What is testicular cancer?
This is a male genital organ cancer that originates from testicles. Testicles are a couple of external genital organs situated in scrotum and they are responsible for sperm production and secretion of testosterone, the male hormone. These cancers are rarely seen over 50 years of age and they are mostly encountered in the younger men between 20 and 35. Currently survival rates for testicular cancer when diagnosed at early stages is 98 %.
Figure 1. Anatomy of testicular cancer
Diagnosis of Testicular Cancer
Usually patients seek medical help for an incidental painless swelling in the testicles. Manual examination and ‘Scrotal Ultrasonography’ are sufficient for diagnosis.
Initial measures after diagnosis
Testicular cancer diagnosis necessitates urgent surgery as soon as possible. Before surgery, a blood sample must be drawn for assessment of certain tumor markers as beta HCG alpha fetoprotein and LDH. Surgery for testicular cancer is Radical Orchiectomy that is carried out through a small incision in the inguinal region through which the ill testicle is removed with all its sheaths and the chord that it is hung.
Figure 2: Cancerous regions in the removed testicle are shown
Preoperative and Postoperative Phases
Following preoperative medical preparation patients with testicular cancer are admitted to the hospital and at the same day radical orchiectomy is performed. This surgery takes 15 to 30 minutes and may be conducted under general or regional anesthesia. Usually patients are discharged the same day and scheduled for evaluation when pathologic evaluation is concluded.
Evaluation Following Surgery and Treatment
We figure out the type of cancer as final pathology is determined. Basically, there are 2 types of testicular cancer:
- Non Seminomatous Germ Cell Tumor (NSGCT)
Treatment of these two types of testicular cancer is partially similar and in part dissimilar. A CT scan of abdomen and thorax is performed in order to evaluate lungs and the lymph nodes around the great abdominal vessels and neck whether there is involvement with cancer.
- Seminoma without distant organ metastases: One or two cycles of chemotherapy with carboplatin
- NSGCT without distant organ metastases: Generally, a short-term, 2 cycles of chemotherapy is sufficient
- Whatever the pathology result is when there is distant organ metastases, with either lungs or lymph nodes are attacked by cancer a full-course chemotherapy of 4 cycles is initiated
Following initial chemotherapy regimen patients are scheduled for surveillance at 3 months intervals in the first 2 years and at 6 months afterwards for a total of 5-10 years. When patients are under surveillance they are observed for disease response to chemotherapy.
Monitoring of Response to Chemotherapy
When CT scans performed at certain intervals during surveillance reveal one of the following:
- Persistence of lymph nodes around great vessels in abdomen
- Enlargement of lymph nodes formerly diminished
- Disappearance of masses but tumor markers (beta HCG, alpha fetoprotein) remain still at elevated levels
Signifies an insufficient response to chemotherapy.
Treatment of Patients Unresponsive to Chemotherapy
In the event that chemotherapy is insufficient for ultimate management of metastatic testicular cancer a Retroperitoneal Lymph Node Dissection (RPLND) has to be performed.
What is RPLND?
RPLND is one of the major operations in urology and should be conducted by an experienced surgical team in this field. In some cases, abdominal masses have expanded to such enormous size that a vascular surgery team is mandatory in order to excise tumor masses without compromising the vital great vessels.
In the CT image down below, you can see the enormous mass surrounding abdominal part of aorta, the main artery of the body, prior to surgical excision.
Suitable candidates for RPLND are admitted to hospital the day before surgery for preoperative medical evaluation. Following surgery, the patient is monitored for 24 hours in the intensive care unit and transported to his room when vital signs are all satisfactory. Usually on the 3rd or 4th postoperative day the patient is discharged. Subsequent management of the disease is accomplished after pathologic evaluation of the resected cancerous tissue.
Pathologic Outcomes of RPLND and Management
In regard to pathology there are 3 possibilities after RPLND surgery:
- In 20 % of the resected mass, pathology may reveal viable cancer tissue, which requires further chemotherapy.
- 2. A pathologic diagnosis of Teratoma may be reported in 40 % of the patients. Chemotherapy is unnecessary in this circumstance, surveillance alone suffices. Teratomas are not cancer but may change into lethal cancers or grow to huge masses that may compress adjacent organs and cause severe symptoms if left untreated.
- With a likelihood of 20 % pathology may yield necrosis in the resected tissue. This does not necessitate further chemotherapy, surveillance is enough.