The testicular cancer begins as a scrotal mass, which is not painful in general. The diagnosis is made by ultrasound. Treatment consists orchiectomy and sometimes retroperitoneal lymph node dissection of, radiation therapy, chemotherapy, or a combination, depending on the histological type and tumor stage.
The testicular cancer is the most common solid tumor in men aged 15-35 years, with about 800 cases per year, but only about 400 deaths. The incidence is 2.5 to 20 times higher in patients with cryptorchidism. This increased risk is reduced or eliminated when a orchidopexy is performed before age 10. A cancer can also form in the contralateral undescended testicle usually. The cause of testicular cancer is unknown.
The testicular cancer begins as a scrotal mass, which is not painful in general. The diagnosis is made by ultrasound. Treatment consists orchiectomy and sometimes retroperitoneal lymph node dissection of, radiation therapy, chemotherapy, or a combination, depending on the histological type and tumor stage. The testicular cancer is the most common solid tumor in men aged 15-35 years, with about 800 cases per year, but only about 400 deaths. The incidence is 2.5 to 20 times higher in patients with cryptorchidism. This increased risk is reduced or eliminated when a orchidopexy is performed before age 10. A cancer can also form in the contralateral undescended testicle usually. The cause of testicular cancer is unknown. Most testicular cancers are derived from the primitive germ cells. Germ cell tumors are divided into seminomas (40%) and Nichtseminome (tumors nichtseminomatöse elements included). Among the non-seminomas include teratoma, embryonal carcinoma, endodermal sinus tumor (yolk sac tumor) and choriocarcinoma. Histologic combinations are common, eg. As part of a teratocarcinoma a teratoma plus. Embryonal carcinoma. Carcinomas of the functional interstitial cells of the testis are rare. Even patients with apparently localized tumors may have occult lymphonoduläre or visceral metastases. For example, nearly 30% of patients will get a recurrence of node or visceral metastases with non Semi Onen when they undergo orchiectomy no treatment. The risk of metastasis is the lowest in choriocarcinoma highest and the teratoma. Tumors that originate from the epididymis, the appendix testis or spermatic cord, are mostly benign fibroids, fibroadenomas, adenomatoid tumors or lipomas. Occasionally – especially in children – including sarcoma, rhabdomyosarcoma most likely to occur. Symptoms and signs Most patients present with a scrotal mass that is painless or sometimes accompanied by a dull ache. A few patients have bleeding can cause acute in the tumor, cause local pain and tenderness. Many patients discover the mass by itself after a small scrotal trauma. Diagnostic ultrasound in scrotal masses exploration, if it is a testicular mass is staging by abdominal, pelvic and thoracic CT and histological examination Many patients discover the mass during a self-examination. A monthly self-examination should be promoted among young men. Origin and nature of a scrotal mass must be accurately determined because most testicular malignant lesions, most extratesticular masses, however, are not malignant. A distinction on physical examination can be difficult. Sonography of the scrotum can confirm a testicular origin. If a testicular mass was confirmed that serum markers ?-fetoprotein and ?-human chorionic gonadotropin should be determined and an x-ray thorax are caused. Then surgical inguinal exploration is indexed, the spermatic cord is exposed and clamped before the abnormal testis is manipulated. Upon confirmation of malignancy is for the staging according to the standardized TNM (tumor, node, metastasis) system, a thorax, abdomen and pelvic CT required (AJCC / TNM staging * of testicular cancer and TMN and serum markers definitions for testicular cancer). (N. D. Übers .: The guidelines of the German Society of Hematology and Oncology [DGHO] recommend a contralateral testicular biopsy, a TIN [testicular neoplasia intralobular] whose frequency is 4-5%, can detect early stage and early diagnosis of potential second testicular tumor allowed.) tissue (during treatment inguinal