Testicular Cancer

Question 1

Epidemiology

Answer 1

Most common cancer in males aged 20-40y

Caucasian and Northern European at highest risk

Question 2

Categories

Answer 2

Germ cell tumours (95%) and non-germ cell tumours (NGCTs, 5%)

Question 3

GCT divisions

Answer 3

Seminomas

Non-seminomatous GCTs

Both are usually malignant

Question 4

NGCTs division

Answer 4

Usually benign

Leydig cell tumours (oestrogen)

Sertoli cell tumours (testosterone)

Question 5

Positive thing about seminomas

Answer 5

Tend to remain localised until late and have a very good prognosis

Question 6

NSGCT division

Answer 6

Yolk sac tumours

Choriocarcinomas

Embryonal carcinomas

Teratomas

Often metastasise early and have worse prognosis than seminomas

Question 7

Risk factors

Answer 7

Cryptoorchidism 4-10x higher risk of GCTs

Previous testicular malignancy

+ve FH

Kleinfelter’s syndrome

Question 8

Clinical features

Answer 8

Unilateral painless testicular lump

Irregular, firm, fixed

Doesnt transilluminate

Metastasis might show weight loss, back pain or dyspnoae

Question 9

Lymphatic drainage of the testes

Answer 9

Para-aortic nodes

This means that localised lymphadenopathy may not be present even in metatstaic disease

Question 10

Differentials

Answer 10

Epididymal cyst

Haematoma

Epididymitis

Hydrocoele

Question 11

Investigations

Answer 11

Tumours markers

beta-HCG in 60% of NSGCTs and 15% of seminomas

AFP can be raised in some NSGCTs as well

LDH can also be a marker for tumour volume

Question 12

Imaging

Answer 12

Scrotal ultrasound

Staging by CT chest-abdo-pelvis with contrast

Question 13

When should trans-scrotal percutaneous biopsy be done?

Answer 13

Shouldnt be done

It can cause seeding

Question 14

Staging of testicular cancer

Answer 14

Royal Marsden Classification

Question 15

Explain Royal Marsden

Answer 15

I - Disease confined to testis

II - Infra-diaphragmatic LN involvement

III - Supra and infra-diaphragmatic LN involvement

IV - Extralymphatic metastatic spread

Question 16

General management

Answer 16

Specialist MDT

Either surgery, radiotherapy or chemo or a combination of them.

Question 17

Treatment of Stage I NSGCTs

Answer 17

Orchidectomy and further management dependent on risk score.

Low risk with no vascular invasion -> Surveillance

High risk -> Adjuvant chemo of cisplatin, etoposide, bleomycin and then surveillance.

Question 18

Treatment of metastatic NSGCTs

Answer 18

Dependent on risk scoring

Cycles of chemotherapy if intermediate

Poor prognosis -> One cycle of chemo before reassessment, might need intensification.

Question 19

Treatment of stage 1 seminomas.

Answer 19

Often with orchidectomy alone and surveillance

If there is a high risk of relapse consider doing chemo.

Question 20

Treatment of metastatic seminoma.

Answer 20

Stage IIA can be treated either with radiotherapy or chemotherapy

Higher stage require primary chemo and treated similar to metastatic NSGCTs

Question 21

What should be done before orchidectomy?

Answer 21

Since sperm abnormalities and Leydic cell dysfunction can ensue you should do a pre-treatment fertility assessment.

Semen analysis

Cryopreservation should be offered as well

Question 22

Complications

Answer 22

Risk of secondary malignancies like leukaemia from radiotherapy and chemo.