Overview】 Testicular tumors are uncommon, accounting for only 1% of systemic malignant tumors. According to the statistics around the world, there are regional and racial differences in the incidence of testicular tumors, with higher incidence in Europe and America and lower incidence in China, but testicular tumors have received special attention because of the following reasons. ①There was a breakthrough in treatment after the 70s, which reduced the mortality rate from 50% to about 10%. ②It is the most common cancer in young people aged 15 to 35 years old, because young people so they can bear the strict integrated treatment such as surgery, radiotherapy and chemotherapy. ③ has the tendency to differentiate and change from malignant to benign spontaneously or after treatment, for example, metastatic carcinoma turns into benign teratoma after chemotherapy. If the mechanism can be clarified, it is possible to differentiate malignant tumors into benign ones. (4) Tumor secreting marker substances can be detected from blood, which is uncommon in other tumors. Etiology】 Cryptorchidism is considered as a risk factor for testicular tumor, and its chance of tumor is 3 times to 4 times higher than that of normal testis. Seven to 10% of testicular tumors occur in cryptorchidism. It is observed that surgery after the age of 10 cannot be prevented, but surgery before the age of 10 can be significantly reduced, and surgery before the age of 3 can avoid the occurrence of tumor. In addition, testicular tumor is also related to genetics, polyspermia, traumatic testicular atrophy and hormone. There are many ways to classify the pathology of testicular tumor. By 1986, Morse et al. summarized various commonly used classification methods (Table 25-1). Among the primary tumors, they can be subdivided into germ cell tumors and non-germ cell tumors, and specifically singled out the most common of the germ cell tumors, seminoma, which is unique in guiding treatment and elucidating prognosis. Testicular germ cell tumors are all of the same origin and are subject to different oncogenic factors, which can lead to seminoma or tumors of embryonic and extra-embryonic tissues such as embryonal carcinoma and teratoma, as well as choriocarcinoma and yolk sac tumors. Diagnosis】 (a) Tumor markers (tumor markers) The most widely used are fetal nail globules (AFP) and human gonadotropin (HCG). AFP: normal value <40ng/ml, half-life 4 days to 5 days. It is elevated in all testicular tumors with yolk sac tumors, 50% to 70% embryonal carcinoma, and teratocarcinoma; it is not elevated in pure choriocarcinoma and pure seminoma. HCG: normal value <1ng/ml, positive for all choriocarcinomas and 40%-60% of embryonal carcinomas, positive for 5%-10% of "pure" seminoma. When applying the above two types of tumor markers, 90% of non-seminomatous tumors were positive for one or both. In pure spermatogonial tumors, HCG is positive in 5-10% of cases, i.e. more than 90% of pure spermatogonial tumors do not produce tumor markers and 10% of non-sematogonial tumors do not produce tumor markers, so once a testicular tumor is clinically diagnosed, orchiectomy should be performed immediately without waiting for tumor marker results. The tumor marker can be used as an indicator to observe the efficacy of treatment. If it decreases rapidly after surgery or chemotherapy or radiotherapy, the prognosis is better; if it decreases slowly or not, there may be residual tumor. Therefore, once the tumor is clinically diagnosed, kujiu resection should be performed immediately without waiting for the result of tumor marker. The tumor marker can be used as an indicator to observe the efficacy of treatment. A rapid decrease after surgery or chemotherapy or radiotherapy is a good prognosis, while a slow decrease or no decrease may have residual tumor. (b) Ultrasound can be used to determine the symptoms of intra-testicular tumor and the presence of metastatic lymph nodes in the groin. (iii)CT and MRI can detect lesions with retroperitoneal lymph node metastases <2 cm. There are also dorsal foot lymphography and urography. Clinical manifestations of testicular tumor 1. Testicular enlargement In 88% of patients, the testicle is enlarged to different degrees, sometimes the testicle is completely replaced by the tumor, the texture is hard, and the normal elasticity disappears. In early stage, the surface is smooth, but in late stage, the surface may be nodular and may adhere to the scrotum, or even break down, and the scrotal skin may be dark red, and there are often blood vessels twisting on the surface. The skin of the scrotum may be dark red and the surface is often vascularized. When doing transillumination test examination, it does not transmit light. If the tumor occurs in cryptorchidism, the mass is mostly found in the abdomen and groin, while the ipsilateral scrotum is empty, and some patients with testicular tumor are accompanied by syringomyelia at the same time. Some of them are still normal or slightly larger, so they seldom notice it by themselves, but are often found during physical examination or treatment of other diseases. 