The testicles (also called testes) are part of the male reproductive system. These two organs are located in a leather pouch called the scrotum, slightly smaller than the golf ball in adult males. The scrotum hangs on both sides of the penis.
The testes produce the male hormone testosterone and sperm. Sperm cells carry the fluid produced by the prostate gland through the sperm duct into the semen sac. During ejaculation, sperm cells, sperm sac fluid and prostatic fluid enter the urinary tract. Both urine and sperm are excreted through the canal in the center of the penis.
The testes consist of several different cells. Each can develop different types of cancer. It is important to distinguish these types of cancer from each other because of differences in the course of cancer and the way it is treated.
Testicular cancer usually develops in one or two testicles in young men. It is a type of cancer that needs to be treated by competent physicians and can often be cured if treated with the right strategies.
Although testicular cancer is rare, it is one of the most common types of cancer in men aged 15-35. Testicular cancer accounts for 1% to 1.5% of male cancers and 5% of urological tumors. While the rarer non-seminoma (15%) are testicular tumors, the most common testicular tumor after the age of 50 is lymphoma, and testicular involvement is present in about 35% of lymphoma patients. While 3-10 cases of testicular cancer are detected in 100,000 men per year, there has been an increase in the rate of testicular cancer in the last 25-30 years. However, because treatment success is high, the risk of loss of life in testicular cancer is as low as 1 in 5,000.
The Risk factor can be expressed as any element that affects the chances of developing a disease, such as cancer. Different types of cancer have different risk factors. Some risk factors, such as smoking, can be changed. Some factors, such as the person’s age or family history, cannot be changed. However, risk factors don’t tell us everything. Having a Risk factor, or having many risk factors, does not mean you will get the disease. Risk factors have been a factor in a few of the many people with cancer.
Scientists have found several risk factors that develop testicular cancer in men. However, having one or several risk factors may not be enough for the development of cancer. In most men with testicular cancer, the known risk factor hasn’t been identified. In this case, risk factors do not play a very active role in getting testicular cancer.
One of the main risk factors for testicular cancer is cryptorchidism, also known as an undescended testicular condition. It is a congenital disorder that occurs when one or two testicles do not land in the testicle bag. In men with cryptorchidism, the rate of developing testicular cancer is several times higher than in men with normal testicular structure.
Orchiopexia, performed at a younger age in children with undescended testicles, reduces the risk of testicular cancer. Although the right time for surgical intervention is not yet clear, some experts recommend that orchiopexy be performed immediately after the first birthday of the child without the development of cancer yet.
Family history increases the risk of testicular cancer. If a man in the family has had testicular cancer, it is likely to be seen in a brother and/or son in the same family. However, only about 3% of testicular cancers occur in the family. Most men with testicular cancer have no family history.
Human immunodeficiency virus (HIV) infection in men, especially in patients with AIDS has increased risk. Another infection that increases the risk of testicular cancer has not been identified.
In testicular cancer, personal history is another risk factor. On average, 3% or 4% of men who are treated for cancer in one testicle are diagnosed with cancer in the other testicle.
About half of testicular cancers occur in men between the ages of 20-34. However, this cancer can affect men of any age, including children and the elderly.
The risk of testicular cancer is 5 times greater in white men than in black men and 3 times greater in Asian American and American Indian. The risk of developing this disease worldwide is high in the Americas and Europe, and lower in Africa or Asia.
Some studies have shown that tall men have a greater risk of testicular cancer. However, this data has not been confirmed by any other research.
Previous trauma to the testicles and repeated movements such as horseback riding has not been linked to the development of testicular cancer.
In most studies, there was no evidence that intense physical activity increased the risk of testicular cancer. On the contrary, exercise and physical activity reduce the risk of certain types of cancer and many other health problems.
As a result, in many cases of testicular cancer, no definitive cause has been found. However, scientists believe that a number of risk factors formed in line with the researches may be related to this disease. A large number of studies have been done to investigate the causes of testicular cancer. In the past few years, researchers have done extensive research and learned more about the changes in certain chromosomes and DNA that can cause normal testis germ cells to develop into germ cell tumors. Chromosomes are long sequences of proteins and DNA that carry genetic information about their hereditary character. Each sperm or egg cell has half the chromosome that other body cells have. The embryo, which is formed when Sperm and eggs merge, has a normal chromosome number, half of which is from both parents. The resemblance to the family stems from this.
