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.
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. 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:
How is the Staging for Testicular Germ Cell Tumors done?
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”.
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.
T2 – Tumor limited to testis/epididymis and has invaded up to the tunica vaginalis or blood vessels/lymphatics involvement by the tumor.
T3 – Tumor has invaded the spermatic cord with or without blood vessels/lymphatics involvement.
T4 – Tumor has invaded the scrotum with or without blood vessels/lymphatics involvement.
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
M0 – No spread to non-regional lymph nodes or distant body parts.
M1a – Tumor spread to non-regional lymph nodes or lungs
For example, spread to mediastinal lymph nodes
Or Inguinal lymph nodes
Or Left supraclavicular lymph node
Or metastasis to one or both the lungs (pulmonary metastasis)
M1b – Tumor spread to distant sites other than non-regional lymph nodes or lungs Like spread to liver
Spread to brain or bones is also M1b.
Testicular Tumor Serum Marker Levels
S0 – Normal tumor marker levels.
S1 – Tumor markers are elevated [LDH <1.5 × upper limit of normal, and beta-HCG <5000 mIU/ml, and AFP <1000 ng/ml].
S2 – Tumor markers are elevated (LDH=1.5-10 × upper limit of normal, or beta-HCG=5000-50000 mIU/ml, or AFP=1000-10000 ng/ml).
S3– Tumor markers are elevated [LDH >10 × upper limit of normal, or beta-HCG >50000 mIU/ml, or AFP >10000 ng/ml].
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 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 0Tis 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 IT1-4 N0 M0 Sx In case of Stage I seminomas, high inguinal orchiectomy (complete removal of the affected testicle) followed by surveillance is the preferred option, mainly for T1-T3 disease. However, chemotherapy or radiation therapy is also an option after high inguinal orchiectomy.
Stage IIAny T N1-3 M0 Sx In case of Stage II seminomas, high inguinal orchiectomy followed by radiotherapy (for non-bulky disease or stage IIA) or chemotherapy (for bulky disease or stage IIB/IIC) is considered as the standard treatment.
Stage IIIAny T Any N M1 Sx In case of Stage III 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.
Treatment of Non-Seminoma Testis
Stage 0Tis 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 IT1-4 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 IIAny T N1-3 M0 Sx In case of Stage II non-seminomas, high inguinal orchiectomy followed by RPLND (for non-bulky disease or stage IIA; with tumor marker(s) normal) or chemotherapy (for bulky disease or stage IIB/IIC, or tumor marker(s) elevated) is considered as the standard treatment.
Stage IIIAny 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.
What are the Surgeries done for Testicular Germ Cell Tumors?
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.
Best Testicular Cancer Specialist in Delhi
Dr Sunny Garg is a renowned Medical Oncologist in New Delhi with an experience of more than 6 years of treating testicular cancer patients. He has practiced in leading cancer hospitals in Delhi, and currently practicing at Manipal Hospital, Dwarka.
He has a vest experience of treating testicular cancer patients in all stages of disease. He is well versed with Chemotherapy for Testicular Cancer treatment and also general supportive care for patients. He works in close collaboration with surgical and radiation oncologists, oncopathologists, nuclear medicine, and genetic counselors for comprehensive cancer care for the patients.
Call +91 9686813020 for appointment.