Testicular Cancer Treatment in Delhi and Gurgaon

testicular cancer information

What are testes and what is their Anatomy?

Testes (singular: testis or testicle) are paired, oval-shaped, male-reproductive glands, which sit in the scrotum (supporting structure for the testes which hangs beneath the base of the penis) and measure about 5 cm in length and 2.5 cm in diameter.  

human testis anatomy

 

  They normally develop in the abdomen and descend into the scrotum through the inguinal canals during the seventh month of fetus development. The main function of the testes is to produce sperms and the male hormones (androgens) such as testosterone.  

What are the types of Testicular Cancers?

The testes are made up of mainly 3 types of cells: spermatogenic cells (germ cells), Sertoli cells, and interstitial (or Leydig) cells. Each of these cells can develop into one or more types of cancer. Germ cell tumors are the most commonly encountered (around 90-95% of all cases) testicular cancer.

testicular cancer types - seminoma non seminoma
Testicular Cancer Types – Seminoma and Non Seminoma

Germ cell tumors are classified into following 2 types based on the type of cells involved, growth rate, and type of treatment approach usually followed for such tumors:

  1. Seminomas
  2. Non-seminomas
    • Embronal Carcinoma
    • Endodermal Sinus/Yolk Sac Tumors
    • Choriocarcinoma
    • Teratoma

Testicular Cancer Risk Factors

Cryptorchidism

cryptorchidism-undescended testis

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.

Race and Ethnicity

race and ethnicity

The risk of testicular cancer is around 4 to 5 times higher in white men living in the United States and Europe compared to that of black men living in Africa or Asia. The incidence of testicular cancer is highest in North-European and least in Asians and Africans. However, the reason for this difference in incidence is unknown.

Personal History

Individuals with a personal history of testicular are generally at higher risk of developing second cancer in another testicle. Previous history of cancer in the opposite testis, previous testicular biopsy, testicular atrophy or impaired fertility also increase the testicular cancer risk factor.

Family history

family history of testicular cancer

Risk of developing testicular cancer increases in an individual with a history of testicular cancer in close relatives.

Genetic Cancer Predisposition Syndromes

genetic cancer predisposition syndromes

Various syndromes such as Down’s syndrome. Klinefelter’s syndrome and testicular dysgenesis syndrome may also be a risk factor for the disease.

  • Down’s Syndrome (caused due to defect in chromosome 21);
  • Klinefelter’s syndrome (caused due to the presence of two or more X chromosomes in males);
  • Testicular dysgenesis, and
  • Testicular feminization syndrome.

Infections

hiv infection

Infection with human immunodeficiency virus (HIV) is associated with an increased risk of testicular cancer.

Other Factors

Abnormal development of testicles, testicular atrophy due to injury, orchitis, and exposure to radiation in past is associated with increased level of follicle-stimulating hormone (FSH) which is postulated to increase the risk of testicular cancer.

Obese and tall men are also considered to be at increased risk of developing testicular cancer.

Symptoms and Signs of Testicular Cancer

Symptoms may be due to local or distant spread.

Local spread may cause:

  • Painless testicular swelling
  • Change in how testicles feel
  • Ache in the lower abdomen.

Distant spread may cause:

  • Cough, breathlessness
  • Bone pain
  • Jaundice

Other symptoms of testicular cancer may depend on the site of metastasis. Most common sites of spread of testicular cancer are liver, lung and bone.

Testicular Cancer Staging Investigations

Ultrasound

testicular ultrasound Ultrasound of the scrotum is generally the first test performed when testicular cancer is suspected. It helps us to differentiate whether the mass is intra-testicular or extra-testicular, that is, whether it is inside or outside the testis. Then we have to see whether it is solid or cystic. A solid, intratesticular mass goes in the favor of testicular cancer.

This helps the doctor to examine both the testes along with the nearby structures for any abnormal areas. This test can distinguish testicular cancer from non-cancerous conditions such as testicular torsion, hydrocele, varicocele, spermatocele, and epididymitis.