2.Pain Nearly 90% of the patients have no painful sensation in the testicles. Therefore, it is generally believed that the tumor is a painless scrotal mass. It is worth noting that we can also see acute painful testicular tumor in clinic, but it is often considered as inflammatory sign. The reason for pain is internal bleeding or central necrosis of the tumor, or pain occurs because the testicular tumor invades the tissues outside the testis. 3.Metastasis symptoms Testicular tumor is mainly metastasis in lymph nodes, commonly in internal iliac, common iliac, para-abdominal aorta and mediastinal lymph nodes, the metastasis foci can be very large, the abdomen can be palpable, and the patient complains of back and back pain. In patients with testicular choriocarcinoma, breast enlargement and nipple areola hyperpigmentation may occur. 【Treatment measures】 The treatment of testicular tumor is determined by its pathological nature and stage, and the treatment can be divided into surgery, radiotherapy and chemotherapy. Radical orchiectomy via groin should be done first. The specimen should be examined in detail, and it is better to perform segmental section to understand the nature of the tumor, especially whether the seminoma is pure or mixed, there is a considerable difference in treatment. If pure seminoma without retroperitoneal lymph node metastasis has only lung or liver metastases, non-seminomatous components should be thought of, and treatment options are discussed separately below. (a) Seminoma Radiation therapy after orchiectomy, 25-35 GY (2500-3500 rad) for 3 weeks to irradiate para-aortic and ipsilateral iliac and inguinal lymph nodes. Stage l patients can survive for 5 years in 90-95% of cases. If retroperitoneal lesions are found clinically, i.e., stage 2, the mediastinum and supraclavicular region can also be irradiated with 20-35 GY (2000-3500 rad) for 2-4 weeks with a 5-year survival rate of 80% or more. Large intra-abdominal metastases and distant lesions have a poor prognosis, with a survival rate of only 20%-30%. In recent years, cisplatin-containing chemotherapy has also been used, and the survival rate can be significantly improved, with 60%-100% effective (PVB or DDP ten GY) chemotherapy regimens being introduced in the lower segment. For those with lesions in the spermatic cord at the time of orchiectomy, half of the scrotum should also be included in the irradiated area. Tumors with >10 cm in the abdomen and metastatic carcinoma in the lung have significant radiotherapy effects. (II) Non-seminomatous cell tumors include embryonal carcinoma, teratoma, choriocarcinoma, yolk sac tumor or various mixed composition tumors. Retroperitoneal lymph node metastasis is extremely common. Since it is less sensitive to radiation than seminoma, retroperitoneal lymph node dissection should be performed at the same time in addition to orchiectomy, and about 10%-20% of stage I cases have metastasis as proven by surgery, i.e. pathology is stage 2. With orchiectomy plus retroperitoneal lymph node dissection, about 90% of those with stage 1 pathology could survive for more than 5 years, and those with stage 2 pathology decreased to about 50%. Among 144 cases of stage 3 distant metastases, 89% of the lungs, 73% of the liver, 31% of the brain, 30% of the bone, 30% of the kidney, 29% of the adrenal gland, 27% of the gastrointestinal tract, 13% of the spleen, and 11% of the vena cava. Chemotherapy was the main treatment. In non-seminomatous tumors, choriocarcinoma often metastasizes to distant lesions such as the lung first. The changes in the tumor markers HCG and AFP are closely monitored during the course of treatment. The malignancy of embryonal carcinoma in infants and children within 3 years of age is lower than that of adults, and they are less tolerant to surgery, chemotherapy and radiotherapy, and the metastasis of retroperitoneal lymph nodes is lower than that of adults, only about 4%. Death is mostly due to hematogenous metastasis. Chemotherapy is administered when necessary. Chemotherapy: Chemotherapy has a certain status in non-seminomatous cell tumors. The main indications are: ①Stage I non-seminomatous cell tumors with poor prognosis, which have invaded the seminiferous cord or the koo-koo, and the tumor marker continues to rise after resection. ②Non-seminomatous cell tumors of IIA-IV. ③Advanced refractory tumor recurrence or drug ineffectiveness with salvage chemotherapy regimen. Chemotherapy regimen PvB is the most widely used based on cisplatin, vincristine and bleomycin. Commonly used regimen: cisplatin 20mg/m2/day. On days 1, 2, 3, 4 and 5, vincristine o.2mg/kg. on year 2, bleomycin 30mg/week on days 2, 9 and 16, 3 weeks as a course of treatment for a total of 12 weeks. The combination of the above three drugs can achieve partial remission up to 100% and complete remission 70%. stage I testicular tumor without metastatic lymph