Testicular Cancer

Question 1

… cancer is responsible for 1% of all new cancers in men.

Answer 1

Testicular cancer is responsible for 1% of all new cancers in men.

Question 2

Testicular cancer is responsible for ….% of all new cancers in men.

Answer 2

Testicular cancer is responsible for 1% of all new cancers in men.

Question 3

Testicular cancer typically presents with a unilateral testicular mass. Incidence appears to be increasing, with approximately 3-10 cases / 100,000 men each year in the Western world.

Answer 3

Testicular cancer typically presents with a unilateral testicular mass. Incidence appears to be increasing, with approximately 3-10 cases / 100,000 men each year in the Western world.

Question 4

The vast majority of testicular cancers are …

Answer 4

The vast majority of testicular cancers are germ-cell tumours (95%). Overall prognosis, following appropriate therapy, is good.

Question 5

Incidence of testicular cancer - when is the peak age?

Answer 5

Incidence rises in adolescence, peaks between the ages of 30-34, before falling significantly over the subsequent decades. There is a small rise in incidence over the age of 90.

Question 6

There are a number of risk factors associated with testicular cancer (5)

Answer 6

Cryptorchidism
Hypospadias
Infertility
Klinefelter’s syndrome
Tall men

Question 7

Testicular germ cell tumours can be classified as …. and …-… germ cell tumours.

Answer 7

Testicular germ cell tumours can be classified as seminoma and non-seminomatous germ cell tumours.

Question 8

The vast majority of testicular tumours are … … in origin (95%).

Answer 8

The vast majority of testicular tumours are germ cell in origin (95%). The two major types are seminoma and non-seminomatous germ cell tumours. Other tumour types are also seen, but these are far less common.

Question 9

Germ cell tumours types

Answer 9

Seminoma
Non-seminomatous germ cell tumours (NSGCT):
- Embryonal carcinoma
- Yolk sac tumour
- Choriocarcinoma
- Teratoma
Mixed

Question 10

Sex cord/gonadal stromal tumours - types

Answer 10

Leydig cell tumour
Sertoli cell tumour
Granulosa cell tumour
Thecoma/fibroma group of tumours

Question 11

Testicular cancer most commonly presents with a … … mass.

Answer 11

Testicular cancer most commonly presents with a unilateral scrotal mass.

Question 12

Clinical features are typically scrotal, but systemic features may be seen:

Answer 12

Testicular …
Testicular …/…
… pain, … pain (indicative of …)
….denopathy
…. (more common in NSGCT)

Question 13

Cases of suspected testicular cancer should be referred urgently via a … week wait pathway

Answer 13

Cases of suspected testicular cancer should be referred urgently via a two-week wait pathway.

Question 14

NICE NG 12 recommends referring all men with … … or change in size or change in texture via a two-week wait pathway to urology. Additionally refer patients describing a dragging sensation, new varicocele or hydrocele.

Answer 14

NICE NG 12 recommends referring all men with non-painful testicular enlargement or change in size or change in texture via a two-week wait pathway to urology. Additionally refer patients describing a dragging sensation, new varicocele or hydrocele.

Question 15

Suspect testicular cancer in patients with unexplained retroperitoneal masses or suspected … on imaging. Also suspect in men presenting with infertility or with elevated AFP / ….

Answer 15

Suspect testicular cancer in patients with unexplained retroperitoneal masses or suspected metastasis on imaging. Also suspect in men presenting with infertility or with elevated AFP / hCG.

Question 16

Testicular … is the diagnostic modality of choice for testicular cancer

Answer 16

Testicular USS is the diagnostic modality of choice for testicular cancer

Question 17

USS offers excellent visualisation and identifies likely malignant lesions (the diagnosis is confirmed with histology following an …). Its sensitivity approaches 100% in trained hands.

Answer 17

USS offers excellent visualisation and identifies likely malignant lesions (the diagnosis is confirmed with histology following an orchidectomy). Its sensitivity approaches 100% in trained hands.

Question 18

Bloods before an orchidectomy

Answer 18

• FBC
• Renal function
• LFT

Question 19

Imaging before testicular cancer diagnosis

Answer 19

CXR: may identify pulmonary metastasis.

