Overview
Testicular tumors or testicular cancers are the most common solid tumors in men age 18 to 45. Lymphomas and leukemias are more common than testicular cancer but there is no solid tumor that is more common than testicular cancer in males ages 18 to 45. While testicular tumor is relatively common it is very treatable especially if it is diagnosed early. The hallmark or most common presenting symptom of a testicular tumor is a hard lump on the testicle. Noncancerous lumps in the scrotum or epididymis are very common and generally are benign and noncancerous. However, it can be very difficult for a lay person to be able to discern the difference between a hard lump on the testicle and a benign cyst or lump elsewhere in the scrotum. For this reason if you palpate a lump or nodule in your scrotum you should call our office so that we can determine whether or not a lesion is threatening or not. It may be appropriate to get an ultrasound. Therefore, the pathology and diagnosis of testicular tumors should really begin with testicular self exam by the patient and subsequent examination by a urologist along with ultrasonography. This evaluation, if worrisome, would be augmented by some blood studies or tumor markers.
If a testicular tumor is suspected the next step after ultrasonography, physical exam, and blood testing is often a radical orchiectomy (the removal of the testicle by way of an incision over the inguinal canal or lower abdomen). Because testicular tumors grow very rapidly radical orchiectomy is often suggested to be done as soon as possible upon diagnosis. This can be a shocking and surprising recommendation for the patient. Often, a patient recommended to undergo orchiectomy for a suspected testicular tumor will have some difficulty in proceeding with such a surgery. Frequently, these patients need time and the counseling of their family and friends to understand the wisdom of proceeding with the loss of the testicle to insure their future health. The diagnosis of testicular cancer cannot be safely made by doing a biopsy of the testicle as this can lead to spread of the cancer in a dangerous way. The pathologic diagnosis and effective treatment of testicular cancer begins with a radical orchiectomy. Once the testicle is removed a pathologist can examine the testicle to determine whether or not there is cancer in the specimen and what type of cancer is present. Watchful waiting or observation of a suspected testicular cancer is not recommended.
In addition to radical orchiectomy, ultrasonography, physical exam, and blood testing the evaluation of testicular cancer also involves radiographic imaging to evaluate the possibility of metastatic spread. Metastatic spread is the spread of cancer outside the organ of origin into lymph nodes and other organs. Testicular cancer has a very highly predictable pattern of spread in most cases. Testicular cancer almost always spread up the spermatic cord and into the lymph nodes that sit along the major blood vessels of the abdominal cavity. The major blood vessels are the aorta and inferior vena cava. There are lymph nodes lying on top and along side of these blood vessels between the kidney and the point at which these major blood vessels split to service the lower extremities and pelvis. The lymph nodes lying along these major vessels are the main landing sites for metastatic spread from testicular cancer. Because of this highly predictable pattern of spread CT scan of the abdomen is extremely useful in assessing the possibility of metastatic spread from testicular cancer. CT scan of the abdomen and a chest x-ray are routine radiographic imaging studies for the metastatic spread of testicular cancer.
Approximately 95% of testicular cancers derive from the germ cells. The germ cells are the cells that go on to become sperm. There are millions of germ cells dividing on a daily basis in the testicles of young healthy men. When these germ cells divide in uncontrolled fashion they can form testicular cancer. There are two main types of germ cell tumors that can develop in the testes. There are nonseminomatous germ cell tumors and there are seminomatous germ cell tumors and these compose 95% of testicular cancers. The remaining 5% of testicular cancers occur in the supporting cells that surround the germ cells and these are Leydig cell tumors and Sertoli cell tumors. Leydig cell tumors and Sertoli tumors are very uncommon and they are generally less threatening than germ cell tumors. Most often Leydig cell and Sertoli cell tumors can be treated with orchiectomy alone but there are rare occasions when adjuvant therapy is necessary.
Nonseminomatous germ cell tumors occur in many varieties and trying to understand which type of nonseminomatous germ cell tumor you have can be highly confusing but it is important information for the urologist and the pathologist to decide upon. Some varieties of nonseminomatous germ cell tumors are more dangerous and aggressive than others. In addition to deciding whether or not you have a more virulent form of nonseminomatous germ cell tumor, the orchiectomy specimen is also important for determining whether or not you have lymphatic or vascular invasion by the tumor within the testicle. Having a more virulent strain of nonseminomatous germ cell tumor or the presence of lymphovascular invasion are worrisome features and might indicate higher risk of metastatic spread. Metastatic nonseminomatous germ cell tumors may require chemotherapy or additional surgery (Retroperitoneal Lymph Node Dissection is a major surgery where the lymph nodes along the aorta/vena cava are removed) to treat the metastatic lymph nodes. The subject of whether or not to treat potential metastatic spread from nonseminomatous germ cell tumor can be highly confusing and very controversial.