nodes can be treated without chemotherapy, and it is also advocated that stage II cases should be treated with chemotherapy again in multiple cases, which can reduce the unnecessary blow to the patient. Large retroperitoneal tumors that do not exceed the diaphragm can also be treated with chemotherapy, and then retroperitoneal lymph node dissection can be performed after the tumor shrinks. In stage III patients, chemotherapy is the main treatment. Cure standard】 Testicular tumor natural history is short, commonly used to judge the efficacy of 2 years survival, because survival is not necessarily cure, in recent years, 5 years survival is used as the efficacy standard. Prognosis】 (a) Complete spontaneous regression is rare. (b) All adult germ cell tumors should be considered malignant, the so-called “benign teratoma” microscopically has invasion to the canal eventually 29% of simple orchiectomized people died from the tumor. Pediatric teratomas are benign. (c) The white membrane is a natural barrier, and tumor penetration is often in the mediastinum, where blood vessels, lymphatic vessels, nerves and tubules pass through. 10%-15% of those who extend to the epididymis and spermatic cord are at increased risk of lymphatic and hematogenous metastasis. (d) All testicular tumors are usually found in lymphatic metastasis, although pure choriocarcinoma also has blood dissemination. Four to eight lymphatic vessels of the spermatic cord fan out upward to the retroperitoneal lymphatic chain. The initial lymph nodes reached in the right testis are those between the aortic area of the L3 vertebrae, and the first echelon of lymph nodes in the left testis are in the para-aortic area: between the left ureter, renal vein, the beginning of the inferior mesenteric artery and the aorta. Upward to the celiac pond, thoracic duct, supraclavicular lymph nodes (left side predominant), and also downward to the iliac and inguinal lymph nodes retrogradely. Inguinal disease may also be caused by metastases from scrotal lesions. (E) Metastases outside the lymph nodes can invade directly into blood vessels or tumor emboli spread from lymphatic venous anastomoses, and most hematogenous metastases follow lymphatic metastases. If stage A non-seminomatous cells are only orchiectomized, 20% spread, most of which, 80%, are retroperitoneal metastatic lymph nodes, and 20% metastases are unrelated to them. Pure seminoma metastases are often seminoma and less than 10% are other component metastases, while those with other component metastases account for 30% to 45% of pure seminoma deaths. Non-seminomatous cell tumors develop rapidly, with a doubling time of only 10 to 30 days, and 85% of those with ineffective treatment die within two years, the rest within three years. The rest die within three years. Spermatogenic tumors can recur after 2 to 10 years of effective treatment. Prevention and care of testicular tumor 1. Prevention 1. Early treatment of testicular ectopic and cryptorchid, prevention and treatment of testicular and epididymal inflammation. 2. Quit smoking and alcohol, and do not eat spicy food. Care 1. Observe the gastrointestinal reaction caused by cisplatin and the series of symptoms brought by nephrotoxicity, so as to deal with them symptomatically in time. 2.When applying BLM, observe the changes of patient’s breathing to be alert to the pulmonary fibrosis caused by BLM. Also pay attention to stomatitis, fever and allergy treatment. 3.Patients are advised to have nutritious diet and intravenous high nutrition therapy to ensure the successful completion of radiotherapy and chemotherapy. Testicular tumor and nutritional prevention and treatment ◎ Nutritional treatment 1.Daily intake of fresh vegetables and fruits, which are rich in vitamins and chlorophyll, have strong anti-cancer effects. 2.Enoki mushroom, rich in various amino acids and nucleotides, has obvious anti-cancer effect and should be eaten more often. 3.Pectin, kelp and seaweed contain sodium algae, which are easily combined with carcinogenic substances and discharged from the body, and have strong anti-cancer effects, and should be eaten frequently. 4.Eating more garlic, which is rich in selenium, has a significant role in inhibiting genitourinary tumors. 5.Eat more foods rich in arginine, such as yam, ginkgo, eel, sea cucumber, cuttlefish and octopus. 6.Eating more carrots, cabbage, cucumber, peas, silver fungus, black fungus and beans is beneficial to the organism to inhibit cancer. [ Preparation ] Vervain washed and cut, and steamed with pork liver slices with seasoning. [ Effects ] Clearing heat and detoxifying, activating blood circulation and dispersing stagnation. [ Remark ] Use with caution for people with cold spleen and stomach. Fructus Ficus Dracaena stewed pork [ Ingredients ] 1~2 Fructus Ficus Dracaena, 100g lean pork, 100g winter melon. [ Preparation ] Split the fruit in half, add lean pork and winter melon to stew. [ Effects ] Promote blood circulation and replenish blood, clear heat and detoxify.