Testicles (Tes Deez Nuts)

Question 1

Anatomy and physiology

Answer 1

Produce sperm
External structure

Question 2

Epidemiology

Answer 2

Most common in 20-40 Year old. Seminoma in 25-40 yo, teratoma in 20-35yo
Wealthy social group
Environmental oestrogen exposure
Western incidence increasing
Decreasing mortality despite increased incidence

Question 3

Aetiology

Answer 3

Testicular cryptorchism - 5 times the risk if one is maldescended, 12 times the risk if both are
Early onset puberty/sexual activity
Reduced sperm count/ low fertility
Maternal smoking, vasectomy, testicular trauma, mumps orchitis
Family correlation, Caucasians, lack of exercise

Question 4

Patterns of spread

Answer 4

Local: epididymis and spermatic cord
Lymphatic: upper para-aortic nodes (level of renal hilum)->up: mediastinal and supra clavicular nodes
or -> down, lower para-aortic and pelvic nodes
Distant: brain - suprasellar or pineal gland, lung

Question 5

Histology

Answer 5

95% germ cell origin - 40% seminoma, 32% teratoma and 14% combination

5% non- germ cell - NHL, met deposits, leydig and sertoli tumours

Question 6

Staging

Answer 6

TNM, IGCCC prognostic grouping, royal marsden staging
Performed following orchiectomy

Question 7

RT treatment technique (fractions and beam arrangement)

Answer 7

Para-aortic +/- ipsilateral pelvic nodes
20-30Gy in 10-15#
Opposed pair - ant/post
Possible dogleg to include pelvic nodes
External shields for gonads

Question 8

RT setup

Answer 8

Supine, straight and level
Arms by sides/on chest
Headrest, knee bolster, foot stocks

Question 9

Clinical management

Answer 9

Surgery: orchiectomy - definitive for all tumours, performed via inguinal incision, spermatic cord removal. Late stage/non-germ cell: nodal dissemination

Surveillance - 80% cured by surgery alone, 20% relapse but 99% curable with salvage chemo

Question 10

Germ cell clinical management

Answer 10

Germ cell stages 1-3b: post-op RT
Germ cell stages beyond 3B: post-op chemo

Non-germ cell: post op chemo
Chemo Germ cell: BEP 3 cycles
NHL: CHOP 6 cycles

Question 11

CT simulation

Answer 11

Sup - mid thoracic (T10)
Inf- 5cm below scrotum

Question 12

OARs

Answer 12

• Lungs • Heart • GIT Gastro-intestinal Tract • Small bowel • Large Bowel • Spinal Cord • Kidneys • Contralateral testicle • Rectum • Prostate • Femoral heads/necks

Question 13

Imaging considerations

Answer 13

AP or PA EPI
First 3 days, then weekly

Question 14

Acute side effects and management

Answer 14

Nausea- antiemetic, zofran
Diarrhoea- imodium, dietary advice
Tiredness - rest
Immunosuppression - regular blood test

Question 15

Late side effects and management

Answer 15

Decrease in sperm count (2-3 years only)- pre-cautionary sperm banking
Psychosocial issues
Dyspepsia
Occasional peptic ulcer
Secondary cancer

Question 16

Signs and symptoms (primary and secondary)

Answer 16

Primary - palpable lump in testicle, dull ache or sharp pain, infertility

Secondary - back pain, abdominal and loin pain, haemoptysis from lung mets, neck lymphadenopathy, gynecomastia, loss of appetite and weight loss

Question 17

Complications of chemo

Answer 17

acute: pulmonary fibrosis, nephrotoxicity
late: tinnitus, hypertension, infertility

Question 17

Why are gonads shielded?

Answer 17

<50cGy can affect spermatogenesis

Question 18

Field size

Answer 18

Para-aortic nodes only:
top of T10 to L5
ISO at midline
8-10cm width

Para-aortic nodes plus pelvic nodes
top of t10 to bottom of obturator foramen