Testis Tümörü Tanı ve Evrelemesi
Özet
Testis kanseri, erkek neoplazmlarının %1'ini, tüm ürolojik tümörlerin %5'ini oluşturmakta ve 20-40 yaş arası erkeklerde en sık görülen malignite olarak öne çıkmaktadır. Genç yaş grubunda izlenmesine rağmen, sisplatin bazlı kemoterapiye çok iyi yanıt vermesi ve 10 yıllık sağ kalım oranının %95'in üzerinde olması nedeniyle doğru tanı ve evreleme süreçleri hayati önem taşır. Tanısal değerlendirmede, en sık başvuru semptomu ağrısız ve tek taraflı testiküler kitle olup detaylı fizik muayene ilk adımı oluşturur. Görüntüleme yöntemlerinden skrotal Doppler ultrasonografi (USG) %100 sensitivitesi ile primer tanıda temel taş vazifesi görürken, bilgisayarlı tomografi (BT) ise uzak metastazların tespiti ve evrelemede en duyarlı yöntemdir. Radikal inguinal orşiektomi öncesi ve sonrasında değerlendirilen serum tümör belirteçleri (AFP, β-HCG ve LDH), hastalığın histopatolojik tipi, evresi, risk sınıflaması ve prognozu hakkında kritik veriler sunar. Şüpheli kitlelerde standart ilk tedavi internal inguinal ringden itibaren testisin çıkarılmasını içeren radikal inguinal orşiektomidir. Soliter veya bilateral tümörü olan seçilmiş hastalarda hormonal fonksiyonu korumak amacıyla parsiyel orşiektomi bir alternatif sunarken, tedavi süreçlerinin germinal epitel üzerindeki olumsuz etkileri nedeniyle çocuk sahibi olmak isteyen hastalara sperm kriyoprezervasyonu mutlaka önerilmelidir. TNM sınıflaması ve IGCCCG kriterlerine göre yapılan evreleme ise klinikte hastaların "iyi", "orta" ve "kötü" risk gruplarına ayrılarak doğru tedavi planlamasının yapılmasını sağlar.
Testicular cancer accounts for 1% of neoplasms in men and 5% of all urological tumors, standing out as the most common malignancy in men aged 20-40. Although observed in a young age group, the importance of accurate diagnosis and staging is immense due to its excellent response to cisplatin-based chemotherapy and a 10-year survival rate exceeding 95%. In clinical evaluation, the most common presenting symptom is a painless, unilateral testicular mass, making detailed physical examination the primary step. Among imaging modalities, scrotal Doppler ultrasonography (USG) serves as the cornerstone in primary diagnosis with 100% sensitivity, while computed tomography (CT) remains the most sensitive method for detecting distant metastases and staging. Serum tumor markers (AFP, β-HCG, and LDH), evaluated before and after radical inguinal orchiectomy, provide critical insights into the histopathological type, stage, risk classification, and prognosis of the disease. Radical inguinal orchiectomy, involving the excision of the testis from the internal inguinal ring, is the standard first-line treatment for suspected masses. While partial orchiectomy offers an alternative to preserve hormonal function in selected patients with solitary or bilateral tumors, sperm cryopreservation must be recommended to patients desiring children due to the adverse effects of treatments on the germinal epithelium. Finally, staging performed according to the TNM classification and IGCCCG criteria allows patients to be categorized into "good," "intermediate," and "poor" risk groups, enabling appropriate treatment planning in clinical practice.
Referanslar
Howlader N, Noone AM, Krapcho M et al. SEER cancer statistics review, 1975-2014. National Cancer Institute: Bethesda, MD; 2017.
Germà-Lluch JR, Garcia del Muro X, Maroto Pet al. Clinical pattern and therapeutic results achieved in 1490 patients with germ-cell tumours of the testis: the experience of the Spanish Germ-Cell Cancer Group (GG). Eur Urol. 2002 Dec;42(6):553-62; discussion 562-3. doi: 10.1016/s0302-2838(02)00439-6.
Moul JW. Timely diagnosis of testicular cancer. Urol Clin North Am. 2007 May;34(2):109-17; abstract vii. doi: 10.1016/j.ucl.2007.02.003.