Blood tests for tumor markers

testicular cancer tumor markers Human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH) are common tumor markers for testicular cancer. Assessment of levels of these markers is very useful in testicular cancer as the blood level of these markers convey useful information concerning diagnosis, staging, prognosis (course of a medical condition), disease progression/recurrence, and response to treatment.

In seminoma, LDH is the most commonly elevated tumor marker, and beta-HCG may be elevated in some cases.
 
Next comes choriocarcinoma, in which beta HCG is significantly elevated, and LDH maybe elevated in some cases. In endodermal sinus or yolk sac tumors, AFP is significantly elevated and LDH maybe elevated in some cases. And in embryonal carcinoma all the three, that is, AFP, beta HCG and LDH maybe elevated.

Beta HCG (Human Chorionic Gonadotropin)

HCG is a glycoprotein consisting of 2 subunits – alpha and beta. HCG level in blood is generally measured with the help of beta-subunit. An elevated level of HCG is usually associated with embryonal carcinoma, choriocarcinoma, and seminoma. Extremely high level of HCG is generally detected in choriocarcinoma. However, an increase in the level of HCG can also be seen in other cancer types such as prostate, bladder, ureteral, renal cancer, etc.

AFP (Alpha Feto Protein)

An elevated level of AFP is usually associated with embryonal carcinoma and yolk sac tumors. Seminomas and choriocarcinoma do not increase the level of AFP. However, increased level of AFP may also be found in patients with hepatocellular carcinoma, liver cirrhosis, hepatitis, etc.

LDH (Lactate Dehydrogenase)

LDH is an enzyme which helps in energy production and normally found in almost all body tissues. An elevated level of LDH is generally associated with the tissue damage. In patients with testicular cancer, it is usually related to tumor burden, disease prognosis, and indicates the response to treatment.

Imaging Tests

So after doing testicular ultrasound and tumor markers, the next step is systemic imaging. This helps us to diagnose the spread of the disease to other part of the body. For systemic imaging, we require the CT scan of abdomen, pelvis and thorax. Very rarely, we may require MRI brain or bone scan to look for the spread of the disease to brain or bones.

  • Computed tomography (CT) scan
  • Positron emission tomography (PET) scan
  • Magnetic resonance imaging (MRI) Scan

High Inguinal orchiectomy

So after doing testicular ultrasound, tumor markers and system imaging, we are very close to diagnosis, but to be 100% sure, we require a tissue histopathology. So for that, we do high inguinal orchiectomy, in which the involved testis is removed. The procedure is both diagnostic as well as therapeutic because it provides tissue for histopathological diagnosis, as well as it removes the involved testis.
 
The pathology report after high inguinal orchiectomy confirms the diagnosis of germ cell tumor. It also tells us whether it is a seminoma or non-seminoma or whether it is a mixed germ cell tumor, having components of both. It also tells about the sub-type of non-seminoma, that is, whether it is embryonal carcinoma, endodermal sinus or yolk sac tumor, choriocarcinoma or teratoma.
 
The tumor markers may not be elevated in all the cases, and even if they are elevated they are highly overlapping in different sub-types, so 100% diagnosis is rarely possible with just the tumor markers. Therefore, for the confirmation of the diagnosis of testicular germ cell tumor, we require both, that is histopathology and tumor markers.
 
Rarely, it is possible that histopathology shows seminoma, but AFP is elevated, such cases are related as non-seminoma. So, always remember that elevation of AFP strictly goes in the favor of non-seminoma even if the histopathological diagnosis is suggestive of a seminoma.
 
Orchiectomy is considered most important for pathological diagnosis and as a curative procedure for testicular cancer. The entire tumor along with the affected testicle and spermatic cord (containing part of the vas deferens), and associated blood and lymph vessels (that can provide passage for cancer spread) are removed during the procedure. The collected sample is then tested in a laboratory to find out the type and extent of disease.

Stages of Testicular Cancer

Before discussing the staging, let’s have a look at the anatomy of human testis. This will help to understand staging better.

human testis anatomy

Testis is the rounded structure, that produces sperm and testosterone.  

It lies in a pouch called scrotum and it is lined by epididymis.

The duct joining the testis is called as vas deferens.

In front of the testis lies the penis, through which urethra passes. It is connected superiorly to the urinary bladder and helps in passing the urine.

