Testicular Cancer

What is Testicular Cancer?

The testicles are part of the male reproductive system and are located in the scrotum (bags). Its main task is to secrete male hormone (testosterone) and produce reproductive cells (sperm). Testicular cancer is a tumoral growth that starts in the testicles and can sometimes spread to other areas of the body. It constitutes 1% of cancers in men, and its incidence is increasing gradually. It is mostly endemic to northern European countries and Scandinavian countries. It is observed more frequently in children of families with a high sociocultural and economic level. The right testis is affected more, because undescended testis pathology, which is a risk factor, appears more on the right side. In rare cases, it can be bilateral (2-3%). The risk of a testicular tumor throughout a person’s life is 0.2%.

Classification of Testicular Cancer

There are many different types of testicular tumors histopathologically. The most common testicular tumors we encounter in the clinic are testicular tumors with germinal cells. 90-95% of testicular tumors are germinal cells. The rest are non-germinal (non-sperm cell origin) tumors. During embryonic development, if the totipotential germ cells differentiate normally, spermatocytes are formed. If these totipotential germ cells become abnormally differentiated (differentiated), seminoma or embryonal carcinoma develops. If embryonal cells are further differentiated following intraembryonic development, a teratoma develops. If embryonal cells follow extraembryonic development and further differentiate, choriocarcinoma or yolk sac tumor occurs. Germinal cell testicular cancers are divided into seminomatous and nonseminomatous cell testicular cancers due to the differences in their treatments.

Seminoma type testicular tumor;Although it is seen in men of all ages, it is a testicular tumor that mostly occurs in men between the ages of 30-40 and has a relatively better course compared to other testicular tumors.

Non-Seminoma Testicular Tumors : Embryonic Cancer, Yolk sack tumor, choriocarcinoma, teratoma. These may be alone or in various combinations, of which seminoma may be a part, and appear as a mixed tumor: They are testicular cancers that occur in the 18-35 age group and have a more aggressive and aggressive course.

1-Seminoma It is the most common tumor among testicular cancers. Although it is seen in men of all ages, it is a testicular tumor that occurs mostly in men between the ages of 30-40 and has a relatively better course compared to other testicular tumors. Its incidence alone is 35%. There are three different types of seminoma; classical seminoma, anaplastic seminoma and spermatocytic seminoma. From a prognostic point of view, there is no difference between the three. 85% of seminomas are of the classical type. 10-15% have syncytiotrophoblastic elements. In this type of seminoma, hCG rate is high in the blood due to hCG production. 5-10% of seminomas are anaplastic type seminomas. 5-10% of seminomas are spermatocytic type seminomas and are mostly seen in men over 50 years of age.

2- Embryonal Carcinoma: The incidence alone is 20%. They are more aggressive and aggressive testicular cancers that occur in the 18-35 age group. There are two types, adult and infantile. has. It is also called infantile type, endodermal sinus tumor or yolk sac tumor.

3-Teratoma: It has a 5% chance of being seen alone. There are two types: Mature Teratoma and Immature Teratoma. A mature teratoma contains three basic embryonic layers: ectoderm, mesoderm, and endoderm, so these tumors contain structures that mimic all kinds of organs (bone, skin, teeth, and other organ cells).

4-Choriocarcinoma: Its incidence alone is less than 1%. It is a very aggressive and aggressive tumor. It differs from other non-seminomatous testicular tumors due to its early hematogenous metastasis.

5-Mixed cell tumors: The incidence of these tumors is around 40%, they are the most common testicular cancers. About ¼ of these types of mixed tumors are teratocarcinoma. Teratocarcinoma is a combination of teratoma and embryonal carcinoma. Approximately 6% of these tumors have seminoma in combination. The higher the rate of embryonal carcinoma in mixed tumors, the worse the tumor prognosis.

6-Carcinoma in situ: In 5.2% of patients with testicular tumor, carcinoma in situ is found in the other testis. There is a risk of these later developing into invasive cancer.

Risk factors for testicular cancer

1- Age 18 to 35 years

2- Those with a history of undescended testis (cryptorchidism) (proven risk factor): 7-10% of patients with testicular tumor have a history of undescended testis. Some factors that play a role in the development of cancer in the undescended testis are blamed. Among them; abnormal germ cell morphology, high temperature, testicular blood supply disorder, endocrine dysfunction (hormonal dysfunction), gonadal dysgenesis (genital development disorder). In patients with undescended testis, the risk of developing testicular tumor is 3 to 14 times higher than expected. In approximately 5 to 10% of undescended testicular patients, there is a risk of developing a tumor in the testis in a normal localization on the opposite side.

