Testicular cancer is a malignant lesion of the genital glands in men. Symptoms of pathology are palpable formation, enlargement and swelling of the scrotum, pain syndrome. Diagnosis of the disease consists in examination, diaphanoscopy, ultrasound of the scrotum, testicular biopsy, determination of tumor markers, MRI of the scrotum, CT of the thoracic and abdominal cavity. Treatment includes performing one- or two-sided orchifuniculectomy, radiation therapy and chemotherapy. The prognosis of the disease depends on the clinical stage and histological type of neoplasm.
ICD 10
C62 Malignant neoplasm of the testicle
General information
Testicular cancer is a relatively rare oncopathology, accounting for about 1.5-2% of all malignant tumors detected in men. In practical oncourology, testicular cancer accounts for 5% of all neoplasms. At the same time, the disease is extremely aggressive, affects mainly young men under the age of 40 and is among them the most common cause of early cancer mortality. A unilateral tumor is more often detected, less often (in 1-2% of cases) a bilateral lesion is observed.
Causes
Three age peaks associated with the occurrence of testicular cancer have been identified: in boys up to 10 years old, young men from 20 to 40 years old and older people over 60 years old. In children, pathology develops in 90% of cases against the background of malignancy of embryonic benign teratoma. At an older age, scrotal injuries, endocrine diseases (hypogonadism, gynecomastia, infertility), radiation radiation, etc. can become factors provoking the development of neoplasms. The risk of neoplasia increases with Klinefelter syndrome.
The disease is most often detected in patients with cryptorchidism – non-discharge of glands into the scrotum. Various forms of cryptorchidism increase the risk of cancer in an undescended testicle by 10 times. With unilateral testicular lesion, the likelihood of a contralateral gland tumor is also high. The probability of developing cancer is higher in men whose relatives of the first degree (brother, father) had a similar disease. Pathology is 5 times more common in Europeans, especially residents of Germany and Scandinavia; less common in Asian and African countries.
Classification
According to the histological principle, germinogenic (originating from the seminal epithelium), non-germinogenic (arising from the testicular stroma) and mixed neoplasms are distinguished. Germinogenic testicular tumors occur in 95% of cases and can be represented by seminoma, embryonic cancer, chorioncarcinoma, malignant teratoma, etc. About 40% of cases of germinogenic neoplasia are seminomas; 60% are non-seminoma tumors. Tumors of the genital stroma (non-germinogenic) include sertolioma, leidigoma, sarcoma.
The determining importance for the treatment of pathology is the staging of the disease according to international TNM criteria.
- T1 – the tumor is localized within the boundaries of the testicle and appendage, possibly growing into the protein envelope.
- T2 – the tumor is located within the testicle and appendage, sprouts the protein and vaginal membrane.
- T3 – the tumor infiltrates the spermatic cord.
- T4 – the tumor sprouts the spermatic cord and scrotum tissue.
To indicate the involvement of regional (iliac, retroperitoneal lymph nodes), criterion N is used:
- N1 – the presence of regional metastases in lymph nodes up to 2 cm in diameter
- N2 – metastases in regional lymph nodes up to 5 cm
- N3 – metastases in lymph nodes over 5 cm
Distant metastases are denoted by the Latin letter M and are classified as follows:
- M1 – distant metastases are detected (M1a – in the lungs and non-regional lymph nodes, M1b – in other organs).
Testicular cancer symptoms
The clinic consists of local symptoms and manifestations of metastasis. The first sign of testicular cancer, as a rule, becomes a gland seal and the appearance of a palpable painless nodule in it. In a quarter of cases, there is pain in the affected testicle or scrotum, a feeling of heaviness or dull pain in the lower abdomen. The initial symptoms may resemble acute orchoepididymitis. With the progression of testicular cancer, the scrotum becomes asymmetrically enlarged and edematous. Further development of clinical manifestations is usually associated with metastasis.