Doherty FJ. Ultrasound of the nonacute scrotum. Semin Ultrasound CT MR. 1991 Apr;12(2):131-56. PMID: 1863475.
Comiter CV, Benson CJ, Capelouto CC et al. Nonpalpable intratesticular masses detected sonographically. J Urol. 1995 Oct;154(4):1367-9. PMID: 7658540
Angulo JC, González J, Rodríguez N et al. Clinicopathological study of regressed testicular tumors (apparent extragonadal germ cell neoplasms). J Urol. 2009 Nov;182(5):2303-10. doi: 10.1016/j.juro.2009.07.045. Epub 2009 Sep 16.
Isidori AM, Pozza C, Gianfrilli D et al. Differential diagnosis of nonpalpable testicular lesions: qualitative and quantitative contrast-enhanced US of benign and malignant testicular tumors. Radiology. 2014 Nov;273(2):606-18. doi: 10.1148/radiol.14132718. Epub 2014 Jun 26
Maizlin ZV, Belenky A, Kunichezky M et al. Leydig cell tumors of the testis: gray scale and color Doppler sonographic appearance. J Ultrasound Med. 2004 Jul;23(7):959-64. doi: 10.7863/jum.2004.23.7.959.
Pierorazio PM, Cheaib JG, Tema G et al. Performance Characteristics of Clinical Staging Modalities for Early Stage Testicular Germ Cell Tumors: A Systematic Review. J Urol. 2020 May;203(5):894-901. doi: 10.1097/JU.0000000000000594. Epub 2020 Oct 14.
Kim W, Rosen MA, Langer JE et al. US MR imaging correlation in pathologic conditions of the scrotum. Radiographics. 2007 Sep-Oct;27(5):1239-53. doi: 10.1148/rg.275065172.
Thurnher S, Hricak H, Carroll PR et al. Imaging the testis: comparison between MR imaging and US. Radiology. 1988 Jun;167(3):631-6. doi: 10.1148/radiology.167.3.3283834. PMID: 3283834
Ellis JH, Bies JR, Kopecky KK et al. Comparison of NMR and CT imaging in the evaluation of metastatic retroperitoneal lymphadenopathy from testicular carcinoma. J Comput Assist Tomogr. 1984 Aug;8(4):709-19. doi: 10.1097/00004728-198408000-00023. PMID: 6539790.
Pope WB. Brain metastases: neuroimaging. Handb Clin Neurol. 2018; 149:89-112. doi: 10.1016/B978-0-12-811161-1.00007-4.
de Wit M, Brenner W, Hartmann M et al. [18F]-FDG-PET in clinical stage I/II non-seminomatous germ cell tumours: results of the German multicentre trial. Ann Oncol. 2008 Sep;19(9):1619-23. doi: 10.1093/annonc/mdn170. Epub 2008 May 2
Beyer J, Albers P, Altena R et al. Maintaining success, reducing treatment burden, focusing on survivorship: highlights from the third European consensus conference on diagnosis and treatment of germ-cell cancer. Ann Oncol. 2013 Apr;24(4):878-88. doi: 10.1093/annonc/mds579. Epub 2012 Nov 14.
Bachner M, Loriot Y, Gross-Goupil M et al. 2-¹⁸fluoro-deoxy-D-glucose positron emission tomography (FDG-PET) for postchemotherapy seminoma residual lesions: a retrospective validation of the SEMPET trial. Ann Oncol. 2012 Jan;23(1):59-64. doi: 10.1093/annonc/mdr052. Epub 2011 Apr 2.
Barlow LJ, Badalato GM, McKiernan JM. Serum tumor markers in the evaluation of male germ cell tumors. Nat Rev Urol. 2010 Nov;7(11):610-7. doi: 10.1038/nrurol.2010.166.
Nicholson BD, Jones NR, Protheroe A et al. The diagnostic performance of current tumour markers in surveillance for recurrent testicular cancer: A diagnostic test accuracy systematic review. Cancer Epidemiol. 2019 Apr; 59:15-21. doi: 10.1016/j.canep.2019.01.001.
