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Testicular Cancer
Optimising Treatment of Testicular Cancer
Christian Winter
1
and Peter Albers
2
1. Senior Resident, Department of Urology, University Clinic Düsseldorf;
2. Professor of Urology, Heinrich Heine University, and Chief, Department of Urology, University Clinic Düsseldorf
Abstract
Testicular cancer is a highly curable malignant tumour disease. In the last few decades excellent cure rates have been achieved by
standardisation of treatment, interdisciplinary management and tremendous success in clinical trials. The current aim of testicular cancer
treatment for patients with low-stage disease is to avoid overtreatment and reduce long-term toxicities. With the help of a risk-adapted
approach, about 50% of patients with clinical stage I testicular cancer will favour close surveillance instead of immediate adjuvant treatment.
The treatment of advanced testicular germ cell tumours is based on risk stratification according to pre-treatment clinical features and
International Germ Cell Cancer Collaborative Group (IGCCCG) classification. For patients with advanced disease and poor prognosis,
intensification of treatment – including high-dose chemotherapy as well as aggressive surgical approaches – is being investigated to improve
long-term cure rates. Future research should focus on treatment quality control and further optimisation of treatment strategies to diminish the
risk of late sequalae without reducing cure rates.
Keywords
Germ cell cancer, testicular cancer, non-seminomatous germ cell tumours (NSGCT), seminoma
Disclosure: The authors have no conflicts of interest to declare.
Received: 2 October 2009 Accepted: 22 December 2009
urologie@uni-duesseldorf.de
Malignant tumours of the testis are rare, but testicular cancer is the treatment based on chemotherapy, radiotherapy and surgery and very
most common cancer among men between 15 and 40 years of age. strict follow-up procedures and salvage therapies.
The majority of patients with testicular cancer present with primary
tumour in the testis, whereas in fewer than 5% the primary tumour Pathogenesis
manifestation is located extragonadally in the retroperitoneum or in The most established risk factor for testicular cancer is cryptorchidism
the mediastinum. Of all primary testicular tumours, 95% are germ cell (maldescendus testis). The association between maldescensus testis
tumours (GCTs), while the remainder are non-germinal neoplasms and GCT was suggested as early as in the beginning of the 19th
such as Leydig cell tumours, Sertoli cell tumours or lymphomas. century. Maldescensus testis is associated with a two- to four-fold
Histopathologically, GCTs divide into two major groups: seminoma increase in the risk of testicular cancer; however, some studies
and non-seminoma. Non-seminomatous germ cell tumours (NSGCTs) have reported a relative risk of testicular cancer associated with
include embryonal carcinoma, teratoma, choriocarcinoma, yolk sac maldescensus testis in the range of five- to 10-fold.
2
tumour and all kinds of mixed GCTs.
Maternal risk factors for GCT development, such as age at pregnancy,
The incidence of GCTs shows marked variation among different maternal in utero estrogen exposure and maternal smoking, may play
countries and ethnic backgrounds. In Scandinavian countries up to 15.2 an important role in the pathogenesis of testicular cancer. For
new cases per 100,000 males are reported, whereas in Japan there are example, McGlynn et al. investigated the role of early-life exposure to
only 0.8 per 100,000 cases per year. In the US, the incidence of GCT in pesticides in the development of testicular cancer. In a case–control
the Afro-American population is approximately one-quarter of the study they showed that high serum levels of the pesticide dichloro-
incidence in Caucasians.
1
The incidence of GCTs is still increasing and diphenyl-dichloroethylene (DDE) was statistically significantly
large geographical differences exist, leading to a hypothesis of a associated with an increased risk of GCT development. A possible
combination of genetic factors and environmental influences, but the exposure to these persistent organic pesticides during foetal life or via
reason for this is still unexplained. breastfeeding may increase the risk of testicular GCT in young men.
3
Although the GCT incidence has risen in recent years, more than 95% Testicular cancer has also been associated with genetic inheritance;
of cases can be cured. To further improve therapeutic strategies in however, the genetic factors linked to GCT development are
patients with testicular cancer it is mandatory to understand the ambiguous. In order to identify the location of putative GCT
pathogenesis of testicular cancer. There must be clear diagnostic susceptibility genes, Rapley et al. recently performed a genome-wide
schemes, definite staging at the time of diagnosis, an adequate early scan by genotyping 1,301 GCT patients and 3,241 controls. They noted
20 © TOUCH BRIEFINGS 2009
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