3- Hypospadias (circumcision of the prophet), genital developmental disorder such as congenital urinary opening to an area other than its normal place

4- Infertility, serious abnormality in sperm count and morphology.

5- Abnormal testicular development, atrophic (small) testicle

6- Family history, gene changes on chromosome Xq27, patients with previous testicular cancer (proven risk factor)

7- Being a member of the White Race

8-Genetic factors (role of genes such as Bcl-2, p53, EGF, Rb)

9-Testicular microlithiasis (calcifications)

10-Excess of endogenous or exogenous estrogen in the mother. It is known that the risk of developing testicular cancer in male babies increases when estrogen is given externally to Hanile mothers.

11-Testicular traumas

12-Sociocultural and economic level

Symptoms

Abnormal enlargement of the testicles and feeling and noticing a hard mass/lump are the most common findings and complaints. However, not every palpable mass or lump is cancer. Apart from this, pain (10-15%) may be felt in the testicle and scrotum. If testicular cancer has spread to other parts of the body (metastasis), blunt pains or some stiffness may be felt in these areas. Hydrocele can be detected together with tumor in 10-15% of patients. The patient can examine himself with his hands, especially after a hot bath, compare the two testicles with each other, and should consult a physician if he feels an abnormal size, stiffness or mass. Patients may come with complaints related to areas of metastasis such as cough, shortness of breath (lung metastasis), abdominal pain, loss of appetite, nausea-vomiting (metastasis in the retroperitoneal region).

Diagnosis

After the patient’s history and history and examination are duly examined, a number of blood tests including ultrasonography and important tumor markers (tumor markers) are required. Biopsy is not recommended for testicular tumors, it is a rule not to be done, it is not done except in very special cases. In some cases, biopsy may be used for frozen pathological (immediate pathological examination) examination during surgery.

Blood Tests: Basically, it contains tumor markers such as Beta-Human chorionic gonodtropin (Beta-HCG), Alpha-fetoprotein (AFP) and Lactic Dehydrogenase (LDH), high levels of one or more of these can be used in determining the type of cancer, making treatment decisions and following up. is used. In non-seminoma tumors; 40-70% AFP or hCG elevation, 20-60% LDH elevation, and 15-20% hCG and 20-60% LDH elevation in Seminomas are detected. AFP is not elevated in pure seminoma and choriocarcinoma. In addition, markers such as Placental Alkaline Phosphatase (PLAP), Neuron-Specific Enolase (NSE), and Gamma-glutamyl transpepdidas (GGT) are sometimes used.

Ultrasonography(USG): It gives us very valuable information about the structure, nature, size, relationship and prevalence of the mass in the testis. In addition, microcalcifications (Microlithiasis “microlites” -Sandy and microcalcifications) which are considered as testicular cancer precursors and risk factors can be detected. USG is considered the basic imaging for detecting testicular cancer, and it can also be used for imaging metastases.

Magnetic resonance imaging (MRI): Detection of the testicular mass provides an idea about its structure and nature, as well as guiding us in the detection and staging of metastases. It can also be used as a guide for biopsy taking.

Spread: Testicular cancers; Except for choriocarcinoma, it makes all metastases by lymphatic route. Choriocarcinoma is hematogenous, metastasizes to atypical sites and early, and has a poor prognosis compared to other types. Primarily, testicular tumors metastasize to lymph nodes between T1 and L4, and around the main vein (aorta and vena cava) around the kidney. The testis metastasizes to these areas where it shares the same congenital origin with the kidney. First, the metastases settle in this region, then gradually metastases to the upper regions of the lung to the mediastinum and supraclavicular lymph nodes occur. While there are metastases upward, lymphatic spread also occurs to the lower regions, to the iliac lymph nodes. In advanced houses, lung, liver, bone and brain metastases are seen.

Staging

For the staging of the disease following high radical orchiectomy surgery, the histological structure and characteristics of the tumor are determined. The values ​​of tumor markers (HCG, AFP) are checked again after surgery. Lung, abdomen and pelvis tomography is performed. The Royal Marsden classification or the American Joint Committee on Cancer (AJCC) TNM classification is used. It is a classification that shows the stages and level of tumor prevalence that guides the treatment and follow-up of cancer. Here, classification is made on the basis of the extent (T) of the primary tumor focus, the extent of its spread to the lymph nodes (L), distant organ metastases (M), and the presence and level (S) of tumor markers. After this information, testicular cancers are staged as follows:

Staging according to the Royal Marsden classification:

Stage I:A cancer confined to the testis, no tumor detected in other areas

Stage II:There is spread to the lymphatics (a: Spread to intra-abdominal lymphatics smaller than 2 cm; b: Spread to lymph nodes larger than 2-5 cm, c: lymphatic spread with a mass larger than 5 cm)

Stage III:Spread to supra-diaphragmatic lymph nodes

Stage IV:Distant organ metastasis (lung, liver, bone, brain, etc.) / blood-borne spread

Differential diagnosis: Testis tumor is easily confused with other intrascrotal diseases. Therefore, approximately 25% of patients with testicular tumors are misdiagnosed at the first examination. Among the diseases confused with testicular cancer; epididymitis or orchioepididymitis, hydrocele which can sometimes be seen together with testicular tumor (10-15%), spermatocele, hematecele, varicocele, tuberculous orchitis, and epidermoid cyst.

