Non-seminoma is a type of germ cell tumor, originating from sperm-producing cells in the testicles. While most commonly found in the testicles, these tumors can also develop in other body areas like the chest or abdomen. Non-seminoma is distinct from seminoma, another germ cell tumor, due to differences in cellular characteristics and behavior. Non-seminoma tumors tend to grow and spread more rapidly than seminomas, typically affecting individuals in their late teens, 20s, and early 30s.
Understanding Non-Seminoma
Non-seminoma encompasses several distinct forms of germ cell cancers. These different cell types often occur together within the same tumor, influencing treatment approach and patient outlook. The specific combination of these cells dictates tumor behavior and treatment effectiveness.
Types of Non-Seminoma
Embryonal Carcinoma: A highly malignant tumor of undifferentiated cells resembling those of an early embryo.
Yolk Sac Tumor (Yolk Sac Carcinoma): Characterized by Schiller-Duval bodies and more common in children than adults.
Choriocarcinoma: A rare but highly aggressive form, often presenting with elevated human chorionic gonadotropin (hCG) and rapid spread.
Teratoma: The fourth main subtype, composed of tissues from all three embryonic germ layers, it may contain various cell types like hair, muscle, or bone.
Signs and Diagnostic Process
A painless lump in the testicle is the most common sign of non-seminoma, although other symptoms can include swelling or a sudden fluid buildup in the scrotum. Some individuals may also experience a feeling of heaviness in the scrotum or a dull ache in the groin or lower abdomen. Pain or discomfort in the testicle or scrotum, or a shrinking testicle, are additional indications that warrant medical attention.
Diagnosis typically begins with a physical examination where a healthcare provider checks the testicles for abnormalities and lymph nodes for signs of spread. If a lump is detected, an ultrasound of the testicles is usually performed to confirm the presence of a mass and distinguish it from other scrotal conditions. This imaging often reveals a heterogeneous mass within the testicle, sometimes with microcalcifications.
Blood tests are a significant part of diagnosis, measuring tumor markers like alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH). Elevated AFP is often seen in 50-80% of non-seminoma cases, while hCG levels may be high in 20-60%. LDH can also be elevated in 20-60% of patients, indicating tumor burden.
After initial blood tests and imaging, definitive diagnosis is made through a radical inguinal orchiectomy, surgically removing the affected testicle through a groin incision. A biopsy through the scrotum is generally avoided due to the risk of spreading cancer cells. Following orchiectomy, staging procedures, including CT scans of the chest, abdomen, and pelvis, determine if and how far the cancer has spread. Staging classifies cancer into categories like Stage I (confined to the testicle), Stage II (spread to abdominal lymph nodes), or Stage III (spread beyond regional lymph nodes), guiding treatment decisions.
Treatment Pathways
Radical inguinal orchiectomy, which surgically removes the affected testicle and spermatic cord through a groin incision, is the initial treatment for suspected non-seminoma. For many with Stage I non-seminoma, this surgery alone can be curative, with about 70% of patients cured.
Depending on the cancer’s stage and individual risk factors, further treatment may be considered. For some Stage I cases, particularly those with risk factors, or if the cancer has spread to abdominal lymph nodes (Stage II), a retroperitoneal lymph node dissection (RPLND) may be performed. This surgery removes lymph nodes from the back of the abdomen where testicular cancer commonly spreads. If cancer cells are found in removed lymph nodes during RPLND, or with advanced disease, chemotherapy is often recommended.
Chemotherapy is a primary treatment for non-seminoma, especially for advanced or metastatic disease. Common chemotherapy regimens include BEP (bleomycin, etoposide, and cisplatin) or EP (etoposide and cisplatin). The choice of regimen and number of cycles (typically three to four) depends on the cancer’s stage and risk factors. Chemotherapy may be given after surgery, or sometimes before orchiectomy if cancer has spread extensively and diagnosis is confirmed.
Radiation therapy is rarely used for non-seminoma because these tumors are not as sensitive to radiation as seminomas, and chemotherapy is typically more effective. Treatment plans are highly individualized, considering specific tumor cell types, cancer stage, and patient health. Given the potential for infertility with certain treatments, sperm banking may be offered before chemotherapy or RPLND.
Prognosis and Follow-Up Care
The outlook for non-seminoma is generally favorable, particularly when detected and treated early. Many cases are highly curable, with a good prognosis even for advanced disease that responds well to treatment. Success rates underscore the importance of prompt diagnosis and comprehensive management.
After initial treatment, ongoing surveillance and follow-up care monitor for recurrence and manage potential long-term effects. This includes regular physical examinations, blood tests for tumor markers (AFP, hCG, LDH), and imaging scans like CT or MRI. Follow-up appointments are typically more frequent in the first few years after treatment (often every three months for non-seminoma), gradually becoming less frequent.
Most Stage I non-seminoma recurrences occur within the first one to two years after surgery, with 80-90% detected within this period. Adhering to the recommended follow-up schedule is important for early detection of any returning cancer, which is often highly curable. Continued monitoring helps ensure timely intervention if needed and supports the patient’s long-term health.