Testicular cancer among men between 15-35 years of age is one of the most common cancer types. This creates 1% of all cancers in men. In the past, the treatment of testicular cancer was very difficult and described as very dangerous. Today’s developments in the early diagnosis of testicular cancer have very promising results and survival rate comes to 95%.

CAUSES

The exact cause is unclear. However, testicular tumours are seen 5-10 times more frequently in the patients with undescended testis than normal patients.

Recently, chromosomal alterations and the use of estrogen in the womb are often considered to be emphasized.

PATHOLOGY

95% of testicular tumours are due the germ cell. (SEMINOMA – NON SEMINOMATOUS). SEMINOMA (classic, anaplastic, and spermositic) NON SEMINOMATOUS (Embryonal carcinoma, choriocarcinoma, yolk sac tumors, teratomas).

DIAGNOSIS

Painless swelling of the testis (rarely can be painful) is the most common symptom. Especially in young adults coming with this complaint need to think about all the cases, such as testicular cancer until proven otherwise. In this type of patient, scrotal ultrasound should be done quickly. Ultrasonography can tell us the diagnosis largely as the bulk in the testicle. After that, necessarily, the doctors should search some tumor markers (alpha-feto protein – beta-HCG (human chorionic gonadotropin) – LDH (lactic dehydrogenase) – placental alkaline phosphatase) in the blood.

It can be distinguished the cellular source of tumor is seminomatous or non-seminomatous or Chorio carcinoma in non-seminomatous, etc. because of the structural features of these tumor markers (determinants). Pursuit of treatment is also very important. Alfa-fötoprotein (AFP) doesn’t rise in pure seminoma and choriocarcinoma!!! Approximately 1 month later, it is necessary to return normal values from orchiectomy.

HCG (human chorionic gonadotropin): It rises in all of the CC (choriocarcinoma), in 40 – 80 per cent of embryonal carcinoma, in 10% of pure seminoma. 1 week later normalization is required in orchiectomy.

After orchiectomy, non-dropping of tumour markers or increased monitoring is in favor of the residual tumor or metastasis!!! If it cannot identify with imaging, situation is only called serological disease. During follow-up, it is essential to identify the symptoms of relapse long before!!!

However, in 10% of cases, the first presenting symptoms can be such ashemoptysis (blood during cough), nausea; vomiting, convulsions and bone fractures rely on METASTATIC BULK, but these complaints may be rare.

Hydrocele symptom may be accompanied by testicular tumor and even can mask the main disease. In examination, hardness of all or part of the testis is palpable.

Testis Tümörleri
Generally, these show LYMPH SPREAD VEINS (lymphatic metastasis) in the earlier.

Hematogenous metastases (BLOOD) mostly occur LUNG, LIVER, brain, and bone.

* Chorionic carcinoma does especially in the early hematogenous metastasis.

Often seminomas can be diagnosed at an early stage and non-seminomas can be able to diagnose in the later stages.

One other test that must be done when the ultrasound revealed a bulk is WHOLE ABDOMEN and CHEST COMPUTED TOMOGRAPHY. In this way, if there is METASTASES, it can be understood.

In the differential diagnosis, testicular diseases such as acute orchitis-epididymitis / hydrocele / spermatocele / hematocele / granulomatous orchitis are thought.

TREATMENT

The first step of treatment is ACCURATE DIAGNOSIS and STAGING. For this, laceration from groin and other environmental elements (funiculus) point as high as is removed as possible. HIGH INGUINAL ORCHIECTOMY:

Testis Tümörleri
Pathological examination of the removed part of the tumor cell type clearly indicates what it is.

 

STAGING:

T: Primary tumor ™
To: No evidence of primary tumor
Tis: CIS = intratubular Canser
T1: Tm is in testis or epididymis, but there is no vascular (vein) invasion (involvement)
T2: Tm has passed tunica albuginea or there stands vascular invasion
T3: Tm spreads to the spermatic cord
T4: Tm keeps scrotumN: Rejional lymph nodes
No: Lymph node evaluation was not detected with clinically significant.
N1: there is metastasis being less than 2 cm in the lymph nodes.
N2: there is metastasis being between 2-5 cm in Lymph nodes or multiple lymph nodes smaller than 5 cm.
N3: there is metastasis being larger than 5 cm in Lymph node.

M: Distant metastasis
Mo: No distant metastasis
M1: There is distant metastasis

S: Serum tm markers
Sx: Could not determine markers
So: markers are in normal limits
S1: LDH < normal X 1.5 and HCG < 5000 and AFP < 1000
S2: LDH: normal x 1.5 – 10 or HCG 5000 – 50000 or AFP 1000 – 10000
S3: LDH: normal X 10 or HCG > 50000 or AFP > 10000

STAGE I: LIMITED TM IN TESTICLE
STAGE II: THERE IS INVOLVEMENT IN RETROPERITONEAL LYMPH NODES
II A: LESS THAN 2 CM
II B: LARGER THAN 2 CM
STAGE III: SUPRA DIAPHRAGMATIC NODAL INVOLVEMENT

 

SEMINOMAS WILL BE DONE AFTER HIGH INGUINAL ORCHIECTOMY

SEMINOMAS

Early stage (I – II A seminoma); over 90% of cure is provided with radiotherapy. Lymph node regions at risk for microscopic spread (iliac and retroperitoneal) dose of 25 Gy are irradiated and cure rate of 98% is provided in stage I. Survival is over 99%. After surgery without irradiation, only 15% recurrence rate was found in patients were followed. These patients could be treated with recurrence radiotherapy and chemotherapy, and survival was reported to be 99.5% by reason of a five-year. Therefore, in low risk patients, without Radiation therapy is one another alternative.

If there is recurrence after radiotherapy, CHEMOTHERAPY should be done. Herein, different combinations of agents (as PROTOCOL Einhorn) such as CYS – platinum, vincristine, bleomycin, ifosfamide, etoposide are used.

NON-SEMINOMAS IN LOW GRADE TUMORS

IN AMERICA: DRPLN (dissection (removal) of retroperitoneal lymph node) is the standard form of treatment; nevertheless, it is one of the alternative therapies can be selected in close monitoring and if necessary in CHEMOTHERAPY.

DRPLN is a surgery that is quite difficult and morbidity is very high if it is made in the form of open surgery. However, laparoscopic techniques can also be done today.

Life expectancy is close to each other, each method has advantages and disadvantages. Cure rate is over 80%.

IN ADVANCED NON-SEMINOMATOUS STAGE TUMORS

It should be initiated to chemotherapy immediately. Cure rate is over 60%.

FOLLOW-UP

Despite the varying according to treatment, generally, in the first years each 3 months all patients need to go to their physicians to control with chest radiography, abdominal computed tomography, abdominal ultrasonography and the all other tumor Markers.

IMPLEMENTATION OF TESTICULAR PROSTHESIS TO THE PEOPLE WHOSE TESTICULAR ARE TAKEN

Sometimes, men whose testes are taken may enter to depression. Testicular prostheses are offered in order to support the patients with esthetic and psychological. For those patients who accepted testicular prostheses inserted with orchiectomy in the same session or at another time. Prosthesis is the same as beads of silicone as female breasts implanted prostheses.