Epidemiology and Causes of Testicular Tumor
Testicular cancer is a relatively rare disease, accounting for about 1.5% of male malignancies and 5% of all urological malignancies. In the western society, the incidence is around 10 new cases per 100,000 individuals per year. Testicular cancer affects young adults with greater incidence, and represents the most common cancer between 15 and 35 years of age.
Different histological subtypes are known, with a significant prevalence (95%) of germ cell defined tumors (i.e., deriving from the population of seminiferous tubules aimed at reproduction) compared to defined tumors of stromal origin (deriving from the remaining testicle cell population). Germ testicular tumors are then divided into seminomas or non-seminomas, a histological classification which is of great importance in therapeutic terms.
Recognized risk factors for the development of testicular cancer are cryptorchidism (presence at birth of one or both testicles outside the scrotal sac but along the normal course of the testicle from the retroperitoneal region and along the inguinal canal), Klinefelter disease, family history of testicular neoplasm, a previous testicular tumor (in 2-3% of cases, testicular cancer can occur simultaneously or after some time in both testicles) and male infertility.
Testicular Cancer: Symptoms, Self-palpation and How to Recognize It
In most cases the tumor manifests itself with the appearance of a hard and indolent lump on a testicle; in 10% of cases it is associated with testicular pain or disorders already ascribable to its metastatic localization, and only in 5% of cases is it associated with gynecomastia (male breast development). Periodic self-examination of the testicles from adolescence is therefore recommended for all children.
Physical examination by the urologist and the execution of a scrotal ultrasound will allow a correct differential diagnosis to be made with other benign pathologies of the scrotum (acute or chronic epididymitis, hydrocele, epididymal cyst), helping to confirm the diagnosis of testicular tumor.
Diagnosis and Staging of Testicular Tumor: Markers and CT scan
The staging of testicular tumor, that is the determination of its characteristics and its extension, takes place through: 1) the blood dosage of some specific and sensitive tumor markers (α-fetoprotein and β-HCG); 2) the orchifunicolectomy (removal of the testicle performed inguinally, which allows the removal of the primary tumor and histological evaluation; and, 3) the execution of a chest-abdomen CT scan with contrast medium, in order to be able to identify the presence of any secondary localization of the disease.
Testicular cancer cells are characterized by a rapid growth which carries a high risk of early secondary dissemination. This can occur via the lymphatic route, with involvement of the retroperitoneal lymph nodes (located in the posterior wall of the abdominal cavity) or by blood, with the appearance of metastases.
Surgery and Testicular Tumor Treatment: Orchifunicolectomy and Retroperitoneal Lymphadenectomy
The surgical approach to testicular cancer involves two different types of procedures, reserved for two different phases of the clinical history of the disease: orchifunicolectomy and retroperitoneal lymphadenectomy.
The inguinal orchiectomy
The removal of the testicle is an intervention that involves the removal of the testicle affected by the tumor and the spermatic cord, through an inguinal incision of a few centimeters. This is the first step to ascertain the diagnosis of testicular cancer, to be able to define the histological type of the disease and to establish the patient’s subsequent procedure. In very selected cases, the patient can undergo only the enucleation of the testicular mass. This approach is only advised in specific cases, i.e. in men with bilateral synchronous or metachronous testicular tumors, testicular tumors in monorchid patients and normal preoperative testosterone level or when the lesion is less than 30% of the testicular volume. Rare but potential complications of the intervention are represented by pain, hematoma, hemorrhage, wound infection, fever and extrusion and rupture of the prosthetic material, in case of prosthesis positioning. Potential and important comorbidities of the presence of the tumor and the sequelae deriving from the removal of the testicle are infertility and the reduction of testosterone levels.
Nerve sparing retroperitoneal lymphadenectomy
Retroperitoneal lymphadenectomy is a major surgery that can be performed with an open, laparoscopic or robot-assisted technique. It has been shown that the short and long term results of this surgical procedure are substantially better when it is performed in centers with adequate surgical volume and a high number of cases per year. Retroperitoneal lymphadenectomy consists in the removal of lymph nodes in the retroperitoneum located near the aorta and vena cava, kidneys and ureters and posterior to the intestine. This operation has therapeutic purposes (removal of residual lymph node masses after chemotherapy or contraindication to the execution of radiotherapy or chemotherapy treatment) and diagnostic purposes (failure to respond to chemotherapy or radiotherapy treatment), for any type of testicular tumor. The extension of the surgical field, and therefore of the lymph node stations to be removed, depends on the side of the
original testicular tumor (right / left) and on the pre-operative radiological finding. The main potential long-term morbidity related to retroperitoneal lymphadenectomy is the loss of ejaculation (flow of seminal fluid from the urethra). This condition can occur in case of damage to the sympathetic nerve fibers that run around the retroperitoneal lymph nodes. The incidence of this complication is linked to the necessary extension of the lymphadenectomy, dictated by the stage of the disease. The lymphadenectomy can therefore be “modified”, that is, limited according to the laterality of the tumor, and “nerve-sparing”, that is, it can provide for the preservation of nerve fibers (with antegrade ejaculation preservation rates reported up to 90-100%). The nerve-sparing technique finds its candidates in patients with stage I or II non-seminomatous tumor (diffusion to retroperitoneal lymph nodes), with low lymph node involvement and in selected cases of post-chemotherapy treatment. Retroperitoneal lymphadenectomy is a major surgery to be performed in reference centers that are highly specialized.
Prognosis and Survival of Testicular Cancer
In face of the high biological activity (30% of testicular tumors appear as metastatic disease at diagnosis), germ cell tumors demonstrate high sensitivity to chemotherapy, and an excellent response to multimodal treatments (surgery, chemotherapy, radiotherapy); these characteristics imply a high cure rate of this of about 99% in the initial stages, and 90%, 75-80% and 50%, for stages defined as “good”, “intermediate” and ” bad”, respectively.
The histology subtype and stage of the tumor (testicular localization, involvement of retroperitoneal lymph nodes or metastases in other locations) determine the therapeutic procedure following orchidectomy (radiotherapy, chemotherapy or removal of retroperitoneal lymph nodes) and the subsequent follow-up.
The high survival rate and long life expectancy of patients have led to an ever greater attention in the treatment of this tumor towards the early and late consequences of cancer treatment, especially in relation to the preservation of the reproductive function and the overall well-being of the individual (selective radiotherapy techniques, dose reduction for chemotherapy, nerve-sparing technique for retroperitoneal lymphadenectomy, cryopreservation of seminal fluid).