Testicular cancer

Question 1

List some DDx for a scrotal mass?

Answer 1

Benign:
- infective: orchitis (mumps, TB, syphilis), epididymis, syphalitic gumma
- mechanical: inguinal hernia, testicular torsion, torsion of appendix testis, torsion of appendix epididymis
- inflammatory: hydrocoele, haematocele, spermatocoele, scrotal oedema
- vascular: varicocele
- other: sebaceous cyst
Malignant:
- germ cell tumours (90%): seminoma or non-seminomatous (embryonal, teratoma, choriocarcinoma, yolk sac)
- non-germ cell tumours (sex cord stromal tumours)- Leydig, Sertoli

Question 2

What are some risk factors for testicular cancer?

Answer 2

Mostly non-modifiable

• androgen insensitivity
• testicular dysgenesis syndromes: hypospadias (penile urethra opening), cryptorchidism (undescended testes)
• abnormal testicular development- Klinefelter syndrome, Kallman syndrome
• infections: mumps orchitis, HIV infection
• FMHx (x4 father, x10 brother)
• PMHx testicular ca

Question 3

What investigations would you order?

Answer 3

Diagnostic:
- testicular US (hypoechoic tunica albuginea)
- inguinal orchiectomy (NOT FNA due to seeding tunica vaginalis)
Labs:
- FBC
- ESR/CRP
- EUC
- Coag
- Tumour markers (bHCG for choriocarcinomas and seminomas, AFP for yolk sac, LDH for germ cell tumours)
- Quantiferon Gold (TB)
- Venereal Disease Research Laboratory (VDRL)- syphilis
- Urine MCS and UA- acute epididymo-orchitis (chlamydia, gonorrhoea)
Imaging (staging, TNM)
- CXR- mets
- CT chest/abo/pelvis- mets, para-aortic LNs
- Bone scan

Question 4

Describe seminomas?

Answer 4

Seminomas:

• Epi: 30-35yo, >65yo, most common germ cell tumour (40%)
• path: germinal epithelium of seminiferous tubules, uniform growth
• tumour marker: bHCG 10%
• mets: localised, lymphatic spread (para-aortic) before haematogenous (lungs)
• prognosis: excellent, radiosensitive

Question 5

Describe embryonal tumours?

Answer 5

Embryonal

• Epi: 20-25yo, most common non-seminomatous (20%)
• path: bulky, haemorrhage, necrosis, poor differentiation
• tumour markers: AFP, bHCG
• mets: haematogenous then lymphatic
• prognosis: intermediate, less radiosensitive

Question 6

Describe teratomas?

Answer 6

Teratomas

• epi: all ages, 5% of non-seminomatous
• path: variable, cystic, from ectoderm/ endoderm/ mesoderm
• tumour markers: pure teratomas do not secrete
• mets: benign in children, malignant in adults (SCC)
• prognosis: good

Question 7

Describe yolk sac tumours?

Answer 7

Yolk sac tumours

• epi: most common testicular ca in <4yo
• path: Schiller-Duval bodies (resemble primitive glomeruli)
• tumour markers: AFP 100%
• prognosis: good

Question 8

Describe choriocarcinomas?

Answer 8

Choriocarcinomas

• epi: 20-30yo
• path: trophoblastic tissue (syncitiotrophoblast and cytotrophoblast), may produce gynaecomastia (bHCG)
• tumour marker: bHCG 100%
• mets: most aggressive, haematogenous to lungs
• prognosis: poor