Prognosis/Condition

The prognosis and response to treatment of testicular cancers is better than other organ cancers and responds better to treatment, especially when caught at an early stage, the chance of cure (becoming disease-free) is high. As mentioned, the prognosis in testicular cancers depends on the stage of the disease, the cell type (seminoma or non-seminoma), the presence of distant organ metastases, especially the level of serum markers in non-seminomatous cancers, and your individual and familial testicular tumor history. How much is the rate of embryonal carcinoma in non-seminomatous tumors? the higher it is, the worse the prognosis. The presence of yolk sack tumor is an indication that the prognosis is relatively good. The age of occurrence of primary choriocarcinoma is low and its prognosis is relatively poor. patients are divided into some risk groups and accordingly, the treatment and follow-up of the patient is arranged. A patient with none of the poor prognostic factors is considered low risk, a patient with 1 or 2 bad bad risk factors is considered medium risk, and a high risk patient with 3-4 factors.

Among the risk factors: the presence of histologically embryonal carcinoma in the orchiectomy material is considered a poor prognostic risk factor, and even the rate of embryonal cancer in the total tumor is important. In addition, the presence of yolk sac tumor is considered a good prognostic factor, and the presence of lymphatic and/or vascular invasion is considered a bad risk factor.

TREATMENT

1-Orchiectomy: The first-line treatment in testicular cancer is the surgical removal of the cancerous testis and its appendages (epididymis, cord and funuculus). In very special cases (the tumor is bilateral, the patient has only one testis, etc.), only the cancerous part of the testis can be removed. Testicular surgery is performed with an incision made from the groin, not from the sac (scrotum) but from above (high inguinal orchiectomy). The tissue is sent to pathology, and according to the results of pathology and imaging examinations, it is determined whether there is a need for additional treatment. Additional treatments; It includes additional surgical interventions, chemotherapy and radiotherapy treatments. After the testicle is removed, a testicular prosthesis can be placed in the same session or later for cosmetic or psychological reasons. It is not a surgery with many complications. Bleeding and infection may develop in the early period after surgery. In the long term, there may be a decrease in infertility (a decrease in the fertility index and a decrease in the production/level of male hormone (testosterone). After testicular cancer treatment, the chances of conceiving naturally continue.

2-Additional Surgery:

a- Biopsy from the other testis: The probability of seeing carcinoma in situ in the testis varies between 1-5%. In cases where carcinoma in situ is found together with the tumor after orchiectomy in patients with testicular tumor, carcinoma in situ should be investigated by performing a biopsy on the other testis. If the remaining testis is not descended, small (atrophic), if the sperm quality and parameters are not good, biopsy can be performed, if there are cancer cells in it, chemotherapy and/or chemotherapy can be performed, and sometimes that testicle may need to be surgically removed. In this case, the patient needs lifelong hormone support.

b- Removal of lymphatic spread (Retroperitonial lymph node dissection-PDNLD): Testicular cancers usually spread to the lymphatics around the posterior abdomen, kidney circumference/level, aorta and great veins due to the congenital origin (origin). Their removal is called retroperitoneal lymphadenectomy. This procedure is performed on Ervre I non-seminoma tumors, residual tissues after chemotherapy, or masses that develop later. After this surgery, the sympathetic nerve chain may be affected and become ill, in which case there may be ejaculation disorder, that is, the ejaculation of the semen into the bladder and not coming out. This removes the chance of having children naturally, and assisted reproductive techniques are needed. Therefore, the patient should be informed about these issues before the operation.

c-Metastasectomy (Surgical removal of distant metastases):Foci of metastases in the lung, liver or brain, in some cases, in these organs may need surgical removal, especially and typically after chemotherapy, residual tissue is removed.

3-Chemotherapy (KT): Almost all types of testicular cancers are highly sensitive to chemotherapy and are used effectively. Cis-platin-based triple combination BEP (bleomycin + Etoposide + Cis-platinum) forms the basis of first line chemotherapy. 3-4 cycles at 3-week intervals is the standard treatment. In some patients, especially in Stage I seminoma, single agent Carboplatin is used alone.