Gilligan TD, Seidenfeld J, Basch EM et al. American Society of Clinical Oncology. American Society of Clinical Oncology Clinical Practice Guideline on uses of serum tumor markers in adult males with germ cell tumors. J Clin Oncol. 2010 Jul 10;28(20):3388-404. doi: 10.1200/JCO.2009.26.4481.
Dieckmann KP, Simonsen-Richter H et al. Serum Tumour Markers in Testicular Germ Cell Tumours: Frequencies of Elevated Levels and Extents of Marker Elevation Are Significantly Associated with Clinical Parameters and with Response to Treatment. Biomed Res Int. 2019 May 28; 2019:5030349. doi: 10.1155/2019/5030349.
Geldart TR, Simmonds PD, Mead GM. Orchidectomy after chemotherapy for patients with metastatic testicular germ cell cancer. BJU Int. 2002 Sep;90(4):451-5. doi: 10.1046/j.1464-410x.2002.02916.x.
Giannarini G, Dieckmann KP, Albers P et al. Organ-sparing surgery for adult testicular tumours: a systematic review of the literature. Eur Urol. 2010 May;57(5):780-90. doi: 10.1016/j.eururo.2010.01.014.
Skoogh J, Steineck G, Cavallin-Ståhl E et al. Feelings of loss and uneasiness or shame after removal of a testicle by orchidectomy: a population-based long-term follow-up of testicular cancer survivors. Int J Androl. 2011 Apr;34(2):183-92. doi: 10.1111/j.1365-2605.2010.01073.x.
Andreassen KE, Grotmol T, Cvancarova MS et al. Risk of metachronous contralateral testicular germ cell tumors: a population-based study of 7,102 Norwegian patients (1953-2007). Int J Cancer. 2011 Dec 15;129(12):2867-74. doi: 10.1002/ijc.25943.
Dieckmann KP, Kulejewski M, Pichlmeier U et al. Diagnosis of contralateral testicular intraepithelial neoplasia (TIN) in patients with testicular germ cell cancer: systematic two-site biopsies are more sensitive than a single random biopsy. Eur Urol. 2007 Jan;51(1):175-83; discussion 183-5. doi: 10.1016/j.eururo.2006.05.051.
Williams DH 4th, Karpman E, Sander JC et al. Pretreatment semen parameters in men with cancer. J Urol. 2009 Feb;181(2):736-40. doi: 10.1016/j.juro.2008.10.023.
Feldman DR, Lorch A, Kramar A et al. Brain Metastases in Patients With Germ Cell Tumors: Prognostic Factors and Treatment Options--An Analysis From the Global Germ Cell Cancer Group. J Clin Oncol. 2016 Feb 1;34(4):345-51. doi: 10.1200/JCO.2015.62.7000.
Ghazarian AA, Kelly SP, Altekruse SF et al. Future of testicular germ cell tumor incidence in the United States: Forecast through 2026. Cancer. 2017 Jun 15;123(12):2320-2328. doi: 10.1002/cncr.30597. Epub 2017 Feb 27.
Laguna MP, Albers P, Albrecht W et al. Guidelines on testicular cancer. EAU 2019; 1:28-33.
Brierley JD, Gospodarowicz MK, Wittekind C. TNM classification of malignant tumours: John Wiley & Sons; 2016.
Gillessen S, Sauvé N, Collette L et al; International Germ Cell Cancer Classification Update Consortium. Predicting Outcomes in Men With Metastatic Nonseminomatous Germ Cell Tumors (NSGCT): Results From the IGCCCG Update Consortium. J Clin Oncol. 2021 May 10;39(14):1563-1574. doi: 10.1200/JCO.20.03296. Epub 2021 Apr 6.
Beyer J, Collette L, Sauvé N et al. International Germ Cell Cancer Classification Update Consortium. Survival and New Prognosticators in Metastatic Seminoma: Results From the IGCCCG-Update Consortium. J Clin Oncol. 2021 May 10;39(14):1553-1562. doi: 10.1200/JCO.20.03292. Epub 2021 Mar 17.