Meiosis is a process formed by the development of 46-chromosome germ cells inside 23-chromosome sperm or egg cells. Testicular germ cell tumors can occur when an abnormal condition occurs during meiosis. Instead of forming normal sperm cells with 23 chromosomes, 46 chromosomes remain the same. These chromosomes are often variable, their appearance and numbers abnormal as cells continue to divide. Testicular cancer cells have extra copies of a part of chromosome 12. By studying DNA from this chromosome, scientists are trying to understand exactly what went wrong during meiosis cleavage, how it could have been prevented or returned.
Several other chromosomes and changes that are abnormal in the factors that regulate cell division and cell cycle are linked to testicular cancer in both animals and humans.
In most cases of testicular cancer, a bulk or swelling or enlargement occurs in the testicle. Sometimes this bulk causes pain, but most of the time it does not. A patient with testicular cancer may feel severity or complain of pain in the lower abdomen or scrotum.
In rare cases, breast growth or tenderness is observed in men with germ cell cancer. These symptoms occur when germ cell tumors raise the level of human chorionic gonadotropin hormone that enables breast development. Blood tests can measure human chorionic gonadotropin levels. These tests are important for the diagnosis, stage and investigation of certain testicular cancers.
As with Germ cell tumors, Leydig and Sertoli cell tumors can cause testicular mass. Leydig cell tumors can produce androgen (male hormone) or estrogen (female hormone). These hormones can cause symptoms that provide clues that confirm the diagnosis. Breast growth or sexual reluctance are symptoms of estrogen-producing tumors. Androgen-producing tumors, on the other hand, may not show any obvious symptoms in men. However, male children can cause abnormal hair growth in the face and body.
Testicular cancer that has spread to other organs can show symptoms in only 1 out of 4 men. Pain in the lower back may indicate that cancer has spread to the lymph nodes in the abdomen. If cancer has spread to the lungs, symptoms such as shortness of breath, chest pain, or cough may be encountered. It is possible to cough blood from time to time. The decongestant abdominal pain may indicate that cancer has spread to the lymph nodes or the liver. In rare cases, testicular cancer spreads to the brain and can cause headaches.
Some men with testicular cancer may not have any symptoms. It is possible to diagnose cancer during another health check or infertility tests.
In a number of non-cancerous conditions, such as testicular injury or inflammation, symptoms close to testicular cancer can be observed. An inflammation of the testicles and epididymis (epididymitis), known as orchitis, can lead to pain and swelling in the testicle. Both can occur as a result of viral or bacterial infection. The mumps virus causes testicular inflammation (orchitis) in 1 out of 5 adults infected with this disease.
More than 90% of testicular cancers develop in specialized cells known as germ cells. These are sperm-producing cells. There are two types of germ cell tumors in men: seminoma and non-seminoma. The seminoma and non-seminoma cells look quite different when examined under a microscope. The separation of these two types of cancer is extremely important for the treatment strategy. Both types of cancer are examined equally in testicular cancer.
Some testicular cancers contain both seminoma and non-seminoma cells. In the same way that the cancer is treated, the same treatment methods are applied because the types of cancer that are associated with such a mixed type are progressing in the same way as non-seminoma testicular tumors.
The seminoma develops from the sperm-producing germ cell of the testis. There are 2 subspecies of these tumors, the classical seminoma and the spermatocyte seminoma. The type of cancer is determined after being examined in a laboratory environment.
Classic Seminoma: more than 95% of Seminoma tumors are classic seminoma tumors and usually occur in men aged 25-45.
Spermatocytic Seminoma: this rare type of seminoma is more common in older men. The average age of male patients diagnosed with spermatocyte seminoma is 65. Spermatocytic tumors develop more slowly and are less likely to spread to other parts of the body than to classical seminomas.
Some seminomas may increase the level of the protein, called human chorionic gonadotropin, in the blood. Human chorionic gonadotropin can be detected by a simple blood test and is considered as a tumor marker for certain types of testicular cancer. It can also be used in diagnosing and observing the course of its response to treatment.
Such germ cell tumors occur in men, usually in their late teens and early 30s. There are 4 types of non-seminoma tumors:
Most of these tumors are a mixture of at least 2 different species. All non-seminoma germ cell cancers are treated in the same way.
Embryonal carcinoma can increase blood levels of tumor marker proteins called alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG).
