Testicular cancer

Question 1

Testicular cancer arises from the?

Answer 1

germ cells in the testes. Germ cells are cells that produce gametes (sperm in males). There are other, rare tumours in the testes, such as non-germ cell tumours and secondary metastases.

Question 2

Testicular cancer is more common?

Answer 2

in younger men, with the highest incidence between 15 and 35 years.

Question 3

Testicular cancer can be divided into two types:

Answer 3

Seminomas
Non-seminomas (mostly teratomas)

Question 4

Risk Factors

Answer 4

Undescended testes
Male infertility
Family history
Increased height

Question 5

Presentation of testicular cancer

Answer 5

The typical presentation is a painless lump on the testicle. Occasionally it can present with testicular pain.

The lump will be:

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

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 6

Investigations

Answer 6

Scrotal ultrasound is the usual initial investigation to confirm the diagnosis.

Tumour markers for testicular cancer are:

• 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

A staging CT scan can be used to look for areas of spread and to stage the cancer.

Question 7

Testicular cancer is staged with the Royal Marsden staging system:

Answer 7

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 8

The common places for testicular cancer to metastasise to are:

Answer 8

Lymphatics
Lungs
Liver
Brain

Question 9

Depending on the grade and stage of testicular cancer, treatment can involve:

Answer 9

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 10

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 10

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 11

Prognosis

Answer 11

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.