If you look at the testis in detail, it is lined by an inner layer called as tunica albuginea and an outer layer, called as tunica vaginalis.

At the upper part is epidydimis, which joins the vas deferens superiorly.

The covering outside the testis is called as spermatic cord. It is composed of three layers, internal and external spermatic fascia and cremasteric muscle. And the outermost pouch like covering that holds both the testis is called a scrotum.

TNM is the most commonly used system for staging testicular cancer. “T” stands for “Tumor Size”, “N” for “Lymph Nodes”, “M” for “Metastasis”, and “S” stands for “Serum level of tumor markers”.

T STAGING

Tis – The cancer cells are present only in the seminiferous tubules (small tube-like structures inside the testes).

T1 – Tumor limited to testis/epididymis and has invaded up to the tunica albuginea but has not grown into tunica vaginalis or nearby blood vessels/lymphatics. T1 - infiltrates into the tunica albuginea T2 – Tumor limited to testis/epididymis and has invaded up to the tunica vaginalis or blood vessels/lymphatics involvement by the tumor. T2 - infiltrates into the tunica vaginalis T3 – Tumor has invaded the spermatic cord with or without blood vessels/lymphatics involvement. T3 - infiltrates into the spermatic cord T4 – Tumor has invaded the scrotum with or without blood vessels/lymphatics involvement. T4 - infiltrates into scrotum

N STAGING

So after the T staging, comes the N staging or the nodal staging. The absence of regional lymph nodes is called as N0, whereas, the involvement of regional lymph nodes is called as N1, N2 or N3 depending upon the size and the number of the nodes.

These nodal structures called retroperitoneal lymph nodes are the regional lymph nodes for testicular cancer. Their size and number determine the N-stage, that is N1, N2 or N3.

metastasis to retroperitoneal lymph nodes N0 – No spread to regional lymph nodes

N1 – Tumor spread to single or multiple regional lymph node(s) none >2 cm in greatest dimension

N2 – Tumor spread to single or multiple regional lymph node(s), any one >2 cm but </=5 cm in greatest dimension

N3 – Tumor spread to lymph node mass >5 cm in greatest dimension

M STAGING

After the T and N staging, comes the M staging for testicular cancer.

It is called as M1a if there is spread to non-regional lymph nodes, that is, any nodes except retroperitoneal lymph nodes as discussed above, or if there is spread to lungs that are called as pulmonary metastasis.

Whereas spread to the organs than lungs is called as M1b.

This figure shows M1a disease due to the involvement of lymph nodes in the mediastinum, this is non-regional lymph nodes because it is outside the retroperitoneum.
 

M1a - involvement of lymph nodes in the mediastinum Similarly, the involvement of inguinal lymph nodes is also M1a disease because it is a non-regional lymph node for testis. M1a - involvement of inguinal lymph nodes And here, the involvement of supraclavicular lymph node is non-regional. M1a - involvement of supraclavicular lymph node M1a disease also includes the cases with pulmonary metastasis, that is spread of the tumor to lungs. M1a - lung metastasis M1b – Whereas, spread to the organs of the body other than lung is called as M1b. In this figure spread to liver makes it M1b. M1b - liver metastasis

Spread to brain or bones is also M1b.

Testicular Tumor Serum Marker Levels

As you can see in the above figure, the tumor markers for each subtype may be different, although there is some overlap.
 
Seminoma mostly presents with LDH and/or beta HCG elevation, choriocarcinoma with beta HCG and/or LDH elevation, endodermal sinus/yolk sac tumors with AFP and/or beta HCG elevation, and embyonal tumors may present with elevation of any one or more of three.
 
SX: Tumor marker levels are not available.
S0: Tumor marker levels are normal.
S1: At least 1 tumor marker level is above normal.
  • 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.
S2: At least 1 tumor marker level is substantially above normal.
  • 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.
S3: At least 1 or more tumor marker level is very highly elevated.
  • LDH > 10 times the ULN
  • beta-hCG > 50,000 mIu/mL, and/or
  • AFP > 10,000 ng/mL.

3 Stages of Testicular Germ Cell Tumors

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.

