Testicular Cancers

Ashray GunjurIntern, Royal Melbourne Hospital

Did you know?

• That the words testify, testimonial and testament are derived from...

Anatomy

http://www.aboutcancer.com/testicle_anatomy1.jpg

Differentials

HISTORY?* Pain??* Time course of symptoms?

PHYSICAL EXAM?* pain?* reducibility?* Lie of teste?

Differentials

Toronto Notes 2010

Differentials

• 1) Hydrocele

Differentials

• 2) Epidydymal cyst/Spermatocele

Differential

• 3) Varicocele

Typical case

• Young man with painless growth of unilateral teste

• On examniation, firm nontender, non-transilluminating mass in one of the testes

Epidemiology

• Relatively rare- 1-2% of men, but..• Most common malignancy in age 20-40• Three peak model: infancy, 30-34 years, >60

years

Risk factors

• Cryptorchidism- 4-8x risk of germ cell tumour– Risk still increased after orchiopexy in pt <6yrs old-

2.23x*– Risk still increased in contralateral testis- 5-20% of

malignancy in normal descended testis!• Prior testicular cancer- 500x– Approx 1-2% of testicular cancer patients will

develop a second primary contralaterally...

*Pettersson A, Richiardi L, Nordenskjold A, Kaijser M, Akre O. Age at surgery for undescended testis and risk of testicular cancer. N Engl J Med. May 3 2007;356(18):1835-41

Risk factors

• Genetics– E.g. Klinefelter syndrom (47XXY)- germ cell

tumours• Diethylstilbestrol (DES) exposure in utero– E.g. ‘Agent Orange’, Industrial occupation

Diagnosis

• Best first testhypoechoic lesion

Diagnosis

• Gold standard?

- inguinal orchidectomy!!

Histologic types

Germ cell tumors (>95%):Seminoma (40%) versus Non seminomatous germ

cell tumors (NSGCT) (40%) vs. mixed (15%)

Non-germ cell tumors (rare, <5%)Leydig cell tumors (precocious puberty)Sertoli cell tumors Mixed sex chord-stromal tumors

Germ cell tumours

• Seminoma (40%)– Generally favourable prognosis, tend to be in older men– Rarely make B-HCG (15%), no aFP (0%)

• Non-seminoma (40%)– Choriocarcinoma

(elevated b-HCG (50%), haematogenous spread)– Embryonal cell– Teratoma (mature and immature)– Yolk sac

(elevated AFP)

Tumour markers

• AFP levels are elevated 50%-70% NSGCT• hCG levels are elevated in 40%-60% NSGCT. • AFP has a half-life of 5-7 days• hCG has a half-life of 36 hours. • Important to follow response after

orchiectomy• LDH is non-specific measure of tumor burden

Risk stratification• Good-risk nonseminoma• Testicular or retroperitoneal primary tumor, and• No nonpulmonary visceral metastases, and• Good markers; all of:Alpha-fetoprotein (AFP) < 1,000 ng/mL, and• Human chorionic gonadotropin (hCG) < 5,000 IU/mL (1,000 ng/mL), and• Lactate dehydrogenase (LDH) < 1.5 times the upper limit of normal

• Intermediate-risk nonseminoma• Testicular or retroperitoneal primary tumor, and• No nonpulmonary visceral metastases, and• Intermediate markers; any of:AFP 1,000 to 10,000 ng/mL, or• hCG 5,000 IU/L to 50,000 IU/L, or• LDH 1.5 to 10 times the upper limit of normal

• Poor-risk nonseminoma• Mediastinal primary, or• Nonpulmonary visceral metastases, or• Poor markers; any of:AFP > 10,000 ng/mL, or• hCG > 50,000 IU/mL (10,000 ng/mL), or• LDH > 10 times the upper limit of normal

Risk stratification

• Good-risk seminoma• Any primary site, and• No nonpulmonary visceral metastases, and• Normal AFP, any hCG, any LDH• Intermediate-risk seminoma• Any primary site, and• Nonpulmonary visceral metastases, and• Normal AFP, any hCG, any LDH• Poor-risk seminoma• No such thing!!

TreatmentPost Orchidectomy…

SeminomaStage IA and B: radiation therapy vs surveillance (? Chemo)NSGCTStage IAretroperitoneal lymph node dissection vs surveillanceStage IBretroperitoneal lymph node dissection vs surveillance vs

chemotherapy

Higher stages-chemo, f/b surgery as needed

Retroperitoneal Lymph Node Dissection

Why?

• Non-seminomas are more aggressive than seminomas

• RPLND is used to guide chemotherapy– No of +ive nodes correlates to cycles of chemo

Surveillance

NCCN guidelines• CT q 2-3 months for first year or two• Then q4, q6• Labs, CXR q month for year one, then q 2

months, etc

• Issues are compliance, anxiety

Question 1

The most common presenting complaint for a testicular cancer is:

a) a painless swelling of a single testeb) a red, painful scrotumc) haematuriad) back pain

Question 2

• All of the following are a risk factor for testicular cancers, save

a) Cryptorchidismb) Maternal DES exposurec) Caucasian raced) Repeated testicular trauma

Question 3

The following statements are false, savea) Testicular cancer is the most common cancer of

infancyb) There are more men aged 15-25 diagnosed with

testicular cancer than >50c) Unilateral surgical orchidectomy precludes the

chance of testicular cancer recurringd) Unilateral surgical orchidectomy is the gold

standard diagnostic procedure for testicular cancer

Question 4

Routine workup and staging of diagnosed testicular cancer should include:

a) a-FPb) B-HcGc) CT A/P + Cd) PET scan

Question 5

The following are incorrect about Seminomas, save

a) Ultrasound features often involve heterogenous cystic components

b) aFP is often raised and used for prognostication

c) Para-aortic radiotherapy is often indicatedd) Patients with metastatic disease have a poor

prognosiss