Egg (Yolk) sac carcinoma: It is so named because it resembles the egg (yolk) sac of an early human embryo. Other names for this cancer are endodermal sinus tumor, infantile (juvenile) embryonal carcinoma, or orchidoblastoma.
Egg (yolk) sac carcinoma is the most common form of testicular cancer in children. It can usually be successfully treated when diagnosed in children. However, this tumor is more worrying when the tumor develops in adults (especially if it does not contain any other type of testicular cancer). Egg (yolk) sac carcinoma responds very positively to chemotherapy treatment, even if it has spread throughout the body. This type of tumor almost always raises the level of alpha-fetoprotein in the blood.
Choriocarcinoma: an aggressive type of testicular cancer that is quite rare in adults. This cancer has spread rapidly to remote areas of the body, including the brain, bones and lungs. Choriocarcinoma is usually not present in the testicles. Choriocarcinoma cells are found mostly in mixed germ cell tumors along with other non-seminoma cell types. This type of tumor raises the level of human chorionic gonadotropin (HCG) protein in the blood.
Teratoma: teratoma, when examined under a microscope 3 layers (endoderm: innermost layer, mesoderm: middle layer and ectoderm: outer layer) each of which gives the appearance of developing embryos are germ cell tumors. Teratoma tumors are of 3 types: mature teratoma, immature teratoma, and malignant alternating teratoma. Salt teratoma tumors do not increase the level of alpha-fetoprotein and human chorionic gonadotropin in the blood.
Mature teratomas are tumors consisting of cells similar to those of adult tissues. It is usually benign and rarely spreads to nearby lymph nodes and distant areas of the body. From time to time, mature teratoma remains may be found after chemotherapy treatment applied to a mixture of non-seminoma and germ cell tumors. These remains may be the rest of the tumor destroyed by chemotherapy. Some experts believe that chemotherapy can turn non-seminoma types of cancer into teratomas.
An immature teratoma is a less developed cancer of cells that appear to be early embryos. Unlike mature teratomas, immature teratomas develop in close tissues and spread outside the testicles. From time to time, it is possible to repeat for many years after treatment.
Malignant alternated teratoma is quite rare. Some areas of this type of cancer appear to be mature teratomas, while other areas are cancers that develop outside the testicles (in novelties, lung glands, or intestines or brain).
Testicular germ cell cancers can begin as cancers that do not spread, called carcinoma in situ or intratubular germ cell neoplasia. Carcinoma in situ may not always spread. Researchers estimate that it takes an average of 5 years for this type of cancer to spread throughout the body and form germ cell cancer.
Carcinoma in situ is a type of cancer that is difficult to diagnose without spreading, as it usually shows no symptoms and does not have a lump or mass on the hand. The only diagnostic method is to examine the tissue sample taken by biopsy method in laboratory environment. Sometimes, it is possible that it occurs accidentally with a testicular biopsy performed for another examination.
Experts do not agree on the best treatment method. Because carcinoma in situ does not always turn into a spreading cancer, treatment options are still under observation.
Cancer cells are no longer just in the tubules of sperm (where sperm cells form) when cancer of the testicles in situ turns into cancer that spreads. It also begins to develop in other parts of the testicle. These cancer cells spread either through lymphatic channels (fluid-filled vessels that connect to a number of lymph nodes) to the lymph nodes (small, infection-fighting bean-shaped white blood cells) or through the bloodstream to other parts of the body.
Stromal tumors
Tumors can also develop in the stroma (the skeleton of the organ consisting of connective tissue) or auxiliary and hormone-producing tissues of the testicles. These tumors are known as tumors caused by gonads. About 20% of childhood testicular tumors are stromal tumors, while less than 5% of adult testicular tumors are. Leydig and Sertoli cell tumors form the 2 main types of stromal tumors.
Leydig cell tumors
These are usually benign tumors that develop in Leydig cells that produce the male hormone (androgen-testosterone) in the testicle. Leydig cell tumors can be seen in both adult men (75%) and boys (25%). They usually produce androgens, but it is also possible that they occasionally produce estrogen (the female hormone).
Most Leydig cell tumors do not spread outside the testicle and are cured by surgery. However, sometimes these tumors spread to other parts of the body. Because chemotherapy and radiotherapy treatments cannot be responded to to the desired extent when the cancer has spread, the course of the disease does not progress in the desired way.
Sertoli cell tumors
These tumors develop in normal Sertoli cells that feed and support germ cells that produce sperm. Like Leydig cell tumors, it is usually benign. If it spreads, it usually does not respond to chemotherapy and radiotherapy.
