4: Testicular & Penile Cancer

Question 1

what is the epidemiology of testicular cancer

Answer 1

• most common in ages 15-45
• Caucasian and Northern European at highest risk

Question 2

how are primary testicular tumours categorised

Answer 2

• germ cells (GCT) 95%
• non germ cell (NGCT) 5%

Question 3

how are GCTs further categorised

Answer 3

• seminom
• non-seminomatous (NSGCT)
• usually malignant

Question 4

what are the characteristics of NGCTs

Answer 4

• usually benign
• Leydig or Sertoli cell tumours
• seminomas remain localised until late and have v good prognosis
• NSGCTs metastasise early and have worse prognosis

Question 5

what are examples of NSGCTs

Answer 5

• yolk sac tumours
• choriocarcinoma
• embyronal carcinoma
• teratoma

Question 6

what are risk factors of testicular cancer

Answer 6

• cryptorchidism
• previous malignancy
• positive FHx
• Kleinfelter’s

Question 7

what is the typical presentation of testicular cancer

Answer 7

• unilateral painless testicular lump which is typically irregular, firm, fixed and does not transilluminate
• systemic symtpoms if metastatic e.g. weight loss, back pain or dyspnoea

Question 8

what are the key investigations in testicular cancer

Answer 8

• tumour markers
• scrotal ultrasound ! then CT w contrast of chest-abdo-pelvis for staging

Question 9

what tumour markers would you be looking for in testicular cancer (3)

Answer 9

• AFP: raised in some NSGCTs but not in pure seminoma
• BHCG: elevated in 60% NSGCTs and 10% pure seminoma
• LDH: surrogate marker for tumour volume and necrosis + response to oncological treatment

Question 10

what investigation would NOT be performed in testicular cancer and why

Answer 10

trans-scrotal percutaneous biopsy as it might cause seeding of the cancer

Question 11

how is testicular cancer staged

Answer 11

Royal Marsden

Question 12

what is the prognosis of testicular cancer

Answer 12

98% 5 year survival
- majority cured even w metastatic disease

Question 13

what is the treatment of testicular cancer

Answer 13

• inguinal radical orchidectomy: allows for limited lymphatic disruption
• if high-volume metastatic disease then upfront chemo (sperm banking and testicular prosthesis insertion)
• retroperitoneal lymph node dissesction for residual NSGCT masses after chemo

Question 14

what is penile cancer strongly associated with

Answer 14

HPV 16,6,18

Question 15

what is the most common penile malignancy

Answer 15

squamous cell carcinoma (SCC) arising from epithelium of inner prepuce/glans
- others e.g. basal cell, sarcoma, melanoma, urethral carcinoma

Question 16

what are risk factors of penile cancer

Answer 16

• HPV
• phimosis
• smoking
• lichen sclerosis
• untreated HIV

Question 17

how does penile cancer present

Answer 17

• palpable or ulcerating lesion on penis
• commonly on glans
• typically painless but can produce discharge and prone to bleeding
• inguinal lymphadenopathy present 30-60%

Question 18

what investigations are necessary in penile cancer

Answer 18

• refer to specialist centre
• penile biopsy
• PET-CT imaging and CT chest-abdo-pelvis for complete staging

Question 19

how is superficial non-invasive penile cancer treated

Answer 19

topical chemo e.g. F-fluorouracil
- laser treatment or glans resurfacing

Question 20

how are most cases of penile cancer managed

Answer 20

surgical
- invasive disease confined to glans: organ sparing treatment e.g. local excision, partial glansectomy or total w reconstruction
- total penectomy w perineal urethrostomy +/- neoadjuvant RT or chemo
- inguinal node involvement may need radical inguinal lymphadenectomy

Question 21

describe the pattern of penile cancer metastasis

Answer 21

inguinal lymph nodes –> pelvic lymph nodes