What’s testicular cancer?
Testicular cancer is rare and responds for 5% of total cancer cases among men. Unlike what happens to other tumors, like in the prostate, testicular cancer is more common among young people, between 15 and 50 years old.
Also known as a Germ Cell Tumor (GCTs) benign or malignant neoplasms derived from germ cells, that originate sperm cells (in men) and ova (in women).
If diagnosed early, testicular cancer has high chances of being cured.
Testicular cancer subtypes
Testicles are composed by several types of cell, and each can develop one or more types of cancer. It’s fundamental to find out what type of cell originated cancer and what kind of tumor developed, because this determines the type of treatment and helps predicting the prognosis.
Germ cell tumors – more than 90% of testicular cancers start on cells known as germ cells, sperm producers. The main types of germ cell tumors (GCTs) on testicles are seminomas and nonseminomas. Many testicular cancers have both seminoma and non-seminoma cells. These mixed tumors are treated as non-seminoma because they grow and spread like non-seminomas;
- Seminomatose tumors – seminomas tend to grow and spread slower than non-seminomas. The two main subtypes of these tumors are classic or typical seminomas and spermatocytic seminomas. More than 95% of seminomas are classic. Usually they occur in men between 25 and 45 years old. Spermatocytic seminoma is rare and tends to occur in older men (averaging 65 years old);
- Nonseminomatous tumors – this type of testicular cancer occurs in men between the end of adolescence and 30 years old. There’s four main non-seminoma types of tumors: embryonal carcinoma, yolk sac carcinoma, choriocarcinoma and teratoma. Most tumors are a mix of different types, but it doesn’t change treatment of most non-seminoma cancers. They correspond to 60% of all testicular tumors.
Each subtype of nonseminomatous tumor may express proteins that fall into the bloodstream and are not only useful for diagnosis, but also for prognosis and monitoring. These proteins are called tumor markers;
- Carcinoma in situ – testicular cancers can start as a non-invasive form of the disease called carcinoma in situ. This type of cancer does not always evolve into an invasive type. It is difficult to diagnose, as it does not cause symptoms and often does not form a mass that can be felt;
- Stromal tumors – develop in the tissues that produce hormones and in the tissues supporting the testicles. They constitute less than 5% of testicular tumors but up to 20% of childhood testicular tumors. There are two main subtypes: Leydig cell tumors, which are usually benign and develop in the cells that produce male sex hormones, and Sertoli cell tumors, which develop from the cells that support and nourish the germ cells. sperm producers. They are usually benign, but if they spread, they tend not to respond to chemotherapy and radiotherapy; and
- Secondary testicular cancer – starts in another organ and spreads to the testicle. It is treated with a focus on the organ of origin. Lymphoma is the most common secondary testicular cancer and occurs more frequently than primary testicular tumors in men over age 50. The prognosis depends on the type and stage of the lymphoma.
Symptoms and signs of testicular cancer
The most common sign of testicular cancer is the appearance of a hard lump that sometimes causes pain, but in most cases does not. Patients may also feel an enlarged testicle and a heaviness or abdominal pain.
Other symptoms that should call attention are:
- Increase or decrease in the size of the testicles;
- Vague pain in the lower abdomen;
- Blood in the urine;
- Nipple tenderness (rare); and
- Precocious puberty, with facial and body hair growing earlier than expected.
Testicular cancer diagnosis
One of the difficulties in detecting the tumor in young people occurs because it can be confused, or even masked, by orchiepididymitis – inflammation of the testicles and epididymis, channels located behind the testicles that collect and carry sperm. Orchiepididymitis is sexually transmitted.
The first phase of the diagnosis is through clinical examination, checking for palpable nodules or alterations that suggest cancer. One of the tests for diagnostic confirmation is scrotum ultrasound, which identifies homogeneous lesions (which suggest seminomatous tumors) or heterogeneous lesions (indicative of non-seminomatous tumors).
Laboratory tests are also performed to identify tumor markers (alpha-fetoprotein, beta-HCG and LDH).
Once the diagnosis is confirmed, it is necessary to define the clinical conduct – when computed tomography of the chest, abdomen and pelvis is fundamental. It allows checking the staging of the disease and the definition of post-orchiectomy therapeutic conduct – removal of the testicle to control the cancer.
The treatment of testicular tumors is based on staging, histological type and risk classification. Each stage of the disease requires a different approach. The main therapeutic alternatives available are:
- Chemotherapy – There are several chemotherapy regimens described for the treatment of testicular cancer. Because it is a systemic treatment, given intravenously, it has more side effects because it also affects healthy cells;
- Radiotherapy – radiotherapy treatment is reserved for seminomatous tumors, as they are more sensitive to this therapy. The application is indicated in localized tumors (Stage I) and low-volume retroperitoneal tumors (Stages II a and b);
- Partial orchiectomy – surgical procedure in which one or both testicles are removed from a small cut in the scrotum. It should be indicated in tumors smaller than 2 cm in the absence of a contralateral testis or marked functional deficit due to the high risk of local recurrence; and
- Radical orchiectomy – this surgical procedure, even alone, cures most patients. In this surgical technique, the cut is made in the abdominal region, and not in the scrotum. Testicular prosthesis implantation can be performed in the same surgery.
The choice of therapies to use alone or in combination depends on the stage of the cancer, as described below.
Stage I (except EI S), seminoma and non-seminoma – patients have local disease or disease restricted to the testis and spermatic cord. The risk of metastasis is around 20% – that is, cure reaches 80% of cases only with radical orchiectomy.
Stage II A or B, non-seminoma – in patients with non-seminomatous tumors, limited retroperitoneal disease (< 5cm) and normal tumor markers, there are two treatment options, with good prognosis. The most used strategy is initial chemotherapy followed by surgery. This combination is associated with high cure rates and, as it is a systemic treatment method, the incidence of distant metastases is also reduced.
Stage II A or B, seminoma – in this case, an alternative to chemotherapy is radiotherapy at higher doses than those administered for stage I, also with a good prognosis.
Stage II C, III and IS, seminoma and non-seminoma – the cure rate of patients with testicular tumor and large-volume metastatic disease can reach 90%, depending on the risk classification. The reason for the therapy’s success is the development of cisplatin-based chemotherapy regimens. The number of cycles will depend on the risk classification. Three cycles can be performed in patients with good prognosis, or four in patients with intermediate and poor prognosis.
There is no way to prevent testicular cancer. The most important thing is to carry out a self-examination for the early detection of the neoplasm, which greatly increases the chances of cure. One of the recommendations is that self-examination be done once a month, after a hot bath. The temperature of the water relaxes the scrotum and makes it easier to check for any changes in size, tenderness or abnormalities.