Secondary Testicular Tumors
Secondary testicular tumors begin in another organ and spread to the testicle. Testicular lymphoma is more common in men over 50 years of age than in primary testicular tumors. The course of the disease depends on the type of cancer and the stage of lymphoma. The general method of treatment is surgery, followed by radiation therapy and/or chemotherapy. In addition, blood cancer cells in boys with acute leukemia can sometimes form tumors in the testicles.
Cancers that develop in the prostate, lung, skin (melanoma), kidney and other organs can spread to the testicles. In cancers that have usually spread to other organs, the course and outcome of the disease are usually not promising. 25
Is early diagnosis and screening possible for testicular cancer? What is AFP and Beta HCG? How is it diagnosed?
If you have any of the symptoms of testicular cancer, you should see your doctor immediately. Many of these symptoms can occur for a different reason than testicular cancer. However, if the cause is a tumor, it will create early detection and effective treatment for the patient.
Most testicular cancers can be diagnosed at an early stage. In some male patients, symptoms of testicular cancer may occur at an early stage. In most, the first sign appears as a mass in the testicle. However, unfortunately, the progression of the disease is possible because some testicular cancers do not show symptoms.
Many doctors believe that testicular control should be part of a general physical examination. My advice is to have a testicular examination as one of the routine cancer checks in a testicular cancer that has a high recovery rate when diagnosed at an early stage.
As with the breast, self-examination in testicular cancer will pave the way for rapid treatment of the disease. It is in your best interest to examine yourself monthly with the information you will receive from your doctor.
Testicular Self-examination
The best time for a self-examination of the testicle is when the skin of the testicle bag relaxes during or after a shower or bath.
Each normal testicle has an epididymis, which gives a feeling of small swelling in the upper or middle outer part. In the normal testicle, blood vessels and tubes that control sperm support tissues. Some men can confuse all this with cancer. In such cases, consulting your doctor if you have any concerns will ensure that you receive the healthiest information.
The testicle can also grow for other reasons other than cancer. A benign health condition called hydrocele can occur with the accumulation of fluid around the testicle. Or, the veins in the testicle open, causing a lump and expansion around the testicle. This is called varicocele (swelling of the veins in the balls). In this case, it would be an appropriate decision to see a specialist doctor to make sure that there is no cancer.
Medical history and physical examination
If symptoms are present that you have testicular cancer, your doctor will want to know your entire medical history to check for risk Factors and symptoms. During a physical examination, the doctor will feel the location and size of the mass if there is tenderness and swelling in the testicles. In addition, the abdominal area, lymph nodes and other areas of the body are carefully examined and the symptoms of whether the tumor has spread are checked. Physical examination results are mostly normal, except for testicular abnormalities.
Testicular Ultrasound
Ultrasound helps to show whether the mass in the testicle is solid or fluid-filled. This test takes images of internal organs using sound waves. The transducer (rod-shaped instrument) sends sound waves and collects echoes that bounce off the organs. The computer creates an image according to the structure of the echoes. Echoes from the tumor are different from normal tissues. These echo structures can help distinguish between benign and malignant tumors.
Ultrasound, which is usually preferred to display the development of the baby in the womb, is an easy test without radiation. It allows the separation of the benign (hydrocele-water collection or varicocele-swelling of the veins) or malignant structure of the echoes from the tissues. If the mass is fluid, there is a possibility of cancer. In such a case, further tests or surgical intervention may be recommended.
Blood tests for tumor markers
Some blood tests play an active role in the diagnosis of testicular tumor. Many testicular cancers secrete high amounts of alpha-fetoprotein and human chorionic gonadotropin proteins. If these proteins (called Tumor Markers) are found in the blood, they indicate the presence of a testicular tumor. The tumor can also raise the level of an enzyme called lactate dehydrogenase. However, lactate dehydrogenase may also increase from other causes other than cancer.
Non-seminoma tumors raise levels of alpha-fetoprotein (AFP) and human chorionic gonadotropin. So any elevation in AFP means that the tumor has non-seminoma components (tumors can be a combination of different types in seminoma and non-seminoma areas). High lactate dehydrogenase is a disease that often (but not always) shows signs of spreading over large areas. Sertoli and Leydig cell tumors do not produce these substances. Also, levels of these proteins may not rise if the tumor is small.