orchiectomy usually) was removed, provides important histopathological information, especially on the ratio of the histological types and the presence of intratumoral infiltration of vascular or lymphatic structures. Such information can predict the risk of occult lymph node and visceral metastases. Patients with non-seminomas have an approximately 30% risk of recurrence, despite normal radiographs and serum markers and with a – as it seems – localized disease. Seminomas recur in about 15% of these patients. AJCC / TNM staging * Regional testicular cancer stage tumor lymph node metastasis Distant metastasis serum tumor markers 0 pTis N0 M0 S0 1 pT1 N0 M0 pT4 SX IA pT1 N0 M0 S0 IB pT2 N0 M0 S0 pT3 N0 M0 S0 pT4 N0 M0 S0 IS All Pt / pTX N0 M0 S1-S3 II All Pt / pTX N1-N3 M0 SX IIA All Pt / pTX N1 M0 S0 All Pt / pTX N1 M0 S1 IIB All Pt / pTX N2 M0 S0 All Pt / pTX N2 M0 S1 IIC All Pt / pTX N3 M0 S0 All Pt / pTX N3 M0 S1 III All Pt / pTX each N M1 SX IIIA Each PTP / TX each N M1a S0-S1 IIIB All Pt / pTX N1-N3 M0 S2 All Pt / pTX each N M1a S2 IIIC Any Pt / pTX N1-N3 M0 S3 All Pt / pTX any N M1a S3 Any Pt / pTX any N M1b Any S * For AJCC / TNM staging definitions, see Table: TMN and serum marker definitions for testicular cancer Taken from Edge SB, Byrd DR, Compton CC, et al: AJCC Cancer staging Manual, 7th edition. Not to judge New York, Springer, 2010. TMN and serum marker definitions for testicular cancer tumor characteristic definition pTX pT0 No evidence of primary tumor (eg. As scar in testis) pTis Intratubular germ cell tumors (Car cinoma in situ) pT1 Limited to testis and epididymis without vascular or lymphatic invasion but can in the tunica albuginea not penetrate the tunica vaginalis pT2 Limited to testis and epididymis with vascular or lymphatic invasion or spreads through tunica albuginea and refers tunica vaginalis on. pT3 Penetrates spermatic cord with or without vascular or lymphatic invasion pT4 infiltrated the scrotum N0 Not to judge with or without vascular or lymphatic invasion Regional lymph node metastasis NX No N1 ? 1 node, all ? 2 cm in greatest dimension N2 ? 1 node> 2 cm and ? 5 cm in greatest dimension, with or without other nodes ? 5 cm in greatest dimension N3 ? 1 Node> 5 cm in greatest dimension distant metastasis M1 M0 No presence M1a Non Local node or lung metastasis M1b Distant metastasis other than non-regional lymph nodes or lungs marker i. S. SX markers are not available or measured values ??within normal limits S0 S1 LDH <1.5 x the upper limit of normal for the LDH assay and hCG <5000 mIU / mL, and AFP <1000 ng / ml LDH S2 = 1 , 5-10 x upper limit of normal for the LDH assay, or from 5000 to 50.000 hCG mIU / ml or AFP 1000-10000 ng / ml LDH S3> 10 x upper limit of normal f r the LDH assay or hCG> 50,000 mIU / ml or AFP> 10,000 ng / ml AFP = alpha-fetoprotein; AJCC = American Joint Commission on Cancer; hCG = human chorionic gonadotrophin; p = pathological staging; pT = primary tumor; N = regional lymph nodes (assessed clinically); M = distant metastases; S = serum tumor markers. Data from Edge SB, Byrd DR, Compton CC, et al: AJCC Cancer Staging Manual, 7th edition. New York, Springer, 2010. Prognosis The prognosis depends on the histology and extent of the tumor. The 5-year survival rate is> 95% for patients with a limited to the testicle seminoma or Nichtseminom or with a Nichtseminom and low volume metastatic retroperitoneal. The 5-year survival rate for patients with extensive retroperitoneal metastasis or pulmonary or other visceral metastases ranges from 48% (for some Nichtseminome) to> 80%, depending on Situs, volume and histology of the metastases. But even patients with advanced disease at presentation can be cured. Therapy radical inguinal orchiectomy radiotherapy for seminoma Usually retroperitoneal lymph node dissection in non-seminomas The radical inguinal orchiectomy is the cornerstone of treatment and provides important diagnostic information. It also helps to set up the subsequent treatment plan. A cosmetic testicular prosthesis can be placed during the orchiectomy. Silicone prostheses are due to the problems with silicone breast implants not available everywhere Alternatively, saline implants were developed. (N. D. Talk .: In any case, the patient about possible complications such as infection, fibrosis formation and allergic reaction must be informed). For men who want to keep their reproductive capacity and the need to undergo radiation or chemotherapy that cryopreservation may be a solution. Radiation therapy Standard therapy for a seminoma after unilateral orchidectomy is radiotherapy, usually with 20-40 Gy (in patients with lymphadenopathy is a higher dose applied) to the para-aortic region up to the diaphragm. The ipsilateral ilioinguinal region is no longer routinely treated. also the mediastinum and the left supraclavicular region irradiated – sometimes – depending on the clinical stage. (N. D. Übers .: According to the guidelines of the DGHO IIc-III is [possibly also IIb] recommended over radiation therapy with platinum based chemotherapy for seminoma of the stages.) (N. D. Talk .: The RPLND is in German speaking countries as RLA = retroperitoneal lymphadenectomy, respectively. It is has moved into the background in recent years due to the very effective chemotherapeutic and risk-adapted treatment options, but it has its importance especially in the Residualtumorresektion after chemotherapy.) lymph node dissection Failure seminomas many experts consider the retroperitoneal lymph node dissection for the standard therapy. In patients with tumors of clinical stage I, who have no prognostic factors for recurrence, is the active monitoring is an alternative (frequent serum marker measurements, X-rays, CT). A medium-sized retroperitoneal lymphadenopathy in stage IIa and IIb of Lugano classification may require a retroperitoneal lymph node dissection and chemotherapy (z. B. bleomycin, etoposide, cisplatin), but the optimal sequence is not fixed yet. A lymph node dissection is performed laparoscopically in some centers. The most common side effect (n. D. Talk .: besides early intra- and postoperative complication options such as bleeding, vascular and nerve injury, thrombosis, embolism, bowel injury, ileus) of an entire lymph node dissection are ejaculation problems. However, a nerve-sparing dissection is often possible, especially in the early-stage tumors, bleibt.Chemotherapie in preserves ejaculation usually a lymphadenopathy of> 5 cm, lymph node metastasis above the diaphragm or visceral metastases make an initial platinum-based combination chemotherapy required, which surgical resection of residual tumor masses followed. This treatment is usually long-term control of tumor disease. (Ed. Note. D .: But even in stage I-IIb is primarily used increasingly chemotherapy to avoid the risks of surgery at the same effectiveness.) The fertility is often limited, but there are no known risks to the fetus if a pregnancy eintritt.Überwachung monitoring is possible for some patients, although many doctors do not offer this option because it requires rigorous follow-up protocols and excellent patient compliance, to be sure. It is frequently offered patients with a low risk of recurrence. In high-risk patients usually have a retroperitoneal lymph node dissection is performed, or – in some centers – two cycles of chemotherapy after orchiectomy rather than a Operation.Rezidive recurrences of non-seminomas are treated with chemotherapy, as a rule, although in some patients with lymph node recurrence and no evidence of visceral metastases retroperitoneal lymph node dissection subsequent secondary may be appropriate. (N. D. Talk .: patients should be advised of the possibility for Spermakryokonservierung before orchiectomy and chemotherapy.) The monitor will not be used in seminomas so often because the morbidity is so low after 2 weeks of radiation therapy and the results in the prevention of late relapse is so high that there are reasons no to avoid the treatment. Important points that testicular cancer is the most common solid tumor in men aged 15-35 years, but is often curable, especially seminoma. Assess scrotal masses by ultrasound and if they are testicular, do a chest x-ray and measure ?-fetoprotein and ?-human chorionic gonadotropin. Perform radical inguinal orchiectomy by, with radiotherapy (with seminomas) usually retroperitoneal lymph node dissection and (in case of non seminomas).