Testicular TumourUro-Oncology Unit
Testicular cancer has high cure rates due to the good response to chemotherapy and surgical treatments, early diagnosis, and multidisciplinary treatment addressed by urologists and oncologists.
Testicle tumours are the most common solid tumours in young men. Between 3 and 10 new cases are diagnosed per 100,000 men/year in Western countries. In 1 or 2% of the cases, both testicles are affected at the time of diagnosis. The incidence peak of non-seminomatous tumours occurs between the ages of 30 and 40, while the incidence peak of seminomatous tumours occurs between the ages of 40 and 50.
90-95% of the cases are germinal tumours (developed from germ cells) and 5-10% of them, from stromal cells.
1. Germ cell tumours
Germ cell tumours are classified as follows:
- Seminomas (35%)
- Non-seminomas (65%): intratubular neoplasia of germ cells, embryonal carcinoma, teratoma, teratocarcinoma, choriocarcinoma, yolk sac tumour, and mixed tumour.
Genetic changes associated with the development of testicular cancer have been described. In addition, epidemiological risk factors have been identified:
» Testicular dysgenesis syndrome (cryptorchidism, hypospadias, and infertility).
» Isolated cryptorchidism (testicles are formed during the embryonic stage inside the abdomen and must descend into the scrotum through the inguinal canal). This happens between the third trimester of pregnancy and the first few months of life. The absence of one or both testicles from the scrotum is called cryptorchidism).
» Klinefelter syndrome.
» A family background of testicular cancer in first-degree relatives.
» A tumour in the other testicle.
Recently, height has been associated with testicular tumours.
A testicular tumour usually appears as a solid painless testicular node that may be detected by self-examination. Scrotal pain is not usual but may occur in cases of intratumoral bleeding. In 7% of the cases, men may undergo gynaecomastia or breast growth as well as infertility and hypogonadism, even after the orchiectomy surgery. In advanced or metastatic cases, it appears with systemic symptoms (weight loss, anorexia) and low back pain, apart from the appearance of a tumour mass in the retroperitoneum (this occurs because the lymphatic drainage of the testicles happens at the level of the nodes that surround the aorta artery and vena cava).
For the diagnosis, the physical exam and the scrotal ultrasound, which can define a testicular mass or the presence of intratesticular calcifications and rule out the presence of tumours in the other testicle, are fundamental. Scrotal NMR is reserved for cases of diagnostic doubt. In all cases, it is necessary to perform a thoracoabdominal-pelvic CT to rule out the presence of distant metastases. In selected cases, a brain CT may be carried out if brain metastases are suspected; PET, to evaluate the presence of residual retroperitoneal tumours, despite treatment; and skeletal scintigraphy in the case of skeletal-related symptoms.
In all young patients with a desire to have children in the future, fertility studies should be offered by means of a seminogram and hormone studies (testosterone, LH and FSH), as well as the possibility to cryopreserve semen.
There are tumour markers characteristic of testicular tumours that rise in blood in 51% of the cases. They also serve to establish the prognosis and are useful during monitoring: B-HCG, alpha-fetoprotein and LDH.
The standard treatment for testicular tumour is the radical inguinal orchiectomy. It consists of removing the testicle through the inguinal canal so as not to open the scrotum skin (to avoid affecting it through tumour seeding during the procedure). It is possible to offer the placement of a testicular prosthesis during the same surgical procedure. Conservative surgery (lumpectomy or exeresis of the tumour only, preserving the rest of the testicle) is only indicated in patients with tumours in both testicles or in patients with only one testicle, with normal testosterone levels, as long as the tumour does not occupy more than 1/3 of the testicular volume.
Retroperitoneal lymphadenectomy involves removing the metastatic node mass or lymph nodes that surround the large vessels (aorta artery, vena cava) to the renal arteries. Preservation of the ejaculatory nerves should be attempted.
Testicular tumours are very chemosensitive, and therefore good results are obtained with the administration of chemotherapy. It is administered after the orchiectomy prophylactically or to treat metastases in other organs.
Radiotherapy is only useful in seminomatous tumours because of their high radiosensitivity.
After treatment, close monitoring using tumour markers, CT scans and exams, is required to rule out tumour recurrence.
2. Stromal cell tumours
» Leydig cell tumour:
It is the most common of all stromal tumours. It appears in the first decade of life or between the third and sixth decade. Only 10% are malignant. It is diagnosed by the presence of a painless testicular mass, gynaecomastia and hormonal disorders. Treatment is surgical (in some cases conservative surgery can be performed) and metastatic cases display little response to chemotherapy or radiotherapy.
» Sertoli cell tumour:
Appears around age 45. 20% are malignant, but have low metastatic capacity. It appears as a testicular mass and rarely presents gynaecomastia or hormonal disorders. The treatment is surgical, and in some cases conservative surgery can be performed.
- Urologists highly specialised in testicular cancer.
- Testicular biopsy.
- Tumour markers in blood.
- Radiodiagnostic service: scrotal ultrasound, CT, NMR and PET.
The ultrasound of the urinary system is fundamental to the diagnosis, and allows the evaluation of the presence of masses in the bladder, renal masses and obstruction of the upper urinary tract.
The cystoscopy is the best diagnostic test and is necessary to monitor patients with bladder tumours. It consists of an endoscopy of the urinary bladder using a cystoscope inserted through the urethra. This must be done under sterile conditions. It allows direct visualisation of bladder tumours, observing their number, location and appearance.
The urine cytology consists of the anatomopathological evaluation of the bladder cells that are released in the urine. This test helps predict the tumour grade and the presence of associated carcinoma in situ.
The Uro-CT is fundamental in the diagnosis and monitoring of patients with bladder tumours, since it allows the evaluation of ureters, pelvis and renal calyces to rule out the presence of tumour implants in these locations. Upper urinary tract tumours can coexist with bladder tumours in 2-4% of the cases, rising up to 7% if the bladder tumour is in the trigone. In addition, thoracoabdominal-pelvic CT is used to rule out the presence of metastasis.