The tests allow us to have an idea of the amount of cancer, evaluate the patient’s response to treatment, and make sure that the cancer does not recur.
Surgery to diagnose testicular cancer
If your doctor detects a solid tumor on ultrasound, he will recommend surgery to remove it as soon as possible. During surgery, the testicle and sperm cord are removed along with the entire tumor. The sperm cord contains blood and lymph vessels that mediate the spread of testicular cancer to other parts of the body. In order to reduce the spread of cancer cells, these vessels are knotted during the operation. The procedure takes place through an incision in the groin. This operation is called radical inguinal orchiectomy.
The sample is examined in the laboratory and presented as a report on the spread and type of cancer.
In rare cases, if the diagnosis of testicular cancer is not clear, the diagnosis is clarified by biopsy the testicles before removal. During the operation, the testicles are pulled from the scrotum (testicular bag) and controlled without cutting the sperm cord. If a suspicious tissue is seen, a pathological examination is performed by taking a sample. If cancer is found, the testicle and sperm cord are removed. If the received tissue is not cancer, only the detected tumor is taken, the testicles are not taken. Drug therapy is performed after surgery.
When signs of cancer are found, your doctor will order other imaging tests to see if they have spread beyond the testicle.
Chest X-Ray
Her türlü sağlık kuruluşunda kolaylıkla çektirebileceğiniz göğüs röntgeni basit bir işlemdir. This test is used to determine whether the cancer has spread to the lymph nodes in the middle part of the chest or lungs known as the mediastinum. If the X-ray results are normal, you probably don’t have cancer in your lungs. Some doctors believe that computed tomography (CT) provides a more detailed image when viewing the spread of cancer to the chest.
Computed tomography scan
In computed tomography (CT) scanning, detailed cross-sectional images of your body are taken using the x-ray process. Instead of taking a single image as in the classic X-ray process, it is possible to obtain many images from the relevant area of your body with a CT scan. After this procedure, computer combines these images into constellation.
CT scanning is an effective diagnostic method for cancer staging. It helps detect the spread of cancer to the lymph nodes, lungs, livers, or other organs.
Before screening, drinking contrast fluid and/or injecting contrast dye intravenously helps the process detect areas of your body that show abnormalities.
This injection can cause redness of the skin (redness and fever that can last hours or even days). Very few people have an allergic reaction to dye injected intravenously. Although rare, more serious side effects such as shortness of breath and low blood pressure may occur. Possible allergic reactions to any contrasting liquid should be informed before the procedure.
A CT scan is sometimes used to guide the biopsy process. This process is called a CT-guided needle biopsy. CT imaging allows the biopsy needle to meet the suspicious mass. The sample is examined in laboratory environment.
MRI imaging (magnetic resonance imaging)
MRI gives sectional images, such as CT imaging. However, MRI uses powerful magnets and radio waves instead of X ray. It determines the structure consisting of possible diseases and tissue types by absorbing energy from radio waves. The computer analyzes the structure of radio waves from suspicious tissues, obtaining highly detailed images from the relevant region of the body. As with CT scanning, contrast agent is injected intravenously into the patient, but this method is less used.
PET Scaning (positron emission tomography)
Currently, it is one of the most sensitive imaging methods to determine the prevalence of cancer in the body. For this test, a special kind of radioactive substance bound glucose (fluorodeoxyglycosis) is injected into the patient intravenously. The rate of radioactivity is quite low. Fluorinated glucose collects in places with cancer over time. About an hour later, the patient is admitted for a PET. About 30 min. along with a special camera, images are taken from the area where cancer is suspected. PET is a useful imaging method for detecting the cancer area when it is suspected that the cancer has spread.
The stage explains how far the cancer has spread in the body. Detection of the cancer stage is very important for proper treatment and acceleration of the healing process. Additional imaging and blood tests used to diagnose testicular cancer play an important role in determining the stage of cancer, allowing proper treatment planning and determining the course of the disease. When testicular cancer is diagnosed, getting detailed information about its stage can help the patient relax. Knowing the stage of cancer will allow you to have more knowledge of the topic when deciding on the treatment method.
In testicular cancer, the staging system consists of 4 key parts:
T: indicates how far the main tumor has spread in the testicle (ovary).
N: indicates how far the cancer has spread to nearby regional lymph nodes.
M: indicates the spread of cancer to other organs of the body and distant lymph nodes.
Q: indicates the level of major proteins (tumor markers) produced by certain testicular cancers.
