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Testicular Cancer: Classification, Risk Factors, Clinical Features, Diagnostic Tests & Treatment

By March 19, 2018 No Comments
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Although only  accounting for about 1% of all cancers in men, testicular cancer is the most common cancer diagnosed in men aging between 15 and 35 years. It is the second most common malignancy in those 35 to 39 years of age. For unknown reasons, worldwide incidence of testicular tumors has more than doubled in the past 40 years. In present, due to the advances in cancer treatment ,testicular cancer is a highly treatable and usually curable form of cancer. After treatment, most of the patients with testicular cancer have a near-normal life.

Classification of Testicular cancer

The testicles contain several types of cells, each of which may later develop into one or more types of cancer. The appropriate treatment and the success of treatment is based on the types of cancer cell. Testicular cancer is classified as Germinal or non germinal (stromal). Secondary cancer may also appear.

Germinal Tumors

Germinal tumors make up approximately 90% of all cancers of the testes; germinal tumors are further classified as seminomas or nonseminomas. These cancers grow from the germ cells that produce sperm, thus the name germinal tumors. Seminomas are slow-progressing type of Testicular cancer that are usually seen in men in their 30s and 40s. Although seminomas can metastasize to the lymph nodes, the cancer is usually localized in the testes. Nonseminomas are more common and tend to grow more quickly than that of seminomas. Nonseminomas are often made up of different cell types and are identified according to the cells in which they start to grow. It is very difficult  to distinguish between seminomas and nonseminomas because the differences affect prognosis and treatment.

Nongerminal Tumors

Nongerminal tumors accounts for less than 10% of Testicular cancers. These cancers may develop in the supportive and hormone-producing tissues, or stroma, of the testicles. The two main types of stromal tumors are Leydig cell tumors and sertoli cell tumors. Although these tumors infrequently spread beyond the testicle, small number metastasize and tend to be resistant to chemotherapy and radiation therapy.

Secondary Testicular tumors

Secondary testicular tumors are those that have metastasized to the testicle from other organ. Lymphoma is the most common cause of secondary testicular cancer. Cancers may also spread to  testicles from other organs such as prostate gland, lung, skin (melanoma), kidney, gastrointestinal tract. The prognosis with these cancers is usually poor because they typically also spread to other organs.

Risk factors

Risk factor for testicular cancer includes;

  • Undescended testicles (cryptorchidism)
  • Family history of Testicular cancer
  • Race and ethnicity are also included as: Caucasian American men have a five times greater risk than African American men and more than two to three times greater risk than Asian, native American and Hispanic men.
  • The risk gets higher in HIV-positive men.
  • Occupational hazard, including exposure to chemicals encountered in mining, oil and gas production, and leather processing have been suggested as possible risk factor
  • No evidence has linked testicular cancer to vasectomy.

Clinical features

  • The symptoms appear gradually, with a mass or lump on the testicle and usually painless enlargement of the testis
  • May complain  heaviness in the scrotum, inguinal area, or lower abdomen.
  • Backache
  • Abdominal pain
  • Weight loss
  • General weakness may result from metastasis
  • Some testicular tumors tend to metastasize early, spreading from the testis to the lymph nodes in the Retro-peritoneum and to the lungs.

Diagnostic tests

  • Testicular cancer generally grow rapidly and are easily detected against a typically smooth and homogeneous texture.
  • Annual testicular examination can reveal signs and lead to early diagnosis and treatment of testicular Tumors.
  • Any suspicious testicular mass warrants prompt evaluation with a thorough history and physical examination, focusing on palpation of the affected testicle.
  • Tumor markers may be elevated in blood like aloha-fetoprotein (AFP) and human chorionic gonadotropin (beta-hCG). These markers are used for diagnosis, staging and monitoring the response to treatment.
  • Blood chemistry is also necessary
  • A chest x-ray to asses for metastasis in the lungs and transscrotal testicular ultrasound will be performed
  • Inguinal orchiectomy is the standard way to establish the diagnosis of testicular cancer
  • In advance stage, to determine the extent of disease Retro-peritoneum, pelvis and chest include an abdominal/pelvic CT and chest CT.

Treatment

Testicular cancer, one of the most curable solid tumors, is highly responsive to treatment. Early -stage disease is curable more than 95% of the time where prompt diagnosis and treatment are essential. The goals of management are to Eradicate the disease and achieve cure. Therapy is based on the cell type, the stage of the disease and  the risk.

Primary treatment includes removal of affected testis by orchiectomy through an inguinal incision with high ligation of the spermatic cord. Although most patients experience no impairment of the endocrine function after unilateral orchiectomy for testicular cancer, some patients have decreased hormonal levels, suggesting that the unaffected testis is not functioning normally.

Two thirds of men who are newly diagnosed with testicular caner may be considering future fatherhood, and sperm quality is reduced in men with testicular cancer; therefore sperm banking before treatment may be considered (Fossa & Dahl, 2008; Girasole, Cookson, smith, et al. 2006)

Radiation therapy seems to be  more effective with seminomas than nonseminomas. Post operatively, radiation may be used in early stage seminomas. It is delivered only to the affected side;  the other testis is shielded from radiation to preserve fertility.

Chemotherapy may be used for seminomas, nonseminomas and advanced metastatic disease. Various types of chemotherapeutic agents given to the patient and results in a high percentage of complete remissions.

With nonseminomas, aggressive surgical resection of all residual masses following chemotherapy is standard therapy. Best results can  be Achieved by combining various types of therapeutical approach including surgery, radiation therapy and chemotherapy. Even with the metastatic testicular cancer, the prognosis is favourable because of advances in treatment. However, for patients who do not respond to high dose salvage chemotherapy, the cancer is nearly always incurable.

Testicular self examination (TSE) is to be performed monthly. The test is not that time consuming. A precise time is usually after a warm bath or shower when the scrotum is more relaxed.

Long term side effects associated with treatment for testicular cancer include renal insufficiency from kidney damage, hearing problems, gonadal damage, peripheral neuropathy, and rarely secondary cancer. Investigation of new medication, combinations of chemotherapeutic agents and stem cell transplantation are ongoing.

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