- Commonest malignancy in young men
- Highest incidence in caucasians in northern Europe and USA
- 1400 new cases per year in UK
- Peak incidence for teratomas is 25 years and seminomas is 35 years
- In those with disease localised to testis more than 95% 5 year
survival possible
- Risk factors include cryptorchidism, testicular maldescent and
Klinefelter's syndrome
Classification
- British Testicular Tumour Panel Classification
- Seminomas (~40%)
- Teratomas (~50%)
- Teratoma differentiated
- Malignant teratoma intermediate
- Malignant teratoma undifferentiated
- Malignant teratoma trophoblastic
- Yolk sac tumours
Presentation
- Usually present with testicular swelling or mass
- Amount of pain is variable, but, often they are painless
- May present with gynaecomastia due to betaHCG production
- May present with symptoms of metastatic disease
- Seminomas metastasize to para-aortic nodes and produce back pain
- Teratomas under go blood borne spread to liver, lung, bone and brain
Investigation
- Diagnosis can often be confirmed by testicular ultrasound
- Pathological diagnosis made by performing an inguinal orchidectomy
- Disease can be staged by thoraco-abdominal CT scanning
- Tumour markers are useful in staging and assessing response to
treatment
- Alpha-fetoprotein (alphaFP)
- Produced by yolk sac elements
- Not produced by seminomas
- Beta-human chorionic gonadotrophin (betaHCG)
- Produced by trophoblastic elements
- Elevated levels seen in both teratomas and seminoma
Royal Marsden staging of testicular tumours
| Stage |
Definition |
|
| I |
Disease confined to testis |
|
| IM |
Rising post-orchidectomy tumour
marker |
|
| II |
Abdominal lymphadenopathy |
A < 2 cm |
|
|
B 2-5 cm |
|
|
C > 5 cm |
| III |
Supra-diaphragmatic disease |
No abdominal disease |
|
|
A, B, C Abdominal nodal disease |
| IV |
Extra-lymphatic metastases |
|
| L1 |
< 3 lung metastases |
|
| L2 |
> 3 lung metastases |
|
| L3 |
> 3 lung metastases 1 or more >2 cm |
|
| H+ |
Liver involvement |
|
Management
Primary orchidectomy
- Initial surgical treatment is radical inguinal orchidectomy in most
cases
- Spermatic cord is divided at deep ring before testis is mobilised
- Testis-preserving surgery may be possible or needed in some cases
- Synchronous bilateral tumours
- Tumours in single testes
- Testis preservation is only possible in tumours less than 2 cm
Contralateral intra-tubular germ-cell neoplasia
- Occurs in 5% men presenting with testicular cancers
- High risk of progression to invasive cancer
- Treated by irradiation of testis
- Patients should be offered storage of semen
- Has been recommended that patients should undergo contralateral
testicular biopsies
- High risk patients include
- Testicular maldescent
- Testicular atrophy
- Age less than 30 years
Seminomas
- Seminomas are radiosensitive
- Stage I and II disease treated by inguinal orchidectomy plus
- Radiotherapy to ipsilateral abdominal and pelvic nodes ('Dog leg')
or
- Surveillance
- Stage IIC and above treated with chemotherapy
Teratomas
- Teratomas are not radiosensitive
- Stage I disease treated by orchidectomy and surveillance
- Chemotherapy (BEP = Bleomycin, Etopiside, Cisplatin) given to:
- Stage I patients who relapse
- Metastatic disease at presentation
Bibliography
Carver B S, Sheinfeld J. Germ cell tumours of the testis.
Ann Surg Oncol 2005; 44: 529-534.
Hall M, Rustin G J S.
Testicular tumour management.
In: Johnson C D,
Taylor I eds.
Recent advances in surgery 22.
Churchill Livingstone 1999:
173-186.
Horwich A, Shipley J, Huddart R. Testicular germ-cell
cancer. Lancet 2006; 367: 754-765.
Lee F, Hamid R, Arya M, Patel H R. Testicular
cancer: current update and controversies. Hosp Med
2002: 63; 615-620.
Oosterhof G O, Verlind J. Testicular tumours
(non-seminomatous). BJU Int 2004; 94: 1196-1201
Wilkins M, Horwich A.
Diagnosis and treatment of urological malignancy: the testes. Br J Hosp Med 1996;
55: 199-203. |