Testicular Cancer

Why Is the Importance of Testicular Cancers Increasing?

Testicular cancers are more common, particularly in high-income countries.

Among solid tumors—what we refer to as mass tumors—treatment success rates remain high even in cases of metastatic disease (spread or metastasis to other sites).

Complete remission is possible in 85–90% of patients. However, because these tumors have the potential to spread rapidly, surgery and treatment are required as soon as possible.

What Are the Reasons for Seeking Medical Care for Testicular Cancers?

Patients typically present with painless swelling and a mass (hardness) on one side. Twenty percent of patients present with scrotal (the skin and subcutaneous tissue covering the testicles) pain.

Unless proven otherwise, painless scrotal mass should be considered a testicular tumor—unless there is a history of inflammatory conditions—and managed accordingly.

Back and flank pain occur in 11% of cases; in addition, rare symptoms such as hemoptysis (coughing up blood), nausea, vomiting, convulsions (seizures), and bone fractures may occur in 10–20% of cases due to metastatic masses. Gynecomastia (enlargement of the breasts) may occur in 7% of patients.

How Is Testicular Cancer Diagnosed?

In a suspected case, a physical examination reveals a hard mass in the entire testis or in a specific area. In such cases, the patient is considered to have testicular cancer until proven otherwise.

During the examination, the patient is screened for lymph node involvement, organ involvement, and breast enlargement, as the condition may have spread throughout the body. It is essential to distinguish between acute epididymo-orchitis (inflammation of the testis and the overlying organ, the epididymis) and testicular cancer; clinically, fever, pain, swelling, skin redness, and increased temperature are indicative of epididymo-orchitis, but a clear distinction may not always be possible.

It is essential to perform the tests for testicular cancer tumor markers—AFP, β-HCG, and LDH. Additionally, the diagnosis should be supported by a scrotal ultrasound; ultrasound has a sensitivity of nearly 100% in detecting masses.

How Is a Definitive Diagnosis Made for Testicular Cancer?

A diagnosis can be made with a high degree of certainty through a physical examination, tumor markers, and scrotal ultrasound. Even if the diagnosis is not fully confirmed by these tests, clinical suspicion

In such cases, it is recommended that the affected testicle be surgically removed and examined pathologically. A definitive diagnosis is confirmed following the pathological examination of the removed testicular tissue.

What Should Be Done If a Patient Has Cancer in One Testicle or If Cancer Is Suspected in the Other Testicle at the Same Time?

If the patient has only one testicle, and the mass is not too large and can be removed, it may be possible to attempt to remove only the mass (testis-sparing surgery). Alternatively, if the patient has tumors in both testicles, testis-sparing surgery may be performed on at least one of them.
This approach is attempted if the mass is smaller than 2 cm. Patients in this situation require close follow-up after surgery.

What Happens After a Preliminary Diagnosis of Testicular Cancer?

When testicular cancer is suspected, an incision is made in the groin to remove the testis and the cord—which contains the testis and the structures surrounding it, including the testicular glands and blood vessels—as a single unit. This procedure is called a radical inguinal orchiectomy.

It is considered a urological emergency requiring surgery. Because testicular cancer has the potential to spread rapidly, the procedure must be performed without delay.

How Is Testicular Cancer Monitored After a Definitive Diagnosis?

Once the diagnosis of the disease has been confirmed, it is essential to determine without delay whether the disease has spread to other areas. To this end, a full abdominal CT scan, a lung CT scan, and blood tests to measure tumor marker levels should be performed at regular intervals following surgery.

What Is the Postoperative Treatment and Follow-Up for Testicular Cancer?

Treatment and follow-up are determined based on the pathology of the removed tumor and the stage of the disease. Treatment planning is based on the classification of patients according to prognostic factors. In general, for tumors with a good prognosis that have not metastasized and are confined to the testis, follow-up consists of periodic tumor marker testing, physical examinations, and imaging studies. For some patients (stage I seminoma), prophylactic radiation therapy or a single course of chemotherapy may be administered due to the possibility of spread to the posterior abdominal wall; alternatively, if the patient is suitable for close follow-up, monitoring may be continued.

In the Stage I nonseminomatous group, chemotherapy, retroperitoneal lymph node dissection (removal of lymphatic tissue surrounding the major blood vessels in the posterior abdominal wall), or watchful waiting may be used.
Radiation therapy is used to treat Stage II disease—seminoma.
For Stage II and higher cases (those that have spread, i.e., metastatic), treatment consists of chemotherapy. Depending on the risk level, 3 or 4 cycles of chemotherapy are administered. After each cycle of chemotherapy, patients are re-evaluated, and either RPLND (retroperitoneal lymph node dissection) or follow-up is performed, as appropriate. When the correct chemotherapy is administered at the right time, the cure rates for metastatic testicular cancer are quite high. However, patients may experience side effects from these drugs during chemotherapy; they should be informed of this, and treatment should only begin after obtaining their consent. Patients should be re-evaluated at the end of each course (chemotherapy treatment period).

In some patients, adjuvant or secondary chemotherapy is administered when resistance to primary chemotherapy is observed or when residual disease (viable tumor cells) is reported in the postoperative pathology report. A very small group of patients, however, experiences disease progression despite these treatments, and these patients may be treated with more intensive (rescue chemotherapy) regimens, rescue surgery, or high-dose chemotherapy in combination with a bone marrow transplant.

Are There Any Preventive Measures for Testicular Cancer?

Although there is no known preventive method for testicular cancer, treatment success rates are quite high when the disease is detected in its early stages. Men between the ages of 15 and 35—the age group most commonly affected—should be advised and taught to perform a self-examination of their testicles at least once a month (similar to how women perform breast self-exams to screen for breast cancer). Anyone who suspects an abnormality in their testicles should see a doctor without delay.

How Should Individuals with Undescended Testicles Be Evaluated?

In normal development, the testicles descend from the back of the abdomen (at the level of the kidneys) into the scrotum at birth. In some individuals, this process may be delayed, but by around 1 year of age, the testicles have descended in 90% of children. Individuals with undescended testicles should be evaluated, and a decision should be made regarding surgery or medical treatment. For testicles that cannot be brought down into the scrotum—particularly those remaining inside the abdomen—removal (orchiectomy) is recommended.
Men whose testicles descend into the scrotum later than normal should be informed about the risk of testicular cancer.

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Prof. Dr. Volkan İzol, Urological Diseases, Urological Treatments, Adana Urology, Adana Urology Specialist, Adana Urologist

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