What is Testicular Cancer?

        This type of cancer generally occurs between 15-35 years of age and characterized by a swelling in one testis. Its prevalence may increase after 60 years of age. Testis Cancer is amongst cancer types that best responds to treatment. The patient may be delayed in noticing it, as it is usually painless. Delay in first diagnosis may occur due to the shyness of patients.

Types of Testicular Cancer

        Testis cancer types are into two cell types, which are “Seminomatous” and “Non-Seminomatous”. Whereas treating Seminomatous types are easy to treat, this is more difficult for Non-Seminomatous types. The type called “Choriocarcinoma”, which is seen in 5-10% of the patients, which advances more rapidly than other types and which may cause growth in male breasts, is very anarchist. The type called teratoma is benign.

Causes of Testicular Cancer

        The disorder generally owes to genetic factors. It may also be seen in patients with undescended testis, even if these testes are descended later on by surgery. Also in patients suffering from male fertility, it is seen at higher numbers compared to normal.

Symptoms of Testis Cancer

        One feels painless swelling and indefinite pain in the testis due to the weight of the growing mass and also pain in the waist and the scrotum. Patients may delay consulting to doctor if they disregard painless swelling during the first step. In this case, the disease may spread to the lungs and the lymph nodes behind the abdomen. The patient’s testes grow constantly. Patient’s own awareness and early application to physician is required for making early diagnosis.

With which diseases can Testicular cancer be confused with?

        It may be confused with the testis inflammation we call epididymis orchitis, testis torsion, water accumulation in the testis we call hydrocele, inguinal hernia, varicosele, and cysts occurring in sperm channels we call spermatocele. The majority of testis cancers are conclusively diagnosed by ultrasonography.

Diagnosis of Testicular Cancer

        Preliminary diagnosis for testis cancer is easily done by ultrasonography. Screenings such as cancer indicators in the blood (alpha-fetoprotein), beta-hCG, LDH, abdominal tomography, chest radiology may be needed for understanding the extent of cancer, and MR imaging may be required if suspicion exists about metastasis to organs such as the brain. The testis is removed with its 10-15 centimeter stem for conclusive diagnosis and determining the cancer type. After removal, the testis is sent to pathology and the cancer type is established after the examination.

Phases of Testicular Cancer

        After the patient is diagnosed with cancer, phasing is made according to the dispersion of cancer within the testis, whether it metastasized to lymph nodes and to other remote tissues and organs.

**1. **Cancer is in the 1st phase if only present inside the testis; **2. **Cancer is in the 2nd phase if it has exceeded the capsule called “Tunica Albugiena”; **3. **Cancer is in the 3rd phase if it has metastasized to the blood structure called “Spermatic Cord”; **4. **And cancer is in the 4th phase if it has metastasized to the “Scrotum” (the testis sac).

We plan phasing and plan treatment according to a numerical and volumetric evaluation of cancer metastasis to the lymph nodes behind the abdomen, to the lungs and to remote tissues and organs. If pathology result shows that the cancer isn’t aggressive, then the patient is placed under periodic follow-up and no separate treatment is applied. If pathology result shows that the cancer is indeed aggressive, we have 3 options for planning the treatment:

  • Chemotherapy,
  • Removing all lymph nodes behind the abdomen “Retroperitoneal Lymphadenectomy”.
  • Radiotherapy is planned.

Phasing testis cancers and planning their treatment requires deep knowledge and experience.

Treatment of Testicular Cancer

        Testis Cancer requires a multidisciplinary treatment that includes surgery, chemotherapy and radiotherapy. If it is established that the testis cancer has not metastasized to the location behind the testis where the sperm canaliculi join, the treatment is concluded by removing the testis and the patient is brought under periodic follow-up. This is only applied for early-diagnosed cancers that are not aggressive.

        Treatment planning is different if the testis cancer is aggressive. Following a pathologic evaluation of the testis and examining the cancer indicators in blood, a cancer commission, which includes a surgical oncologist, a chemotherapist (medical oncologist) and a radiotherapist (radiation oncologist), plan the treatment. There are 3 options for selecting the treatment method if the testis cancer is aggressive and dispersed. After the removal of testis, 1, 2 or 3 cures of chemotherapy is applied depending on the dispersion and type of cancer. Or we recommend a surgery for removing the lymph nodes. Chemotherapy lead to infertility as it destroys sperm production in the intact testis. As a precaution, the patient gives sperm to the sperm bank. Operation for removing the lymph nodes doesn’t have this side effect. But the lymph operation lasts 5-7 hours and represents a sensitive operation for the patient. In general, the patient doesn’t need chemotherapy after all lymph nodes are removed. Radiotherapy therapy is a treatment method that is generally required at later phases of cancer. The planning of 3-option treatment is made by the cancer commission. Sometimes the combination of these 3 options is applied.

        “Retroperitoneal Lymphadenectomy” (removing lymph nodes), which is briefly known as RPLND”, is a very difficult but life-saving operation. It should always be performed in experienced centers. As testis cancers are generally seen young adults, military physicians and educational institutions are more experienced on this subject. Especially operator doctors such as us, who are of military origin and who possess knowledge and experience on both fields, have very high rates of success.

        The basic principle of retroperitoneal lymphadenectomy is to remove all lymph nodes behind the abdomen until the diaphragm, including the adrenal ones. No imaging method shows the dispersion degree of cancer into the lymph nodes. Only a suspicion may exist. During the RPLND surgery, it is a mistake to only the remove the section where the cancer is known to have metastasized. All lymph nodes should be removed. Removing only one section may leave cancerous tissues behind. Unfortunately, neither our country nor other parts of the world show sufficient sensitivity and rigor on this issue.

Chemotherapy After Testicular Cancer

        Through information sharing, the cancer commission decides upon the surgical, chemotherapy and radiotherapy treatment planning of testis cancer. Chemotherapy is applied as a single cure in some cases and in three cures in other cases. Patients that receive treatment in more than one cure may not have children in their future lives, as the entire sperm producing mechanism in their intact testis will be destroyed. For this reason, leaving sperm to the sperm bank prior to surgery bears importance.

Sperm Bank Application in Testicular Cancer

        Although nearly 100% of testis cancer patients can be fully treated, their sperms should be taken and frozen prior to chemotherapy, radiotherapy or surgical operations. That is because chemotherapy and radiotherapy remove the patient’s ability to have children in the future. Patients that have healed pursuant to treatment can have a normal sexual live in the future. They don’t encounter erection problems. But patients that have undergone chemotherapy-radiotherapy can have children in the future through the in vitro fertilization method, which uses their frozen sperms. For this reason, one should always take sperms from the patient and froze them before the commencement of treatment.

Erectile Dysfunction After Testicular Cancer

        Erectile dysfunction in patients is generally associated with psychological or organic reasons. Other than psychological trauma, cancer has no impacts in terms of erectile dysfunction. That is because no damage is inflicted on the blood vessels and the nervous system that erect the penis. But sperms are completely destroyed in patients that undergo chemotherapy and radiotherapy. The patient achieves a psychological relief after the disease is treated and erectile dysfunctions disappear entirely.