3-Chemotherapy (KT):

-Infection: KT drugs reduce body resistance, and as a result of bone marrow suppression, the amount of leukocytes decreases and it can become open to infections. It is manifested by fever and chills, antibiotics may be needed.

-Cough:May occur as a side effect of bleomycin or as a result of lung infection

-Hair loss:Temporary, usually grows back in 3-6 months

– Deterioration in Semen Quality: Depending on the KT and RT applied after the surgery, deterioration in semen quality and infertility may develop. As explained above, it is recommended to store semen by giving semen to the sperm bank a few times before these treatments. Thus, in case of future infertility, these samples are used in assisted reproductive techniques. However, the deterioration in semen quality is usually temporary, and these patients have a high chance of conceiving naturally.

-Tiredness:Generally, there may be short-term fatigue, it is recommended to be active and active.

– Stomach Discomfort (Nausea): Some stomach discomfort, nausea and loss of appetite may occur during LT. Nausea medications, high-calorie diet drinks may be recommended, or if symptoms persist, a dietitian may be assisted.

-Diarrhea:There may be diarrhea due to KT drugs, antidiarrheal drugs, plenty of fluids and a low fiber diet may be recommended.

– Mouth sores:G Temporary aphthae and wounds may occur, oral hygiene and carbonate mouthwash are recommended

-Sensitivities in taste and hearing function

-Some changes in skin or nails:There may be redness such as sunburn due to radiotherapy, a moisturizer is recommended, this is temporary.

-Tingling in fingers or toes

4-Radiotherapy (RT)

FOLLOW-UP

It is followed up every 3-4 months at regular intervals, and for 5 years if everything goes well. In the follow-ups, examination, blood tests, chest X-ray and tomography are performed, if necessary, PET-CT can be recommended.

LIVING WITH TESTES CANCER: Cancer diagnosis is a very stressful and overwhelming situation for patients. The more the patient is informed about testicular cancers, the more difficult it will be to overcome these difficulties.

1-Living with a single testis: In fact, with a single healthy testicle, it can continue its life without any problems (sexual or infertility, etc.) until the end of its life, usually one testicle is sufficient. However, there may be a cosmetic and psychological deficiency, which can be eliminated by removing the testis or by placing a testicular prosthesis (silicone testis) in a future period. Although having a single testis may reduce the chance of becoming a father naturally, the majority of these patients do not have any problems. If necessary, the sperm sample given to the sperm bank before the treatment can be used for this purpose. Again, some patients may experience insufficiency of male hormone (Testosterone) produced by one testis after these treatments, in this case, external testosterone supplementation can be made.

2-Testosterone deficiency: Patients in case of Testosterone deficiency that may occur after testicular cancer treatment; They may apply with complaints of fatigue, sexual reluctance (loss of libido), enlargement of breast tissue (gynecomastia), or reduction in body hair, hair and beard. Even if the serum testosterone level is normal, these complaints may occur, but generally those with this complaint have a low serum testosterone level, in this case most of these problems can be solved with testosterone supplementation.

3-Partner Protection: Testicular cancer is not an infection, there is no sexual transmission to your partner, sexuality does not harm cancer treatment. However, it is also beneficial to use condoms during the period of KT, so the possibility of harming the partner with KT drugs in the semen is eliminated.

4-Sexuality: Treatment of testicular cancer does not interfere with sexuality. Although these treatments generally do not cause much problems in sexuality and fertility (infertility), patients may experience some problems. Some problems may occur in ejaculation after testicular surgery. Especially since retroperitoneal lymphadenectomy (RPNLD) is expected to cause such problems, patients who are candidates for this surgery should be informed before the operation and it should be said that they may experience ejaculation difficulties or retrograde ejaculation problems after the operation. In this case, there may not be a chance to have children naturally, and there may be a need for assisted reproductive techniques. Medications given may not be effective. Again, erection problems may occur after nerve damage that may occur in RPNLD surgery, and drug therapy is recommended if necessary.

5-Decrease in sexual desire (loss of libido):After the treatment of testicular cancer patients, there may be loss of libido, albeit mostly temporary. This may be caused by partial testosterone deficiency, the stress caused by cancer treatment, and some emotional and intellectual problems.

6-Protection of Fertility (Prevention of Infertility): As discussed above, after testicular cancer treatment, there may be a temporary deterioration in semen quality and a decrease in the fertility index. If there is a desire to have a child, it should be recommended to give semen samples to the sperm bank before the operation.

7-Dealing with social and psychological effects: After cancer treatment, you may experience anxiety, anger, or depression. In this law, psychological counseling can be obtained, familial help can be requested to solve social problems. Anxiety and anxiety reliever or anti-depressant drugs can be started if needed.

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