Testicular Cancer Flashcards
Who is commonly affected by testicular cancer?
Testicular cancer is most common cancer in males aged 20-40yrs, with those of Caucasian and Northern European descent at highest risk.
Briefly describe the classification of testicular cancer
Primary testicular tumours are categorised into germ cell tumours (GCT) (95%) and non-germ cell tumours (NGCTs) (5%).
GCTs can be further sub-classified into seminomas and non-seminomatous GCTs (NSGCT), and are usually malignant.
NGCTs are usually benign, comprising of either Leydig cell tumors or Sertoli cell tumors*.
What are the risk factors for testicular cancer?
Cryptorchidism (undescended testes) is associated with a 4-10x higher risk of GCTs. Other risk factors include previous testicular malignancy, a positive family history, and Kleinfelter’s syndrome.
What are the clinical features of testicular cancer?
Patients will present with a unilateral painless testicular lump. On examination, the mass is typically irregular, firm, fixed, and does not transilluminate.
Evidence of metastasis may present with weight loss, back pain (from retroperitoneal metastases), or dyspnoea (secondary to lung metastases).
Which nodes to the testes drain to?
Lymphatic drainage of the testes is to the para-aortic nodes.
What investigations should be ordered for testicular cancer?
For patients with suspected cases of testicular cancer, tumour markers can be used for both diagnostic and prognostic means. ßHCG is elevated in 60% of NSGCTs and 15% of seminomas, whilst AFP can be raised in some NSGCTs as well. LDH can also be used as a surrogate marker for tumour volume.
Scrotal ultrasound should be used in the initial assessment of scrotal lumps, alongside concurrent tumour markers. The disease will then be staged via CT imaging with contrast of the chest-abdomen-pelvis.
Crucially, a trans-scrotal percutaneous biopsy should not be performed, as it might cause seeding of the cancer. Diagnosis is made through tumour marker and imaging alone.
Briefly describe The Royal Marsden Classification of testicular cancers
I: disease confined to testes
II: infra-diaphragmatic lymph node involvement
III: supra- and infra-diaphragmatic lymph node involvement
IV: extralymphatic metastatic spread
Briefly describe the management of testicular cancer
All patients with confirmed testicular cancer he should be discussed in a specialist MDT. The main treatment options for testicular cancer are surgery, radiotherapy and chemotherapy; the treatment of choice depends on the tumour type, risk scoring, and prognosis.
Most cases suitable for surgery will undergo an inguinal radical orchidectomy. This removes the testes along with the spermatic cord, allowing for maximal lymphatic system to be removed.
How does testicular cancer and its treatment affect fertility?
Sperm abnormalities and Leydig cell dysfunction are frequently found in patients with testicular cancer prior to orchiectomy. Furthermore, chemotherapy and radiation treatment can additionally impair fertility. Therefore, in patients in the reproductive age group, pre-treatment fertility assessment should be performed, and semen analysis and cryopreservation offered accordingly.
Briefly describe the treatment for Non-Seminomatous Germ Cell Tumours
Stage 1 NSGCTs will require orchidectomy then further managed dependent on their risk score. Low risk patients without any evidence of vascular invasion can routinely enter just surveillance, whilst high risk patients or those with vascular invasion require adjuvant chemotherapy (typically cisplatin, etoposide, bleomycin) and then surveillance.
Metastatic NSGCTs management is also dependent on risk scoring. Cases with intermediate prognosis should be treated with cycles of chemotherapy, whilst those with poor prognosis should be treated with one cycle of chemotherapy before reassessment (those with marker decline should have continued chemotherapy cycles, whilst those with unfavourable decline should have their chemotherapy intensified).
Briefly describe the treatment of Seminomas
Stage 1 seminoma can often be managed with orchidectomy alone and surveillance monitoring. Patients have a high relapse risk are often considered for chemotherapy.
For metastatic seminoma, stage IIA can be treated with either radiotherapy or chemotherapy, whilst higher stage disease will require primary chemotherapy and treated similar to metastatic NSGCTs.
What are the complications of testicular cancer?
Radiotherapy and chemotherapy often carry an associated risk of secondary malignancies, such as leukaemia.
Prognosis of the disease depends on the tumour type and stage. However, fortunately the condition overall has a high rate of complete remission.
What differentials should be considered for testicular cancer?
Differentials for a scrotal lump include epididymal cyst, haematoma, epididymitis or hydrocoele.
