Testicular Cancer

Question 1

What kind of tumours are testicular tumours predominantly?

Answer 1

germ cell tumours.

Question 2

Where do other germ cell tumours commonly arise?

Answer 2

• retroperitoneum

- mediastinum

Question 3

What is the predominant age bracket for testicular cancer?

how many new cases every year

Answer 3

• 15 to 45 years old

- 2000 cases in the UK

Question 4

what is the risk factors?

Answer 4

• maldescent of the testes predisposes germ cell tumours
• testicular atrophy
• family history

Question 5

Describe the aetiology of the tumour

Answer 5

• pre-invasive lesion called an “intratubular germ cell neoplasia”
• when contralateral testis is small it should be biopsied
• treat with radiotherapy as it eventually turns into cancer

Question 6

1) Describe the histology in 60% of cases

2) Describe the histology of the other 40%

Answer 6

• Non-seminomatous germ cell tumours (NSGC1)
• Seminomas

Note that rare ones include combined (seminoma / non-seminoma), yolk sac tumours,

Question 7

where is the common spread of seminomas? and how?

Answer 7

• via lymphatics to para-aortic nodes (reflects the embryological origin from para-renal tissue)
• Blood borne spreads to lungs, liver, bone, brain

Question 8

How might the patient present?

Answer 8

• painless testicular swelling
• in metastasis:
  > cough/ dyspnoea due to lung mets
  > low- back pain due to para- aortic involvement

Question 9

What imaging/ bloods?

Answer 9

• testicular ultrasound mandatory (differentiates solid from fluid filled masses)
• beta- HCG and AFP

Question 10

which marker is raised in both seminomatous and non-seminomatous tumours?

Answer 10

• B-HCG (in 75% of patients)

- AFP only raised in presence of non- seminomatous elements

Question 11

What other marker can be used and how useful is it?

Answer 11

• Lactate dehydrogenase useful in assessing prognosis, response to treatment and detect relapse

Question 12

What kind of surgery should be done? and why?

Answer 12

• Orchidectomy done for diagnosis and therapy for localised disease

Question 13

Why would you do a biopsy of the other testicle? (2)

Answer 13

• cryptorchidism patients
• history of maldescent
  (increase risk of bilateral disease)

Question 14

What kind of imaging should be done?

Answer 14

• CT chest, abdo and pelvis

- usually done post- op

Question 15

Describe the staging system

Answer 15

Royal Mardsen staging system:

Stage 1- confined to testicle

Stage 2- involves para-aortic lymph nodes below diaphragm

Stage 3- involves para- aortic lymph nodes above diaphragm

Stage 4- involves visceral mets

Question 16

Why is the royal marsden grouping system not good?

Answer 16

• does not incorporate useful information from tumour markers
• led to formation of prognostic grouping

Question 17

Describe the IGCCC

Answer 17

• split into seminoma and non- seminoma
• Divided into good, medium and poor prognosis
• incorporating tumour markers, LDH, and the RMG staging system

Question 18

Describe the nature of germ cell tumours

Answer 18

• highly malignant with rapid growth and high metastatic potential
• generally chemo/ radiosensitive
• The clinical distinction between a seminoma and a tumour with non-seminomatous elements determines management

Question 19

What is the normal surgical protocol?

Answer 19

• Orchidectomy required for definitive treatment of localised disease
• should be performed via inguinal canal to stop spread through scrotal tissue planes

Question 20

In metastatic teratoma when is surgery performed?

Answer 20

• surgery performed after chemotherapy for resection of residual mass
• careful examination of edges is performed to see no tumour, removal prevents regrowth

Question 21

How is adjuvant chemotherapy given?

Answer 21

• Stage 1: carboplatin (seminoma), Non seminoma two cycles of BEP (Bleomycin, etoposide, cisplatin)
  some low risk patients for stage 1 do not have chemo
• 3-4 cycles of BEP are used in those with more extensive disease

Question 22

What is BEP?

Answer 22

Bleomycin, etoposide, cisplatin.

It is very intensive and gives expected rates of neutropenia

Question 23

What is the role of radiotherapy in testicular cancer?

Answer 23

• can be used in conjunction with adjuvant chemotherapy

- for malignant teratoma, radiotherapy to sites of bulky mets used in conjunction with chemotherapy

Question 24

Describe prognostic factors.

Answer 24

• bulky tumour sites carry a worse prognosis
  (the presence of pulmonary mets does not affect prognosis)
• presence of yolk sac/ vascular/ lymphatic invasion
• tumour markers (AFP BHCG and LDH associated with poor prognosis)