The numbers added after T,N,M and S are used to give more detailed information. In numbering from 0 to 4, the rate of cancer spread increases as the number grows. ”Is “after” T ” means in situ, which means that the tumor has not yet spread to the deep layers of tissue in one place. “X” after T,N,M and S means “cannot be evaluated” because there is not enough information.
Primary tumor (T)
TX: primary tumor cannot be evaluated.
T0: there is no evidence of the presence of a primary tumor.
Tis: carcinoma in situ (non-spreading cancer cells)
T1: the tumor has not spread beyond the testicles and narrow tubules through which the sperm passes. Cancer cells are not found in lymph vessels or blood vessels close to the tumor. The cancer can spread to the inner layer surrounding the testicle, but it has not spread to the outer layer covering the testicle.
T2: has the same properties as T1, but in T2, the cancer has also spread to lymph nodes or blood near the outer layer of the tumor or testicle.
T3: the tumor is developed in the sperm cord (which includes blood vessels, lymph vessels, nerves, and the sperm canal).
T4: the tumor is developed on the skin covering the testicle (scrotum).
Regional lymph nodes (N)
NX: regional (near) lymph nodes cannot be evaluated.
N0: no spread to regional lymph nodes was observed on X-ray.
N1: has spread to at least one lymph node. However, no lymph nodes are wider than 2 cm.
N2: has spread to at least one lymph node wider than 2 cm. However, its width is not more than 5 cm.
N3: has spread to at least one lymph node wider than 5 cm.
There is a different classification, albeit small, when lymph nodes are removed during surgery:
pNX: regional (near) lymph nodes cannot be evaluated.
pN0: did not spread to regional lymph nodes.
pN1: has spread to 1-5 lymph nodes not wider than 2 cm.
pN2: has spread to at least one lymph node more than 2 cm wide but not more than 5 cm wide, or has spread to more than 5 lymph nodes not more than 5 cm wide, or the cancer has developed outside the lymph nodes.
pN3: has spread to at least one lymph node greater than 5cm.
Distant Metastasis (M)
M0: no distant metastases were detected (did not spread to lymph nodes or other organs such as the lungs in the area other than the tumor).
M1: distant metastases have been detected.
M1a: the tumor has spread to distant lymph nodes or lungs.
M1b: the tumor has spread to other organs such as the liver, brain, or bone.
In recent years, the treatment of testicular cancer has taken quite a path. The surgical methods used have been revised and more information has been obtained about the best chemotherapy and radiotherapy methods to treat different types of testicular cancer.
After the cancer is diagnosed and its stage is determined, the doctor discusses treatment options with the patient. All options offered should be reviewed without haste. The type of cancer, stage and general health status of the patient are factors that are taken into account when determining the treatment plan. If time allows, a second treatment option may be a good idea. The second option, which provides more information, makes the patient feel good about the selected treatment plan.
It matters where you are treated. Because experience is important, it is often recommended to choose hospitals that treat testicular cancer.
The main methods of treatment for testicular cancer:
For early stage seminoma tumors, radiation therapy is a preferred treatment method. But in recent studies, a similar level of success has been achieved with single-dose chemotherapy (carboplatin) and radiation therapy, and it has even become preferred due to some of its advantages. Radiation therapy usually does not last more than a few minutes, the patient does not experience any discomfort. During radiation therapy, a method that does not require anesthesia, patients ‘ movement is limited. Many patients can easily maintain their working life during radiation therapy.
The first method of treatment for testicular cancer is surgical intervention.
A cancerous testicle is removed through an incision (inguinal orchiectomy) from the skin of the groin. Cancer testicles taken by entering through an incision opened from the lower part of the abdomen are examined in laboratory environment and the type of cancer and subsequent treatment plan are determined. Chemotherapy can be given after orchiectomy surgery if abdominal lymph node or blood samples determine the presence of cancer.
If the tumor contains non-seminoma cells that are more aggressive, a surgical procedure (retroperitoneal lymph node dissection) can be performed to the abdominal cavity lymph nodes after chemotherapy. During this procedure, a laparoscopic instrument is inserted through a small incision in the abdomen and the cancer cells and abdominal lymph glands are removed. The decision to be made for all these applications should be taken by competent physicians who specialize in this field.
