Testicular cancer

The testicular cancer or testicular tumors account for 1-2% of cancers in men and are one of the most common in the aged between 20-35 years. 95% of them come from the malignancy of the germ cells. They can be classified by their histological characteristics as:

Seminomas : can increase testicular size up to 10 times without distorting its morphology. It is the most frequent, up to 45%.

Non-seminomatous tumors :

1. Embryonal carcinoma.
2. Endodermal sinus tumor.
3. Choriocarcinoma.
4. Teratoma
5. Teratocarcinoma.
6. Gonadoblastoma.
7. Sertoli cell tumors.

Causes of testicular cancer

Several factors have been involved in the etiology of the testicular tumor:

• History of testicular trauma: although between 8 and 25% of patients have a history of testicular trauma, this is more the reason for discovering a scrotal mass than its origin.
• Undescended testes have a higher risk of developing tumors, and this probability increases if the test situation is intra-abdominal. Likewise, the contralateral testis, although scrotal in location, has a greater probability of developing a tumor. 20% of tumors in patients with cryptorchidism develop in the non-cryptorchid testis. For these reasons, undescended testicles should be operated on, preferably between the first and second year of age.
• Other related factors are infantile inguinal hernias and urlian orchitis .

The testicle originates from a structure that is found first in the peritoneal cavity, descends together with the vessels and their lymphatic drainage (from the abdomen), to the scrotum. Thus, once malignant degeneration occurs, seminomatous tumors usually metastasize through regional lymph nodes.

On the other hand, non-seminomatous patients metastasize through lymphatic and hematogenous routes (particularly to the liver and lungs).

The staging of the different testicular tumors is carried out on the basis of the clinical and histology:

• Stage I. It is characterized because the tumor process is limited to the testicle, the epididymis or the spermatic cord.
• Stage II. The tumor has reached the retroperitoneal lymph nodes.
• Stage III. The process has gone beyond the retroperitoneum and affects the supradiaphragmatic lymph nodes or viscera.

Symptoms of testicular cancer

It is more common for patients to consult for testicular discomfort or inflammation compatible with epididymitis or orchitis. In these circumstances it is reasonable to try a course of antibiotics. But if symptoms persist or some residual abnormality remains, an ultrasound examination is indicated.

Sometimes the patient can consult for back pain due to retroperitoneal metastases. On other occasions, lung metastases can cause dyspnea.

When diagnosis is delayed, the process reaches a more advanced stage and survival against testicular cancer may then decrease.

How is it diagnosed?

An important element in the diagnosis of testicular cancer are the tumor markers alpha fetoprotein and human chorionic gonadotropin (both are important for monitoring the tumor during and after treatment). Altogether, 70% of testicular tumors produce some marker.

Ultrasound is a simple and reliable method for the differentiation between solid and cystic masses, and their exact intratesticular location.

When the diagnosis is not clear despite the examination and ultrasound, surgical exploration through an inguinal incision is indicated to avoid the possibility of tumor implants in the scrotal skin. If the examination confirms the presence of a mass, the testicle should be removed.

The evaluation of the tumor extension will be completed by thoraco-abdominal CT to evaluate the retroperitoneal and mediastinal lymph node involvement, abdominal viscera and lung.

Treatment of testicular cancer

Treatment depends on the type of tumor and its stage.

Stage I and II seminomas

Inguinal orchiectomy, followed by retroperitoneal radiation therapy , cures approximately 98% of patients with stage I seminoma. The radiation therapy dose is low and well tolerated, and the local recurrence rate is negligible.

Stage II tumors are treated with retroperitoneal radiation therapy after orchitectomy and when there are recurrences, they will be treated with chemotherapy.

Non-seminomatous in stage I

If after an orchiectomy, the X-rays and physical examination show no evidence of the tumor, and the AFP and HCG levels are normal or normalizing, there are two therapeutic options:

• intense surveillance and monitoring.
• a retroperitoneal lymph node dissection (such a surgical procedure causes long-term side effects of retrograde ejaculation and, in some cases, sterility)

Stage II non-seminomatous

A retroperitoneal lymph node dissection is performed and, depending on the extent of the tumor process, the therapeutic possibilities after the intervention are: surveillance (which involves periodic chest x-rays, physical examination, abdominal CT, and determination of tumor markers ) or two cycles of chemotherapy.

Seminomas and non-seminomas in very advanced stages II and stage III

They are treated with chemotherapy. The combination of bleomycin, cisplatin, and etoposide is used. The complete response to chemotherapy appears in only about 60% of patients, while 10-20% are disease-free by surgically removing all residual tumor sites. The side effects are mainly:

• sickness
• vomiting
• hair loss
• hematological abnormalities

After chemotherapy, a resection of the residual metastases is performed and, finally, in those cases in which an adequate response is not obtained, a second phase of chemotherapy is prescribed.