With compression of nerve roots by enlarged retroperitoneal lymph nodes, back pain may be noted; with compression of the intestine, intestinal obstruction. In the case of blockage of the lymphatic pathways and the inferior vena cava, lymphostasis and edema of the lower extremities develop. Compression of the ureters may be accompanied by the development of hydronephrosis and renal failure. Metastasis to the lymph nodes of the mediastinum causes coughing and shortness of breath. With the development of cancer intoxication, nausea, weakness, loss of appetite, cachexia are noted.
Non-germinogenic forms of testicular cancer can initiate dishormonal manifestations. In these cases, boys often develop gynecomastia, premature masculinization (hirsutism, voice mutation, macrogenitosomy, frequent erections). In adults, hormone-active cancer can be accompanied by a decrease in libido, impotence, and feminization.
Diagnostics
Step-by-step diagnosis of testicular cancer includes physical examination, diaphanoscopy, ultrasound diagnostics (ultrasound of the scrotum), examination of tumor markers, tomography, testicular biopsy with morphological examination of tissues.
- Examination by a urologist. The initial examination begins with palpation of the organs of the scrotum (to detect the primary tumor), abdomen, inguinal and supraclavicular areas (to detect palpable lymph nodes), breast glands (to detect gynecomastia). With the help of diaphanoscopy – screening of scrotum tissues with a light source, it is possible to differentiate the cyst of the epididymis, hydrocele and spermatocele from the tumor.
- Sonography. Ultrasound of the scrotum organs is aimed at determining the localization of cancer, its magnitude and degree of invasion, as well as the exclusion of damage to the contralateral gland.
- Tomographic diagnostics. MRI of the scrotum organs has high sensitivity and specificity in the diagnosis of testicular tumors, which makes it possible to assess the estimated depth of tumor invasion.
- Determination of serum markers. It is a significant factor in the diagnosis, staging and prognosis of testicular cancer. It is necessary to investigate AFP (a-fetoprotein), HCG (chorionic gonadotropin), LDH (lactate dehydrogenase), PSF (placental alkaline phosphatase). An increase in the level of markers is registered in 51% of patients, but a negative result also does not exclude the presence of a tumor.
- Biopsy. The final morphological verification of the diagnosis is carried out during an open testicular biopsy through inguinal access. Usually, during the diagnostic operation, an urgent morphological examination of the biopsy is carried out and, when testicular cancer is confirmed, the genital gland is removed together with the spermatic cord (orchifuniculectomy).
Distant metastases can be detected by performing abdominal ultrasound and kidney sonography, chest x-ray, MRI and CT of the thoracic and abdominal cavity, osteoscintigraphy.
Treatment
The possibility of organ-preserving surgery is considered in case of a bilateral tumor or a lesion of a single gland. After testicular resection, adjuvant radiation therapy is indicated for all patients. The standard of surgical treatment of pathology is orchiectomy, if necessary with retroperitoneal lymphadenectomy. Removal of seminoma tumors of stages T1-T2 is supplemented by radiation therapy; with stages of seminoma T3-T4, as well as with non-seminoma cancer, systemic chemotherapy is required. In the case of bilateral orchifuniculectomy or low testosterone levels, hormone replacement therapy is prescribed to patients.
Complex treatment (orchiectomy, radiotherapy, chemotherapy) can lead to temporary or prolonged infertility and impotence. Therefore, patients of fertile age before starting therapy are recommended to be examined by an oncourologist with an assessment of the level of hormones (testosterone, LH, FSH) and spermograms. If a man intends to have children in the future before starting treatment, he may resort to cryopreservation of sperm.
Prognosis and prevention
The multifactorial analysis of the prognosis takes into account the clinical stage, the histotype of the tumor, the correct and complete complex of the treatment. Thus, in the stages of T1-T2 cancer, recovery is possible in 90-95% of patients. The worst prognosis should be expected with angiolymphatic invasion of the tumor, the presence of metastases. Prevention consists in timely elimination of cryptorchidism, prevention of scrotal injuries, exclusion of genital irradiation. Timely detection of pathology is facilitated by regular self-examination and early referral to a urologist-andrologist if any changes are detected.
