Testicular Cancer

Testicular cancer is an unorganized growth of cells in the testicle. If the cancer growth starts on the testis surface, we’ll feel a hard lump or nodule. If it starts from inside, we’ll have a testicular swelling. The bump and the bulge are typically painless and can develop and progress rapidly in a few weeks. Any recent painless testicle lump or swelling onset must prompt immediate medical consultation.

Symptoms of testicular cancer

Early symptoms of testicular cancer are related to local growth. Recent lump and swelling are only exceptionally painful. Sometimes, we can feel heaviness or acute pain after minor trauma. In the late stages, symptoms are primarily caused by cancer spreading to the lymph nodes in the posterior abdominal wall, close to the kidneys, big vessels and the upper gastroenteric tract. The cancer growth cause compression of the urinary tract causing back pain or symptoms of renal failure. The stomach compression and the intestine’s first part may cause dyspepsia, acidic reflux or vomiting. Fever and malaise are other possible symptoms of late advanced stages.

Diagnostics

The physical examination is more than enough to suspect testicular cancer. The Ultrasound scan does confirm the solid and irregular nature of the testicular growth. We test alpha-fetoprotein and Beta HCG produced by some testicular cancer in the blood. If we suspect testicular cancer, normal Beta HCG and alpha-fetoprotein do not exclude the presence of testicular cancer. If detected, these markers have an essential role in evaluating the effect of treatment. If they do not fall to average values after orchiectomy, there is still an active producing tumour (metastatic disease). Also, after chemotherapy, their presence in the blood means ineffective treatment.

The inguinal orchiectomy is the surgery to treat testicular cancer. Except in selected cases, we remove all the testicles and the cord until the deepest part of the inguinal canal. This surgery is also an important diagnostic step. It defines precisely which type of testicle cell in tumour growth. This information is essential to determine the prognosis and possible further treatment.

The CT scan accurately defines the spread of cancer to the abdomen or the lungs, which are the main landing sites of its metastasis.

Magnetic resonance imaging (MRI) of the scrotum provides higher sensitivity and specificity than the scrotal US in diagnosing testicular cancer. Still, its high cost does not justify its routine use for this purpose. However, it may be helpful to distinguish between an intra- and extra-testicular mass when this cannot be confirmed clinically or with the US.

PET (FluoroDeoxyGlucose-Positron Emission Tomography) study is a diagnostic that combines the morphology of the metastatic retroperitoneal mass and its metabolic activity. High metabolic activity means a higher risk of malignant mass. However, there is no evidence to support the use of FDG-PET for the initial staging and follow-up of Testicular Cancer. We recommend FDG-PET to study the abdominal (retroperitoneal) residual masses after treatment with chemotherapy only. FDG-PET should not be performed until at least two months after completion of the last cycle of chemotherapy, as inflammation and the fibrotic reaction induced by chemotherapy may result in metabolic activity and a false-positive result.

Treatment of Testicular Cancer

The first step of treatment is the inguinal orchiectomy without delay. Before surgery, the surgeon should discuss the insertion of a testicular prosthesis with the patient. However, we can implant the prosthesis even later if the patient is unsure or the surgeon cannot insert it in the same orchiectomy session.

Since 2% of Testicular Cancers at diagnosis are bilateral, we must ensure that the contralateral testicle is disease-free (physical examination, US scan) before the surgery. In addition, we perform random biopsies in the contralateral healthy testicle for higher-risk patients to exclude microscopic cancer (Germ-Cell Neoplasia in Situ), which we consider a precursor of solid Testicular Cancer. We define high-risk patients for GCNIS when the testicular volume is less than 12 mL and their history of cryptorchidism.

The further treatment of Testicular Cancer depends on the type of testicular cancer (the differentiation between Seminoma and Non-Seminomatous Germ Cell Cancer comes from a histopathology study). The size of the tumour and how far it has spread from the testicle define the prognosis. Other prognostic factors are some microscopic cancer features and serum markers. We need to determine the prognosis to understand the risk of cancer relapse and progression and plan the best treatment strategy. If the patient has a good prognosis, the probability of being disease-free at five years will be 99%.

The treatment of Testicular Cancer aims to complete eradication. We can achieve complete eradication after the orchiectomy. However, there is a variable risk of microscopic metastatic disease that may relapse later in months or years. The prognosis defines this risk and guides us towards active surveillance or treatments. We call them adjuvant treatments or treatments given after the orchiectomy to reduce the chance of cancer returning by destroying any remaining cancer cells.

Treatment of Seminoma

After orchiectomy, we have three options:

• Active surveillance only in suitable prognosis patients. Since patients have a low risk of relapse in this group, any adjuvant treatment (Chemotherapy or Radiation Therapy) may give them more toxicity than benefits. However, we must offer active surveillance to well-informed patients who accept frequent follow-up, imaging scans and blood works. They must strictly respect the follow-up schedule. We must consider the patient’s anxiety and compliance to the follow-up schedule during the treatment counselling.
• Chemotherapy in patients with a high risk of cancer relapse after orchiectomy or patient with already metastatic disease. We can also treat those anxious or low compliant patients in the good prognosis group (low risk of cancer relapse).
• Radiation Therapy only in cases unsuitable for adjuvant chemotherapy or surveillance and the elderly. The main concern with adjuvant RT is the long-term risk of radiation-induced secondary non-germ cell malignancies. Otherwise, seminomas are extremely radiosensitive tumours, and there is no difference in efficacy between Chemotherapy and Radiation Therapy.

Treatment of Non-Seminomatous Germ Cell Cancers (NSGCC)

In the good prognosis group, this tumour has more relapse risk than Seminoma. Active surveillance must include a rigorous follow-up schedule, and the patient must be compliant and not anxious. However, in patients who relapse, the chemotherapy has good results.

Then, we still have three options:

• In low-risk patients, rigorous active surveillance is still an option. Patient compliance is a must.
• In high-risk patients and metastatic disease, chemotherapy is a strong recommendation.
• We indicate nerve-sparing retroperitoneal lymph node dissection (RPLND) to highly selected patients who have a contraindication to adjuvant chemotherapy and are unwilling to accept surveillance. Retroperitoneal lymph node dissection is a major surgery to excise the retroperitoneal lymph nodes, a possible site of metastatic cancer landing. We do this surgery also to excise solid metastases already formed.

Final considerations on treatment of Testicular Cancer

We outlined on this page the main guidelines for treatment. However, each patient must be considered not only tumour stage and prognosis but also according to his feelings, concerns, and expectations. It is essential to have a shared strategy because patient compliance is crucial to obtaining the best disease-free status and survival results. Also, the physician experience is critical. It has been proven that high volume centres, the results are more optimal than in peripheral, low-cases hospitals. Getting a second opinion from experienced physicians is another good practice. Patients and not experienced physicians must be humble and sure they’re doing the proper disease management.

Infertility and Testicular Cancer

We recommend fertility screening before the treatment (semen analysis, serum testosterone, FSH and LH). Almost 50% of patients have abnormal sperm counts before treatment. There is also the possibility that patients with Testicular Cancer are completely infertile with “zero” sperm. Moreover, treatment for Testicular Cancer, including orchiectomy, may harm reproductive function.

If cryopreservation is desired and feasible, sperm banking should be offered before orchiectomy, maximizing the chances of fertilization. If the patient cannot do it before orchiectomy, he can do it before chemotherapy.

External resources

European Urological Association Guidelines on Testicular Cancer