STAGE TNM  
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 Stage 3 Disease? Is it Curable?

Stage 3 includes cases of testicular cancer that has spread to non-regional lymph nodes (other than retroperitoneal lymph nodes) like mediastinal, supraclavicular, inguinal, etc. Also, it includes cases with spread to distant sites like lungs, brain, liver, bones, etc. Also, the cases with serum tumor marker levels in S2 or S3 range (discussed above) are classified as stage 3. Stage 3 testicular cancer is definitely curable, with 5 year survival rate of around 80%.

What is Stage 4 Disease?

As you can see in the stage grouping above, there is no stage 4 in testicular cancer. Involvement of non-regional lymph nodes and/or distant metastasis is classified as Stage 3, unlike other cancers where it is stage 4.

Treatment of Testicular Germ Cell Tumor

The testicular cancer treatment depends on the type of testicular cancer (seminoma versus non-seminoma), stage of the disease, performance status of the patient, along with other factors.

Treatment of Seminoma Testis

Stage 0

Tis N0 M0 S0 Surveillance is generally preferred approach for patients with Stage 0 seminomas. The patient should be screened frequently for any sign of disease progression. No other treatment is generally recommended.

Stage I 

T1-4 N0 M0 Sx
 
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.

Stage II 

Any T N1-3 M0 Sx
 
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.

Stage III 

Any T Any N M1 Sx
 
In case of Stage III seminoma, radical inguinal orchiectomy followed by chemotherapy is the standard treatment. Radiation therapy and/or other palliative treatment may be given for relief of symptoms.
 
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 Testis

Stage 0

Tis N0 M0 S0
 
Surveillance is generally preferred approach for patients with Stage 0 non-seminomas. The patient should be screened frequently for any sign of disease progression. No other treatment is generally recommended.

Stage I 

T1-4 N0 M0 Sx
 
In case of Stage I non-seminomas, high inguinal orchiectomy followed by surveillance is preferred for T1 disease. However, for T2-T4 tumors, chemotherapy or nerve-sparing retroperitoneal lymph node dissection (RPLND) are preferred after high inguinal orchiectomy.

Stage II 

Any T N1-3 M0 Sx
 
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.

Stage III 

Any T Any N M1 Sx
 
In case of Stage III  non-seminomas, radical inguinal orchiectomy followed by chemotherapy is the standard treatment. Radiation therapy and/or other palliative treatment may be given for relief of symptoms. 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.

Surgery for Testicular Cancer

surgery for testicular cancer Mainly 2 types of surgeries are performed for testicular cancer treatment: High inguinal orchiectomy and retroperitoneal lymph node dissection (RPLND).

In high inguinal orchiectomy, the affected testicle, spermatic cord, and associated blood and lymph vessels (that can provide passage for cancer spread) are removed.

In RPLND, the cancer-containing lymph nodes in the abdomen (known as retroperitoneal lymph nodes surrounding the aorta and inferior vena cava) are removed. RPLND can be performed as an open surgery or as a laparoscopic procedure. Also, some patients may opt for sperm banking for fertility preservation before the surgery.

Chemotherapy for Testicular Cancer

chemotherapy for testicular cancer Testicular cancer is one of the most chemoresponsive tumor. Indications of chemotherapy in seminoma and non-seminoma are discussed above.

Some chemotherapy drugs that are a part of testicular cancer treatment regimens are-

  • Bleomycin
  • Etoposide
  • Cisplatin
  • Vinblastine
  • Ifosfamide

Best Testicular Cancer (Germ Cell Tumor) Specialist in Delhi

Dr Sunny Garg is a renowned Medical Oncologist in New Delhi with an experience of around 10 years of treating testicular cancer patients with chemotherapy. He is currently practicing at Manipal Hospital, Dwarka.

Diagnostic modalities available at our hospital include Tumor Markers- AFP, Beta HCG, LDH, High Inguinal Orchidectomy, CT Guided Biopsy, etc. Other treatment facilities for Testicular Cancer available are Retroperitoneal Lymph Node Dissection, Radical Inguinal Orchidectomy, Laproscopic Sugery, Radiation Therapy, etc.

Call +91 9686813020 for appointment.