
Stage2a: any T, N1, M0, S0-1
Stage2b: any T, N2, M0, S0-1
Stage2c: any T, N3, M0, S0-1
Stage3: Any T, N, Any N, M1, SX-3
Stage3a: any T, any N, M1, S0-1
Stage3b: any T, any N, M0-1, S2
Stage3c: Any T, Any N, M1, Any S
What Should Be Done in the Diagnosis of Testicular Cancer?
1. Testicular ultrasonography is mandatory.
2. Diagnosis cannot be made without performing inguinal orchiectomy.
3. Serum tumor markers should definitely be checked before and after orchiectomy.
4. Intra-abdominal lymph nodes, lung area, and regional lymph nodes should be evaluated.
Treatment of Testicular Cancers
Inguinal orchiectomy is the first procedure to be performed on patients with testicular tumors without losing time. This procedure is done through a small incision in the inguinal (groin) area. After the testicle is removed, sending it to pathology and knowing what type of tumor it is is necessary information during the treatment phase. Later, the patient’s lung and abdominal tomographs are taken and lymph nodes and distant organ metastases are evaluated. After all this evaluation and orchiectomy, treatment should be applied according to the tumor stage and type.
Post-orchiectomy treatment options are as follows …
Treatment of Stage 1 Seminomas
1. Adjuvant radiotherapy: covering the abdominal area and the groin area on the side of the tumor.
2. Adjuvant chemotherapy: It is made based on carboplatin. It can be given as an alternative to radiotherapy.
3. Close follow-up.
Treatment of Stage 2 Seminomas
1. Primary chemotherapy (BEP based chemotherapy)
2. Adjuvant chemotherapy
3. RPLND: Surgical removal of lymph nodes in the posterior abdominal wall. Making it in experienced hands increases the chance of success.
Treatment of Stage 3 Seminomas
1. Primary chemotherapy (BEP based chemotherapy)
2. Metastatectomy: Removal of the tumor that has spread to distant areas
Non-Seminomatic Germ Cell Tumors Treatment;
1. If the patient is in the low-risk group (no vascular invasion) and tumor PT1a, strict follow-up can be done after orchiectomy.
2. Adjuvant chemotherapy or RPLND
Stage -2, 3
1. Primary chemotherapy should be applied at least twice.
2. Chemotherapy + RPLND
Stage-4 Metastatic Disease
1. BEP chemotherapy at least 3 times
2. If serum markers are elevated RPLND