Seminomatous germ cell tumor is generally less threatening than nonseminomatous germ cell tumor and somewhat more straightforward to treat unless it is widely metastatic. Widely metastatic seminomatous germ cell tumor can be every bit as dangerous as aggressive nonseminomatous tumor and it can require a combination of chemotherapy and major abdominal surgery and even radiation. These occasions are fortunately rare. The majority of nonseminomatous germ cell tumors can be treated with orchiectomy and if there is any evidence of metastatic spread some radiation to the pelvis or abdomen. The majority of seminomatous cases do not need chemotherapy or major abdominal surgery.
If you have a nonseminomatous tumor and there is evidence that you may have cancer spread to the lymph nodes (a very virulent form of cancer, e.g. lymphovascular invasion on the pathologic specimen, or a positive CT scan), then you may need to consider further treatment with surgery or chemotherapy or both.
Deciding whether to treat nonseminomatous germ cell tumor with chemotherapy or retroperitoneal lymph nodes disection can be a very confusing and difficult decision process. Using a collection of data that includes the findings on CT scan and chest x-ray as well as the findings on blood studies and the pathology from the orchiectomy one can try to assess the stage of testicular cancer for nonseminomatous germ cell tumor. If there is visible adenopathy on CT scan around the lymph nodes adjacent to the aorta and vena cava then the patient may have stage two or three testicular cancer. If there is spread into the chest or to other distant organs beyond these retroperitoneal lymph nodes then the patient will have stage-four disease. If a patient has stage three or four nonseminomatous germ cell tumors then chemotherapy is usually the first step without much controversy. If the patient has no visible sign of retroperitoneal adenopathy on CT scan or minimal adenopathy on CT scan the treatment choices become less clear. When there is limited adenopathy or small volume retroperitoneal adenopathy on CT scan then a patient can consider chemotherapy or retroperitoneal lymph nodes dissection to treat the retroperitoneal adenopathy. Retroperitoneal lymph nodes dissection is a major operation and its risks and the details of the procedure are discussed below.
If the patient has no visible sign of retroperitoneal lymphadenopathy on the CT scan there may be micrometastases to the lymph nodes that are not visible on CT scan and can only be diagnosed by doing a retroperitoneal lymph node dissection. In fact, studies show that retroperitoneal lymph nodes dissection of nonseminomatous germ cell tumor of stage one tumors (no visible sign of retroperitoneal lymphadenopathy on CT scan) that there is actually a 25% rate of positive lymph nodes (i.e. micrometastases) on the retroperitoneal lymph node sampling. This is generally assumed to mean that 25% of the time when the CT scan shows no positive lymph nodes that there are in fact micrometastases to the lymph nodes that are simply not visible on CT scan. Because of this error rate with CT scanning patients with no visible sign of retroperitoneal lymphadenopathy can elect to undergo chemotherapy or retroperitoneal lymph node dissection surgery to treat their microscopic metastatic spread from nonseminomatous germ cell tumor. Patients who choose not to have chemotherapy or retroperitoneal lymphadenectomy for nonvisible lymph nodes with stage one nonseminomatous germ cell tumor must undergo rigorous follow-up with follow-up CT scans and tumor markers (blood testing) and chest x-ray every three months for two years and then less often thereafter. This observational protocol is necessarily rigorous because one must identify visible signs of metastatic spread at the earliest possible moment to maximize the potential cure rate of chemotherapy and or retroperitoneal lymph nodes dissection. Deciding whether or not to undergo close serial observation or chemotherapy or retroperitoneal lymph node dissection can be an extremely difficult decision and the number of factors and data points that need to be considered can be quite confusing. These discussions between the patient and the urologist and the oncology doctor are necessarily detailed and time-consuming and sometimes need to be repeated several times before a patient can come to an appropriate conclusion. In a sense, when a patient elects observation this dialogue is repeated at most follow-up examinations.
Chemotherapy for nonseminomatous germ cell tumor is based on the tremendous success of the cisplatin chemotherapy against germ cell tumors. In 1980, cisplatin chemotherapy was developed and shown to have fantastic results in the treatment of testicular cancer. Many other chemotherapeutic agents are very important in the treatment of testicular cancer but none has made the tremendous impact of cisplatin. Chemotherapy for testicular cancer is so effective that it can potentially cure very advanced testicular cancers. Nonetheless, cure rates directly correspond to stages. That is, the earlier a testicular cancer is diagnosed the more likely you are to achieve cure. Every chemotherapeutic agent used in the treatment of testicular cancer (or for any cancer for that matter) can have significant toxicity and side effects.
