TESTICULAR CANCER
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Diagnosis and Treatment of Testicular Cancers
Unlike other types of cancer, testicular tumors are all malignant diseases in men. These are cancers that make up 1-1.5% of tumors and are more common in the younger population. Recently, its incidence has been increasing, albeit slightly. However, 70% of those currently diagnosed with testicular cancer are stage 1 disease, and they have almost a 100% chance of treatment and cure. As a result of advances in diagnostic methods, accurate tumor markers used in diagnosis and follow-up of treatment, development of surgical techniques and the development of new generation chemotherapy models, there are cure rates of up to 80-100% even in metastatic disease. Testicular tumors often occur in advanced adolescence. and is seen in early adulthood. The highest incidence is in young adult males. Some factors pose a risk for the development of the disease.
Risk factors for the development of testicular cancer;
• History of undescended testicles
• Klinifelter syndrome
• Family history of testicular tumor
• History of tumor in the other side testicle
• History of infertility
Classification
Testicular cancers in general They are divided into two classes. The most common type is germ cell cancers and is seen in 90%. Among these, the most common are seminomas. Seminomas constitute 30-35% of germ cell tumors.
1. Germ cell tumors
• Seminoma
• Embryonal carcinoma
• Yolk-sac tumors
• Choriocarcinoma
• Teratoma
• Mixed type
2. Sex-cord stromal tumors
• Leydig cell tumor
•Sertoli cell tumors
•Granulosa cell tumors
•Thecoma
•Mixed type tumors
Diagnosis
Patient history, physical examination and testicular ultrasonography are the most valuable methods in diagnosis. Clinically, a painless, hard and palpable mass lesion in the testicle is sufficient to suspect a tumor. The first thing to do in such a patient is testicular ultrasonography. Ultrasonography can show a mass lesion in the testicle, as well as other pathologies in the abdomen.
Another test used in diagnosis is tumor markers. The values of these parameters measured in blood may be high or normal depending on the type of tumor. In addition, these tumor markers have very important roles in post-treatment monitoring and determining the course of the disease. As serum tumor markers, glycoprotein hormones called alphafetoprotein (AFP), betahumanchorionogonadotropin (B-hCG) and lactate dehydrogenase (LDH) are checked. These hormones are released from tumor tissue, but are not expected to increase in pure seminomas. Solid and hard masses confined to the testicle should be considered testicular tumors until proven otherwise.
If there is any doubt in the diagnosis of a testicular tumor, testicular MRI can be performed to obtain information about the structure of the mass. However, despite all these diagnostic methods, definitive diagnosis is made through pathological examination. Pathological examination of testicular tumors is performed by completely removing the testicle. In other words, procedures such as needle biopsy are not performed for pathology in testicular tumors.
Staging and Classification
In order for the treatment and follow-up of the disease to be carried out correctly, accurate staging is necessary. For an accurate staging, A body scan should be performed. Measurement of serum tumor markers by abdominal and lung tomography and the characteristics of the testicular mass should be well known. TNM classification system is used in staging.
Primary tumor (T)
• PTx: No primary tumor detected
• PT0: No evidence of primary tumor
• PTis: Intratubular germ cell neoplasia
• PT1: Tumor limited to testis and epididymis, no vascular or lymphatic invasion
• PT2: Tumor limited to testis and epididymis, with vascular or lymphatic invasion or tunica albuginea with tunica vaginalis involvement There is spread beyond.
• PT3: The tumor has invaded the spermatic cord, with or without vascular / lymphatic invasion
• PT4: The tumor has invaded the scrotum skin, with or without vascular or lymphatic invasion
Lymph nodes (N)
• Nx: No regional lymph nodes detected
• N0: No lymph node metastasis
• N1: 2 cm in largest dimension or less lymph node involvement, or multiple lymph node involvement, none of which exceeds 2 cm. • N2: Single lymph node greater than 2 cm, less than 5 cm, or multiple lymph nodes, any of which is greater than 2 cm and less than 5 cm involvement
• N3: Lymph node involvement greater than 5cm
Distant metastasis (M)
• M0: No sign of distant metastasis
• M1: Distant organ metastasis is present
• M1a: non-regional lymph node involvement or lung metastasis
• M1b: extrapulmonary organ metastases
Serum tumor markers (S)
• S0: Markers at normal values
• S1: hCG below 5000 and AFP below 1000
• S2: hCG between 5000-50000 and AFP between 1000-10000
• S3: hCG above 50000 and AFP above 10000
Staging is as follows
Using the TNM Classification system makes. Treatment and follow-up programs are 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 inguinal orchiectomy.
3. Serum tumor markers should definitely be checked before and after orchiectomy.
4. Intra-abdominal lymph nodes, lung region and regional lymph nodes should be evaluated.
Treatment of Testicular Cancers
The first procedure that should be performed in patients with a testicular tumor is inguinal orchiectomy without delay. This procedure is performed through a small incision in the inguinal area. After the testicle is removed, sending it to pathology and knowing what type of tumor is is necessary information during the treatment phase. Then, the patient's lung and abdominal tomography is performed to evaluate lymph nodes and distant organ metastases. After all this evaluation and orchiectomy, treatment should be applied according to the tumor stage and type.
Treatment options after orchiectomy are as follows…
Treatment of Stage 1 Seminomas
1. Adjuvant radiotherapy: including the abdominal region and the groin area on the side of the tumor.
2. Adjuvant chemotherapy i: It is made on the basis of 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)
Treatment of Stage 2 Seminomas
1. Primary chemotherapy (BEP-based chemotherapy)
2. Adjuvant chemotherapy
3. RPLND: It is the surgical removal of lymph nodes in the posterior abdominal wall. Performing 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
3. Adjuvant chemotherapy
Treatment in Non-Seminoma Germ Cell Tumors;
Stage-1:
1 If the patient is in the low risk group (no vascular spread) and the tumor is PT1a, close monitoring can be performed 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 if rising RPLND
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