Testicular (Germ Cell) Cancer

Testicular tumors are the most common cancers affecting men between 15 to 35 years, of which 90% are germ cell tumors (GCT). Germ cell tumors are cancers derived from germ cells which are cells that produce sperms. It can also occur outside the gonads (testis) called extragonadal germ cell tumors. When it happens, the most common site is anterior mediastinum (central part of the chest). Germ cell tumors are broadly classified into seminoma or non-seminomatous germ cell tumors (NSGCTs).

Symptoms:

The most common presenting complaint is testicular swelling which the patients may feel as pressure-like sensation, heaviness or pain. Other symptoms in case of extragonadal or advanced disease include back pain, shortness of breath, cough, enlarged male breast, coughing up blood and weight loss.

Diagnosis:

In patients with suspected testicular mass, a blood test for serum tumor markers (AFP, Beta-HCG & LDH) and ultrasound of testis are the first and foremost investigations to be done. For complete staging evaluation CT scan or PET CT scan is recommended.

If tumor markers are elevated with normal testicular ultrasound, then the patient should be evaluated for the presence of extragonadal germ cell tumors on the CT or PET CT scan.

Treatment: Testicular Germ cell tumors:

Germ cell tumours are curative in most of the times if treated properly via a multidisciplinary team with experience in treating them. If USG shows a testicular mass, the first step in treatment is surgery and removal of the testis (high inguinal orchidectomy). A biopsy is not recommended in such patients. Post-surgery tumor markers need to be repeated. Further treatment depends on the histological type – Seminoma or non-seminomatous germ cell tumors.

1. Seminoma:

• Stage I (patients with only testicular mass and no lymph node involvement)

• Patients who are willing for regular follow-ups and without any high-risk features surveillance is the preferred option.

• Patients with high-risk features are considered for adjuvant treatment with single-drug chemotherapy or radiation to lymph nodes.

• Stage II & III (Patients with involvement of Lymph nodes or distant spread)

• Patients with limited lymph node involvement should receive either adjuvant chemotherapy or radiation.

• Stage II patients with extensive lymph node involvement and Stage III patients, adjuvant chemotherapy is the treatment of choice followed by surgical removal of residual mass if required.

2. Non-seminomatous germ cell tumors:

• Stage I (patients with only testicular mass and no lymph node involvement)

• Patients who are willing for regular follow-ups and without any high-risk features surveillance is the preferred option.
• Patients with high-risk features are considered for adjuvant treatment with combination chemotherapy or surgery (Retroperitoneal Lymph node dissection).
• Stage II & III (Patients with involvement of Lymph nodes or distant spread)
• Patients with limited Lymph node involvement should be treated with chemotherapy or surgery.
• Patients with extensive lymph node involvement and Stage III patients, adjuvant chemotherapy followed by surgical removal of all residual disease is the preferred treatment.

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