Testicular cancer Flashcards
What is the aetiology of testicular cancer?
Congenital -all germ cell tumours are believed to start during fetal development and progress through non-invasive (carcinoma in situ) stage to eventual malignant growth
Environmental - trauma, hormones, atrophy
Genetic - gain of chromosomal arm 12p
What are the risk factors for testicular cancer?
- Age
- Teratomas 20-35yrs
- Seminomas 35-45yrs
- Lymphoma >60yrs
- Yolk sac tumour rare <10yrs
- Cryptorchidism - x3-14 risk; 5-10% develop cancer in contralateral testicle (descended)
- FH
- White ethnicity 3:1
- HIV infection - x5 risk
Other:
- Gonadal dysgenesis
- Testicular atrophy - secondary to trauma/hormones/viral orchitis etc
- Chemical carcinogens and low sperm count - pesticides, gasoline
- Inguinal hernia
- Genetic abnormality of Chr12
How common is testicular cancer? Who is most affected?
Most common malignancy in young men (20-34yrs) but rare overall (<1% of all cancer incidence and <1% of all cancer deaths)
White ethnicity x3 risk compared to black men
Highly curable when diagnosed early
What are the two main types of (primary) testicular cancer?
Germ Cell (90-95% of all cancers of the testis)
- Seminoma (56%)
- Non-seminomatous e.g. embryonal carcinoma, teratoma, teratocarcinoma, choriocarcinoma, Yolk sac tumour.
Non-Germ Cell (5-10%) - e.f. leydig cell, gonadoblastoma, adenocarcinoma, carcinoid, mesenchymal, adrenal rest
How does testicular cancer present?
Testicular mass - usually right (55%), painless in >85%, 2% have bilateral masses. May be painful swelling if infection/haemorrhage of the mass occurs.
Extratesticular manifestation (5-10%)
- Bone pain - skeletal metastases
- Lower extremity swelling (venous occlusion)
- Supraclavicular lymph nodes
- Symptoms +/- signs or hypertrophy
- Gynaecomastia
- Lumbar back pain - involvement of psoas muscles and nerve roots
- Neurological - spinal cord and cerebral metastases
Painful mass is more likely to be infectious.
What investigations would you do for testicular cancer?
Initially:
- Bloods - FBC, U&Es, AFP, bhCG, LDH
- Ultrasound (colour Doppler)– urgent on same day; does not exclude cancer
- Urine dip
Later: once referred to urology
- CXR - same day, assesses for metastases and if positive then CT.
- Orchidectomy - inguinal approach; then sent for histology. Move towards partial orchidectomies now.
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NB: Serum tumour markers – beta-hCG, (alpha-fetoprotein) AFP, (lactate dehydrogenase) LDH are diagnostic of the disease.
- b-hCG - choriocarcinomas
- AFP -embryonal carcinoma, teratoma, yolk sac tumours. Return to normal in 35days post-surgery.
- LDH - elevated in 50% of cases
The diagnosis of testicular cancer is generally established by removing and examining the involved testicle (orchiectomy) after obtaining serum tumour markers. Orchiectomy is essential at all stages of the disease.
How are the testicles taken out in testicular cancer and why?
Inguinal approach to prevent spreading cancer cells to different lymphatic drainage sites
Which tumour markers are important to test for and why?
Test to monitor treatment
AFP = 50-70% of NSGCT (normal is <10ng/mL)
hCG = 40% teratomas, ALL choriocarcinomas, 10% seminoma (normal is <5mIU/mL)
LDH - elevated in 20% seminomas
Why might testicular cancer cause gynaecomastia?
Some testicular malignancies produce beta human chorionic gonadotrophin (beta-hCG), which leads to gynaecomastia.
When do seminomas vs teratomas occur?
Teratomas more common at ages 20 – 35 while Seminomas are more common at ages 30 -45 years.
Which marker is most likely found in teratoma?
AFP - 50-70% of teratomas produce AFP
hCG is produced by 100% choricarcinomas and 40% teratomas.
What is the management of a teratoma/NSGCT?
Non-metastatic:
- Radical removal of testes by inguinal (not scrotal) incision to prevent seeding of tumour
- AND Surveillance OR adjuvant chemotherapy (platinum based*)
Metastatic:
- Cryptorchidectomy
- Chemotherapy
- +/- Retroperitoneal LN dissection
*E.g. “BEP” - bleomycin, etopiside, cisplatin.
What is the management of seminoma testicular tumours?
Non-metastatic:
- Orchidectomy
- Surveillance OR Adjuvant chemotherapy
Metastatic:
- Orchidectomy
- Chemotherapy
- +/- RPLND if N3 or M1+
What is the management of testicular cancer?
- Counselling
- Sperm banking
- Prosthesis (does the patient want one?) - can be inserted at time of orchidectomy
- NB: radiotherapy not often used as adjunct because it causes a lot of scarring which makes future surgery impossible. These patients are also mostly young so may have surgery for other reasons later.
Which of these is true about testicular cancer?
- Cryptorchidism is not a risk factor
- 10% of testicular cancers occur in undescended testes
- 5 – 10% of patients with a cryptorchid testis develop malignancy in the normal descended contralateral testis
- In HIV patients, an increase in the incidence of teratomas is seen
- First degree male relatives are at higher risk
- Bilateral testicular cancers occur in 90% of cases
2, 3, 5
Cryptochidism - congenital undescended testis. Self examination is encouraged.
Label this:
A - spermatic cord
B- appendix epididymis
C - appendix testis
D - epididymis
E - testis
Which testicle is abnormal?
Both - heterogenous mass (the dark grey circle in the centre)