Chemotherapeutic agents attack and kill cells but primarily they attack and kill cells that are trying to divide very rapidly. Cancer cells by their very nature are always trying to divide very rapidly and thus they are sensitive to these chemotherapeutic agents. Some cells in your body are also trying to divide very rapidly such as the inside lining of your intestine. Therefore these cells may be affected to a higher degree than other cells in your body. The detailed list of side effects associated with your chemotherapeutic agents is a matter best discussed with the oncologist (the medical doctor who administers chemotherapy).
Retroperitoneal lymph nodes dissection or retroperitoneal lymphadenectomy is the procedure to remove the lymph nodes along the inferior vena cava and aorta between the kidneys and where these major blood vessels divide in the pelvis. Because testicular cancer spreads in such a predictable fashion we can identify which lymph nodes need to be removed in cases of testicular cancer with a high degree of accuracy. Unfortunately the position of these nodes along these major blood vessels where there are also many sympathetic nerves and many vital organs creates the potential for significant risk with retroperitoneal lymph nodes dissection. Generally, this procedure is achieved with an incision that carries the length of the abdominal cavity from the sternum to the pubic bone. This procedure can also be achieved through laparoscopy with robotic assistance to reduce recovery time and pain. Whatever means of achieving the lymphadenectomy (whether it is open or laparoscopic) there is a significant potential risk for blood loss due to the positioning of these lymph nodes on these major blood vessels and significant risk to the sympathetic nervous chain that runs along these large blood vessels. Dissection of the lymph nodes will by its very nature include removal of some of the sympathetic nerve chain along the aorta and vena cava. It is possible to limit the dissection of these nerves by modifying the template used to outline the lymph nodes targeted to be resected. However, removing any lymph nodes will result in the loss of some of these sympathetic nerve fibers. The single most dramatic and notable side effect of injury to the sympathetic nerves is the loss of the ability to ejaculate. Injury to the sympathetic nerves does not appear to affect other major bodily functions and it does not appear to affect erectile activity or the ability to achieve orgasm but the patient with a lack of ejaculation simply orgasms but does not ejaculate. This problem can be extremely hard to overcome or correct once there has been significant injury to the sympathetic nerves chain along the aorta and vena cava. With lower stage disease it is possible to modify the resection template to just take lymph nodes on one side of these major blood vessels and thus greatly reduce the risk of injury and loss of ejaculation. If the template can be modified to take just one side of lymph nodes then the risk of ejaculation can sometimes be reduced to 25% risk of a loss of ejaculation. If the patient has the need for a full bilateral lymph nodes dissection the risk of loss of ejaculation approaches 75 to 100%. Other risks of this surgery include injury to any nearby associated organs such as loss of a kidney or loss of the spleen or injury to the intestines requiring emergent re-exploration and re-operation to repair the injury or a delay in healing such as a delay in the return of bowel function or a wound infection.
Sometimes the patient may be diagnosed with testicular cancer of an advanced nature and undergo chemotherapy and have a residual mass in place that needs resection. This is an extremely problematic situation where the mass might be called a post chemotherapy residual tumor and surgical resection is sometimes called a post chemotherapy retroperitoneal lymph node dissection. Post chemotherapy retroperitoneal lymph node dissection is a full bilateral lymph node dissection with a nearly 100% risk of loss of ejaculation and a very high risk of needing a blood transfusion due to the tedious and difficult nature of resecting a post chemotherapy mass off of the major blood vessels the vena cava and aorta.
Chemotherapy changes the nature of the tissues of the lymph nodes on the aorta and vena cava. Prior to chemotherapy these tissues are supple and easily lifted off the blood vessels without difficulty but after chemotherapy these tissues become vigorously adherent to the blood vessels so that removing them off the blood vessels can result in a tear in the blood vessel that needs repair. These repairs can usually be achieved by oversewing the hole in the blood vessel but sometimes these repairs involve a resection of the vascular wall itself which requires replacement of the vascular wall with a patch. Such serious resections and repairs may even involve the cooperation of a vascular surgeon for his specialized talents in the repairing of major blood vessels. A post chemotherapy retroperitoneal lymph node dissection is a major operation indeed with many significant risks.
