How a Patient with Test Cancer Presents?
To further understand the disease in a better way, have a look at the video below where CancerBro meets Mr. Tiesto who has recently being diagnosed with testicular cancer. CancerBro asks Mr. Tiesto several important questions related to his disease from SYMPTOMS which lead him to contact an oncologist, to various other risk factors related to testicular cancer.
CancerBro, can you please discuss in detail how the disease presents and what are the risk factors for disease?
Yeah sure, let’s meet Mr. Tiesto.
He is Tiesto, 25 years old boy. One fine day when he got up he incidentally noticed a mass in his right testis. He got very worried and straight away rushed to the hospital. After a series of investigations, he was finally diagnosed as a case of testicular germ cell cancer, let’s meet him.
CancerBro: Hi Mr. Tiesto, how are you feeling today?
Mr. Tiesto: I was very worried for the last few days after I was diagnosed with cancer but after talking to you and learning more about the disease I am feeling better.
CancerBro: That’s great Mr. Tiesto, can I ask you a few questions related to your disease?
Mr. Tiesto: Yeah sure CancerBro, please go ahead.
CancerBro: What were your initial complaints for which you consulted the doctor?
Mr. Tiesto: I was feeling pressure-like sensation and heaviness in my right scrotum. When I palpated it, I felt some mass in my right scrotum.
CancerBro: Did you feel any pain in the mass on applying pressure?
Mr. Tiesto: Not at all CancerBro, it is totally painless.
CancerBro: Did you have any developmental abnormalities in childhood or any sexual complaints as an adult?
Mr. Tiesto: My parents didn’t tell me regarding any developmental issues in my childhood, otherwise, I am absolutely normal as an adult with no sexual problems.
CancerBro: That’s great Mr. Tiesto, did anyone else in your family had similar complaints?
Mr. Tiesto: No CancerBro, as far as I can remember I am the first one to have any such complaint in my family.
CancerBro: Okay Mr. Tiesto, thank you very much.
What are the Risk Factors for Testicular Cancer?
The incidence of testicular cancer is highest in North-European and least in Asians and Africans.
Cryptorchidism, or failure of descent of the testis into the scrotal sac, is also a risk factor for the disease. In this condition, testis may lie either in the abdomen or in the inguinal canal, as you can see in the figure.
Various syndromes such as Down’s syndrome. Klinefelter’s syndrome and testicular dysgenesis syndrome may also be a risk factor for the disease.
Previous history of cancer in the opposite testis, previous testicular biopsy, testicular atrophy or impaired fertility also increase the testicular cancer risk factor.
What are the Testicular Cancer Signs and Symptoms?
Most commonly, testicular cancer symptom present in the form of painless swelling, but sometimes torsion may cause severe pain.
In some cases, pressure like sensation or heaviness may be present in the testis.
Very rarely, back pain, breathlessness or a headache may be present due to the spread of cancer to bones, lungs or brain.
What are the Investigations for Diagnosis and Staging of Testicular Cancer?
What is the TNM Staging of Testicular Cancer?So after discussing the normal anatomy of the testis, we now come to the T staging for testicular tumors. This figure shows the T1 stage in which the tumor is limited to the testis. It may invade the tunica albuginea but not the tunica vaginalis. There is no lymphovascular invasion by the tumor. Next comes the T2 disease. In this, the disease is limited to the testis or epididymis. The tumor may extend through tunica albuginea to involve tunica vaginalis, or there might be the lymphovascular invasion by the tumor. This figure shows T3 disease in which the tumor infiltrates into the spermatic cord. And here the tumor infiltrates into the scrotum, called as T4.
What are S1, S2 and S3 Tumor Markers in Testicular Cancer?
As you can see in the above figure, the tumor markers for each subtype may be different, although there is some overlap.
- LDH <1.5 times the upper limit of the normal (ULN) range,
- beta-hCG < 5,000 mIu/mL, and/or
- AFP < 1,000 ng/mL.
- LDH is 1.5 to 10 times the ULN
- beta-hCG is 5,000 to 50,000 mIu/mL, and/or
- AFP is 1,000 to 10,000 ng/mL.
- LDH > 10 times the ULN
- beta-hCG > 50,000 mIu/mL, and/or
- AFP > 10,000 ng/mL.
What is Testicular Cancer Stage Grouping?Once T, N, M, and S categories are determined through different diagnostic techniques, this information is combined to assign an overall stage (from 0 to IV) to the disease.
|0||Tis N0 M0 S0|
|IA||T1 N0 M0 S0|
|IB||T2 N0 M0 S0|
|T3 N0 M0 S0|
|T4 N0 M0 S0|
|IS||Any T N0 M0 S1-3|
|IIA||Any T N1 M0 S0-1|
|IIB||Any T N2 M0 S0-1|
|IIC||Any T N3 M0 S0-1|
|IIIA||Any T Any N M1a S0-1|
|IIIB||Any T N1-3 M0 S2|
|Any T Any N M1a S2|
|IIIC||Any T N1-3 M0 S3|
|Any T Any N M1a S3|
|Any T Any N M1b Any S|
What is the Treatment of Testicular Cancer?
Treatment for Seminoma Germ Cell Tumor
The seminoma testicular cancer treatment depends on whether it is seminoma or non-seminoma. First, we will discuss the treatment for seminoma.
The treatment options for stage 1 seminoma are surveillance, radiation therapy or chemotherapy. Surveillance is usually preferred from T1 to T3 disease. The final decision is taken by the oncologist after assessing the patient’s condition and discussing all the treatment options with the patient.
For stage 2 seminoma, the treatment depends on whether it is stage 2A, 2B or 2C. For stage 2A, the treatment options are radiotherapy and chemotherapy. For stage 2B also, chemotherapy and radiotherapy are the treatment options but chemotherapy is preferred over radiotherapy in most of the cases. And for stage 2C, chemotherapy is the treatment of choice.
For stage 3 disease also, chemotherapy is the treatment of choice.
So these were the treatment options for seminomatous germ cell tumor, but the final decision is taken by the oncologist after assessing the condition of the patient and discussing with the patient the toxicities with various treatments.
In some cases of seminoma, the residual disease may be present even after chemotherapy. In such cases, surgery may be required depending upon the scan findings and if a viable tissue is found after surgery further chemotherapy is given.
Treatment of Non Seminoma Germ Cell Tumor
Now we come to the Non-seminoma testicular cancer treatment.
The treatment options for stage 1 non-seminoma are surveillance, surgery or chemotherapy. Surveillance is usually preferred in T1 disease. The surgery that is done for non-seminomatous germ cell tumors is called as retroperitoneal lymph node dissection or RPLND.
Treatment for stage 2 non-seminoma depends on whether the markers are S0 or S1, that is whether they are normal or elevated. If the markers are elevated, then chemotherapy is the treatment of choice. For stage 2 disease with normal markers, the treatment depends on whether it is stage 2A, 2B or 2C. For stage 2A disease, the treatment options are surgery or chemotherapy. For stage 2B disease also, the treatment options are the same, but chemotherapy is preferred over surgery. And for stage 2C disease, chemotherapy is the treatment of choice.
For stage 3 disease also, chemotherapy is the treatment of choice. So, these were the treatment options for non-seminomatous germ cell tumors.
Again, always remember that of all the treatment options the final decision is taken by the oncologist, after assessing the condition of the patient and discussing the various treatment option with the patient.