Surgery After Chemotherapy for Advanced Testicular Germ Cell Tumor

Introduction:

Cancer develops when cells start to multiply unchecked. Cancer cells may grow in almost any body portion and spread to adjacent organs. Chemotherapy or chemo is used widely to treat cancer. In general terms, chemo is a mode of treatment that uses chemicals to kill fast-developing cells. Chemotherapy is a system-wide treatment as the medications move throughout the body and can destroy cancer cells that have started to spread or have already spread to locations beyond the initial site.

For this reason, it differs from therapies like surgery and radiation. This therapy may not remove the entire tumor, and cancer may reoccur. In such cases in the last couple of decades, surgery after chemotherapy has evolved. This is mostly recommended for patients with advanced testicular germ cell tumors.

What Is Testicular Germ Cell Tumor?

Testicular cancer is a subtype that originates in the testicles. Over 90 percent of cancer in the testis are in germ cells (sperm-producing cells). The two primary germ cell tumors (GCT) forms are seminomas and nonseminomas.

• Seminomas - This form of GCT's immune to radiation treatment exhibits a slow growth and spread tendency. Seminomas take longer to multiply and transmit than nonseminomas.

• Non-seminomas - These GCTs occur in several different kinds. Certain testicular tumors contain both seminomas and nonseminomas. These hybrid GCTs are treated as nonseminomas because of their growth and spread rate characteristics.

What Are the Symptoms of Advanced Testicular Germ Cell Tumor?

• Swelling or lump in either of the testis.

• Pain in the scrotal sacs, where testis is present.

• Dull ache in the lower abdomen.

Why Is Surgery Performed After Chemotherapy for Advanced Testicular Germ Cell Tumors?

Patients with advanced testicular GCTs, who received chemo, are usually advised surgery. The importance of surgery after primary treatment for testicular cancer has increased over the past 30 to 40 years. The major reasons are:

• To boost the benefit of chemotherapy through surgery in patients who do not respond completely to chemotherapy.

• Due to mild development or as a side effect of chemotherapy, GCTs can develop into teratomas (a tumor that may be made up of various types of tissues, along with hair, muscle, and bone) that are naturally immune to chemo. Hence, those who have GCT undergo surgery post-chemotherapy to ensure long-term survival.

What Are the Diagnostic Methods for Advanced Testicular Germ Cell Tumors?

In most cases, testicular GCT is a painless detectable mass. Symptoms such as fever and pain can be noticed in a few cases. The following are the diagnosis methods.

• Blood Marker Tests - A test that measures the number of certain substances called blood markers, such as alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and beta-human chorionic gonadotropin (HCG), is used to detect GCT.

• Ultrasound - It is a diagnostic method that uses high-frequency sound waves to visualize the internal abnormalities of the testis. In addition to serving as a guide for inserting the needle during a biopsy, ultrasonography is also helpful in evaluating other organs in the abdomen to detect the spread of cancer.

• Biopsy - A complete biopsy can serve as a treatment for testicular cancer rather than a diagnostic method. Ultrasound and blood marker tests are sufficient to confirm the results.

• Computed Tomography (CT) - Large-volume tumors may be detected. Weakness of CT is small volume lymph nodes which are important for treatment. It cannot differentiate between normal size nodes and tiny deposits of tumors.

• Magnetic Resonance Imaging (MRI) - The lengthy testing times, high cost, and low supply of MRI have all resulted in its little use to date. But its usage may increase as new, faster procedures emerge and MRI becomes more easily available. It has become increasingly routine to screen for testicular GCT using MRI. MRI is known to have higher soft tissue visual quality than CT and is precise in recognizing abdomen lymph nodes.

What Are the Various Surgical Methods Performed After Chemotherapy for Advanced Testicular Germ Cell Tumors?

Various surgical procedures performed after chemotherapy for advanced testicular germ cell tumors are as follows:

Retroperitoneal Lymph Node Dissection (Rplnd) -

1. "Retroperitoneal lymph nodes" refers to the lymph nodes at the back of the abdomen.

2. As there is a chance for testicular cancer to spread to the surrounding abdominal tissue, the application and indications for retroperitoneal lymph node dissection (RPLND) have significantly changed.

3. Hence testicular cancer is most commonly assessed and treated with an RPLND.

Surgical Procedure in Patients With Non-seminomas -

1. To completely cut the possible tumors or teratoma with signs of leftover masses and infection post-chemo.

Surgical Procedure in Patients With GCT Type Seminomas -

1. In seminomas, leftover teratoma poses no concern, as 80% of remaining tumors are observed to undergo degeneration.

2. Pure seminoma tumors larger than 3 cm on positron emission imaging (a scan that differentiates abnormal activities with the help of radioactive rays) should be completely removed.

Surgery After Chemotherapy in Sites Apart From the Abdomen -

Approximately 40 percent of the advanced disease may exceed the normal abdominal (RPLND) limits. In this situation, total tumor removal should always be the goal, including removing extra retroperitoneal (outside the abdominal cavity) tumors wherever possible. This tumor could be common among patients up to 30 percent of the time.

1. Areas apart from the abdomen include:

2. The supra hilar region (a region near the lungs).

3. Posterior mediastinum or retro crural area (area in the chest).

4. Neck nodal region. These are among the main locations outside the abdomen causing illness.

5. Lung and liver tumors are common and may be removed together with RPLND, usually through an abdominal incision.

Conclusion

Complex and challenging surgical treatment is required post-chemo for managing testicular cancer. Surgical removal is usually the only option for a patient with chemo-resistant GCT and might be an important step toward a cure. It is essential for increasing the lifespan of the patient. Excellent results can be achieved with strict surgical indications. Specialized centers and oncologists must be preferred owing to the complexity of the treatment.