Question 20

In testicular cancer, tumour markers may be measured to support the diagnosis and offer prognostic information. However, normal levels do not exclude cancer and levels may be elevated in other pathologies. The three major markers are:

Answer 20

Alpha-fetoprotein (AFP): may be seen in NSGCT, particularly the yolk sac subtype. AFP is not seen in pure seminoma.
Beta-human chorionic gonadotrophin (beta-hCG): may be seen in NSGCT, particularly the choriocarcinoma subtype. Can also be seen in seminomas.
Lactate dehydrogenase (LDH): general marker of increased cell turnover, may be raised in either seminomas or NSGCTs.

Question 21

Placental alkaline phosphatase may also be measured and is indicative of … (testicular cancer)

Answer 21

Placental alkaline phosphatase may also be measured and is indicative of seminoma.

Question 22

… should be discussed with patients prior orchidectomy.

Answer 22

Fertility should be discussed with patients prior orchidectomy.

Question 23

Testicular cancer two types

Answer 23

Seminomas

Non-seminomas (mostly teratomas)

Question 24

Risk Factors for testicular cancer (4)

Answer 24

Undescended testes
Male infertility
Family history
Increased height

Question 25

Testicular cancer The typical presentation is a painless lump on the testicle. Occasionally it can present with testicular pain. The lump will be:

Answer 25

``` Non-tender (or even reduced sensation) Arising from testicle Hard Irregular Not fluctuant No transillumination ```

Question 26

Rarely, gynaecomastia (breast enlargement) can be a presentation of testicular cancer, particularly a rare type of tumour called a … cell tumour. About 2% of patients presenting with gynaecomastia have a testicular tumour.

Answer 26

Rarely, gynaecomastia (breast enlargement) can be a presentation of testicular cancer, particularly a rare type of tumour called a Leydig cell tumour. About 2% of patients presenting with gynaecomastia have a testicular tumour.

Question 27

Scrotal ultrasound is the usual initial investigation to confirm the diagnosis. Tumour markers for testicular cancer are:

Answer 27

``` Alpha-fetoprotein – may be raised in teratomas (not in pure seminomas) Beta-hCG – may be raised in both teratomas and seminomas Lactate dehydrogenase (LDH) is a very non-specific tumour marker ```

Question 28

Testicular cancer is staged with the Royal Marsden staging system:

Answer 28

Stage 1 – isolated to the testicle Stage 2 – spread to the retroperitoneal lymph nodes Stage 3 – spread to the lymph nodes above the diaphragm Stage 4 – metastasised to other organs

Question 29

The common places for testicular cancer to metastasise to are:

Answer 29

Lymphatics Lungs Liver Brain

Question 30

Management of any cancer is guided by a multidisciplinary team (MDT) meeting to decide the best course of action for the individual patient. Depending on the grade and stage of testicular cancer, treatment can involve:

Answer 30

Surgery to remove the affected testicle (radical orchidectomy) – a prosthesis can be inserted Chemotherapy Radiotherapy Sperm banking to save sperm for future use, as treatment may cause infertility

Question 31

Long term side effects of treatment are particularly significant, as most patients are young and expected to live many years after treatment of testicular cancer. Side effects include:

Answer 31

``` Infertility Hypogonadism (testosterone replacement may be required) Peripheral neuropathy Hearing loss Lasting kidney, liver or heart damage Increased risk of cancer in the future ```

Question 32

The prognosis for early testicular cancer is…

Answer 32

The prognosis for early testicular cancer is good, with a greater than 90% cure rate. Metastatic disease is also often curable. Seminomas have a slightly better prognosis than non-seminomas. Patients will require follow-up to monitor for reoccurrence. This usually involves monitoring tumour markers, and may include imaging such as CT scans or chest x-rays.

Question 33

Seminomas vs non seminomas - which has a better prognosis

Answer 33

Seminomas have a slightly better prognosis than non-seminomas.

Question 34

Common pulmonary manifestation of metastatic choriocarcinoma on imaging is … metastases.

Answer 34

Common pulmonary manifestation of metastatic choriocarcinoma on imaging is cannonball metastases. They typically appear as multiple round well-defined pulmonary nodules representing hematological spread of the malignancy.