Testicular Tumors (Testicular Malignancies): Surgical Therapy

The type of therapy depends on the histologic (fine tissue) picture of the tumor:

Proceed in the following steps:

• Suspicion of a germ cell tumor (CRT) → expose testis inguinally (“belonging to the inguinal region”): thereafter, only ablation testis in case of definite evidence of a CRTNote: In case of a CRT, there is always a germ cell neoplasia in situ (GCNIS) in the surrounding tissue, which is an obligate precancerous lesion (tissue that transforms into tumor tissue), thus ablation testis of the affected testis is always indicated.
• In marker-negative, small tumors → excision (surgical removal) of the tumor and frozen section examination.

At all stages, semicastration (removal of one testis) is performed and a double biopsy of the contralateral testis is performed. The latter is used to exclude TIN (testicular intraepithelial neoplasia) when risk factors such as previous cryptorchidism, low testicular volume < 12 ml, impaired spermatogenesis and age < 40 years are present. Further recommendations according to S3 guideline:

• “Organ-preserving excision should not be performed in the presence of a healthy contralateral testis in the presence of a malignant germ cell tumor (GCNT) (with the exception of a teratoma without concomitant GCNIS (Germ cell neoplasia in situ; Germ cell tumor in situ)).”
• “In patients with bilateral GCNIS, tumor in the solitary testis, stromal tumors, or other benign tumors (epidermoid cyst, monodermal teratoma), organ-preserving tumor excision should be considered.”
• “In patients with microlithiasis (formation of small crystalline deposits) on sonographic findings without other risk factors, testicular biopsy should not be performed. In patients with microlithiasis with additional one of the following parameters: Infertility, previous tumor disease of the testis, first-degree relative with KZT, history of maldescensus testis (undescended testis), or testicular atrophy with sonographic testicular volume < 12 ml, a testicular biopsy may be recommended.”

Thereafter, the following complementary procedures are used:

Stage-adapted therapy of germ cell tumors (KZT)

Seminoma

Stage*	Frequency (%)	Therapy
I	75-80 %	Surveillance (monitoring) with CT abdomen; Note: In tumor size > 4 cm and rete-testis infiltration, metastasis (formation of daughter tumors) is present in 32% of caseseither/or: Carboplatin AUC 7 (for patients with risk factors; for tumors > 5 cm, one cycle is likely to be insufficient Adjuvant irradiation of the paraortic/paracaval fields with 20 Gy.
IIA	7-14 %	Radiotherapy (radiotherapy, radiatio) of regional (paraaortic/paracaval) lymph nodes (30 Gy) or 3 x PEB.
IIB	3,5 %	3 x PEB
IIC/III		3 x PEB (4 x PE if contraindications/counterindications to bleomycin).
Good prognosis or intermediate prognosis		4 x PEB
Residual tumor after chemotherapy		Close-meshed observation for residuals (“remnants”) > 3 cm. Resection (surgical removal) in selected cases.

* Lugano classification

Recurrence

• Systemic relapse: chemotherapy (PEB).
• Locoregional recurrence: radiotherapy (radiotherapy) or chemotherapy (PEB) (decision depending on size).

Legend

• AUC = Area under the curve
• PEB = cisplatin, etoposide, bleomycin.
• PE = cisplatin, etoposide

Non-seminoma

Stage	Therapy
I	Surveillance (low risk) 2 x PEB (high risk) Surveillance without risk stratification
II / II
Good prognosis	3 x PEB or 4 x PE
Intermediate prognosis	4 x PEB
Unfavorable prognosis	4 x PEB
Residual tumor after chemotherapy	Resection of residuals > 1 cm

More hints

• Patients already diagnosed with a testicular tumor have an increased risk of also developing disease on the contralateral (“on the opposite side of the body”) testis.
• The European Society of Medical Oncology lets patients make their own informed decision about whether they want a biopsy.
• The European Association of Urology recommends biopsy (tissue sampling) in high-risk patients (with atrophic testes, microcalcifications (microcalcifications) or infertility/infertility).
• According to one study, biopsies (double sampling) of the contralateral testis found intraepithelial neoplasms (precancerous/cancerous lesions), so-called TIN (testicular intraepithelial neoplasms), in 4.8% of seminoma patients and in 5.3% of non-seminoma patients; patients under 35 years of age benefited particularly from this procedure.
• Patients with stage I testicular tumor after radical inguinal orchiectomy (removal of the testes via the groin) probably do not require adjuvant therapy initially. Strict non-risk-adapted active close monitoring results in a survival rate of testicular cancer patients close to 100%.Monitoring as follows: Initially, depending on tumor type, bi-monthly check-ups (clinical, laboratory and radiological) in some cases during the first year. In the course of time, the intervals can be increased. In the fifth year, only control examinations at intervals of six months (non-seminomas) or only once a year (seminomas) are necessary.
• Wg. partial rather than a radical orchiectomy: indication for a partial orchidectomy is according to the U.S. Urological Association AUA give if:
  • Space-occupying lesion <2 cm
  • Healthy testis shows no abnormalities on ultrasound
  • No increased tumor marker values

  In 77 men with a mean age of 31 years who underwent partial orchiectomy (i.e., complete enucleation/removal of a limited tissue area of the mass) according to the above indication, one-third of all men were found to have benign (benign) tumors; among the malignant (malignant) tumors (all pT1), seminomas were most frequently observed. Benign tumors were detected in half of the men with tumors less than 10 mm. After a median after observation period of 3, 7 years, a total of 16 patients (21%) eventually had to undergo radical orchiectomy after all, ten because of local recurrence (local recurrence of the tumor; in total 13% of all men), four because of positive resection margins (no safety margin), two because of other evidence of a high risk of recurrence (risk of recurrence).