In radiation therapy, the goal is to kill testicular cancer cells to ensure maximum treatment with minimal side effects. Radiation therapy is high-energy X-rays applied to the area being treated to kill cancer cells. In this method, which is a regional treatment, a direct radiation beam is sent from the outside to the retroperitoneal lymph nodes. The radiation beam sent will kill the cancer cells that are likely to spread.
The role of radiation in the treatment of testicular cancer depends on histological classification and stage of cancer. Radiation therapy may also be recommended for seminoma tumors.
Radiotherapy for cancers resistant to chemotherapy, distant metastases or palliation
Cancer that has spread from time to time, especially over a large area, may not respond to chemotherapy after a while. In such cases, radiation therapy may be the best option for the treatment to respond more positively. For example, the cancer may have spread to a critical area, such as the spinal cord, and some symptoms may occur, such as pain or weakness. Radiation therapy in such cases will benefit the patient by seeing the palliation effect. In some patients, the cancer has spread widely and has progressed to areas that are difficult to treat with chemotherapy, such as the brain. Such metastases are usually treated with radiotherapy. However, side effects that develop with radiation therapy cause temporary discomfort to the patient, as they will be limited to the area of treatment. The dose of radiation therapy is determined according to the condition of the cancer, taking into account the normal tissues – organs nearby and the patient’s chemotherapy treatment.
Immunotherapies are relatively new generation cancer treatments. Although there are many varieties, the most effective immunotherapy drugs are drugs called immune checkpoint suppressors (today, this group of drugs that receive FDA approval for use in the treatment of various cancers are ipilimumab, nivolumab, pembrolizumab, atezolizumab).
Immunotherapies are drugs that indirectly act on our immune system to take on this work, rather than directly kill cancer cells. Unlike conventional chemotherapy drugs, they have longer-term Disease Control and fewer side effects.
In testicular cancer, there is no immunotherapy method that has yet received approval. On the other hand, the fact that chemotherapy is very effective in this type of cancer has partially pushed back the study of immunotherapies in this area. We will be following the developments on this issue closely and sharing them with you if there is a positive development.
Hyperthermia, also known as heat therapy or thermotherapy, is a complementary cancer treatment method applied by exposing body tissue to high heat (39 to 44 °C).
Research has shown that high heat damages or kills cancer cells, with little damage to normal tissues. Hyperthermia can shrink a tumor by killing cancer cells and damaging proteins and structure in cells, making the cancer noticeable by the immune system.
There are no significant studies that hyperthermia – heat treatment is effective in testicular cancer. On the other hand, testicular cancer is a type of cancer that is generally very sensitive to chemotherapy; with the drugs and methods that we have today, more than 90% of patients get rid of the disease completely if the patient is initially well managed. For this reason, we do not recommend hyperthermia as a treatment for testicular cancer in routine.
In recent years, researchers have found that variations inherited in genes such as KITLG, SPRY4, DMRT1, BAK1, TERT and atf7ip increase the risk of testicular cancer. Although such inventions help identify men at high risk, they need to be investigated further.
Scientists are also investigating genetic changes in testicular cancer cells to gain more insight into the causes of the disease. In this way, they aim to better understand the disease and be more successful in treatment. Some gene mutations found in testicular cancer cells were associated with resistance to chemotherapy, resulting in poor results (lack of response to chemotherapy). These inventions could help personalise treatment and develop new testicular cancer drugs that target mutations in those genes. A better understanding of genetic changes will also help doctors decide which patients will be reliably treated only with surgery, and which patients will need further treatment.
Clinical trials have improved doctors ‘ approach to treating these types of cancer. For example, studies have found factors that predict which patients will have a good prognosis (disease course) and will not need lymph node surgery or radiation therapy. Negative prognostic factors were also found in these studies, indicating that some patients would need to receive more intensive treatment.
A large part of these studies were conducted on limiting the long-term toxicity (side effects) that can occur when administering high-dose therapy. Doctors want to be able to predict which patient is more curable and determine the amount of treatment they will give accordingly, so that they do not give anyone incomplete or excessive treatment.
For example, a study of the decline of AFP and Beta-HCG tumor markers after chemotherapy in metastatic testicular cancer in men showed good results in terms of individualizing treatment. It showed that intensive treatment provided better results for those with less rate of tumor markers falling from these patients.
New drugs and drug combinations are being trialled for patients with recurrent cancer. Chemotherapy combinations are trying to see without reducing the treatment effect to see if eliminating hard drugs and replacing them with new ones in some men or reducing doses will reduce the side effects of treatment.
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