Testicular Cancers
Ashray Gunjur
Intern, 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, nontransilluminating 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 old2.23x*
– 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 test
hypoechoic 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
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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
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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
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•
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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
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•
•
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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
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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!!
Treatment
Post Orchidectomy…
Seminoma
Stage IA and B:
radiation therapy vs surveillance (? Chemo)
NSGCT
Stage IA
retroperitoneal lymph node dissection vs surveillance
Stage IB
retroperitoneal 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 teste
b) a red, painful scrotum
c) haematuria
d) back pain
Question 2
• All of the following are a risk factor for
testicular cancers, save
a) Cryptorchidism
b) Maternal DES exposure
c) Caucasian race
d) Repeated testicular trauma
Question 3
The following statements are false, save
a) Testicular cancer is the most common cancer of
infancy
b) There are more men aged 15-25 diagnosed with
testicular cancer than >50
c) Unilateral surgical orchidectomy precludes the
chance of testicular cancer recurring
d) 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-FP
b) B-HcG
c) CT A/P + C
d) 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 indicated
d) Patients with metastatic disease have a poor
prognosiss