Second opinion on testicular cancer

Malignant tumors of the testes are not widely spread in general. But it is the most common cancer in men between 20 and 40 years of age. The diagnosis sounds frightening; however, the good news is, it can be cured. The outcome largely depends on correct treatment strategy. A second opinion on testicular cancer is therefore highly recommended to ensure the best results.

Origin and types

In more than 90 percent of cases, malignant growth in the testes arises from male reproductive cells (the so-called germ cells); accordingly, the majority of such masses are germ cell tumors. The remaining 10% develop from supportive tissue (stromal cells) and become malignant only very rarely.

Germs cell tumors are further divided into seminomas (slow-growing type) and non-seminomas (that are more aggressive).

Exact causes of testicular cancer have not been defined, but men with undescended testicles, even after correction in childhood, and men with relatives who were affected (e.g., father or brother) have a definitely higher risk.

Symptoms

In its early stages, the condition does not cause any symptoms.  With time, patients may notice a lump or swelling in either testicle and an increase in its size. Other possible signs include a feeling of heaviness in the scrotum, pain or discomfort, as well as enlargement or tenderness of the breast tissue.

Diagnosis

A tentative diagnosis can usually be made at a clinical examination. The next step will be an ultrasound scan of the testicles and the abdominal cavity, which provides essential data for further decisions. If a mass is detected, an exploratory surgical procedure will follow. Should it confirm a tumor, the affected testicle together with the spermatic cord is removed. A histological examination of the removed tissue is then performed to determine the exact type of the disease (seminoma or non-seminoma).

Imaging studies, such as computed tomography of the abdominal cavity and thorax, are made to evaluate the tumor stage (whether and how far it has spread into other areas).

Blood tests aimed at looking for specific tumor markers (proteins which are released by testicular tumors in varying amounts depending on their type and stage) give significant information both in terms of primary diagnostics and follow-up case monitoring.

Staging and histology

As in the case of other malignant conditions, tumors of the testes are classified into stages according to their extent. The key criteria are, in particular, the involvement of lymph nodes in the abdominal cavity (retroperitoneum) and metastases growth in other organs, usually in the lungs and liver:

stage I: no evidence of metastasis;

stage II: retroperitoneal lymph node metastases;

stage III: affected lymph nodes in the thorax (mediastinum) or distant metastases.

Testicular cancers differ in their cell structure. The majority of them are germ cell tumors which fall into seminomas and non-seminomas. The former may be classic or spermatocytic (occurring more frequently in older men and having an excellent prognosis). The latter are very variable and most more than one type is present in one patient. The four main non-seminoma types are: embryonal carcinoma, yolk sack carcinoma, choriocarcinoma, and teratoma.  

Histologic features are of major importance since they determine the way a tumor will react to a particular treatment, as well as overall disease prognosis.

Treatment

Surgery is usually the primary option, which includes the removal of the affected testicle, and, in some cases, a biopsy of the other testicle in order to rule out simultaneous malignancy. This procedure does not affect the reproductive function, as the healthy counter-testicle takes over the function of the ill one. The follow-up treatment depends on the tumor histology, the stage of the disease, as well as tumor marker values.

Further operations may sometimes become necessary. In particular, if exams prove that the cancer can spread, or has already spread, to the lymph nodes, retroperitoneal lymph node dissection (RPLND) is recommended. It involves resection of lymph nodes in the posterior abdominal cavity. In most cases, the procedure can be performed in a nerve-sparing manner, so that the ability to ejaculate is preserved.

In certain cases, tumor manifestations (metastases) to other body parts can also be treated surgically. Depending on the testicular cancer type and stage, other treatment options will include systemic chemotherapy and, in the case of seminomas, radiation. Often a combination of therapies is recommended.

A second opinion matters

Despite the availability of evidence-based guidelines, determining the optimal therapy for testicular cancer is obviously a challenge. In particular, studies conducted by the German Cancer Society have shown that around 30 percent of prescribed therapies deviate from general recommendations. To avoid mistakes, patients are encouraged to seek second opinions from experts at specialized centers with extensive experience in research and clinical practice. For example, such advice is of special value when it comes to very complex surgical procedures to remove residual tumor tissue after chemotherapy.