Testicular cancer

Question 1

Risk factors

Answer 1

Cryptorchidism (undescended testes) is associated with a 4-10x higher risk of GCTs. Other risk factors include previous testicular malignancy, a positive family history, and Kleinfelter’s syndrome.

Question 2

Hx

Answer 2

Patients will present with a unilateral painless testicular lump. On examination*, the mass is typically irregular, firm, fixed, and does not transilluminate.

Evidence of metastasis may present with weight loss, back pain (from retroperitoneal metastases), or dyspnoea (secondary to lung metastases).

*Lymphatic drainage of the testes is to the para-aortic nodes, therefore localised lymphadenopathy may not be present, even in cases of metastatic disease

Question 3

DDx

Answer 3

Differentials for a scrotal lump include epididymal cyst, haematoma, epididymitis, or hydrocoele.

Question 4

Investigations

Answer 4

For patients with suspected cases of testicular cancer, tumour markers can be used for both diagnostic and prognostic* means. ßHCG is elevated in 60% of NSGCTs and 15% of seminomas, whilst AFP can be raised in some NSGCTs as well. LDH can also be used as a surrogate marker for tumour volume.

Scrotal ultrasound (Fig. 2) should be used in the initial assessment of scrotal lumps, alongside concurrent tumour markers. The disease will then be staged via CT imaging with contrast of the chest-abdomen-pelvis.

Crucially, a trans-scrotal percutaneous biopsy should not be performed, as it might cause seeding of the cancer. Diagnosis is made through tumour marker and imaging alone.

*Levels can be used post-treatment to determine its efficacy

Question 5

Staging of testicular cancer

Answer 5

Staging of Testicular Cancer
The Royal Marsden Classification can be used in the staging of the testicular cancer

Stage
I - Disease confined to testes
II - Infra-diaphragmatic lymph node involvement
III - Supra- and infra-diaphragmatic lymph node involvement
IV - Extralymphatic metastatic spread

Question 6

Mx

Answer 6

All patients with confirmed testicular cancer he should be discussed in a specialist MDT. The main treatment options for testicular cancer are surgery, radiotherapy, and chemotherapy; the treatment of choice depends on the tumour type, risk scoring, and prognosis.

Most cases suitable for surgery will undergo an inguinal radical orchidectomy. This removes the testes along with the spermatic cord, allowing for maximal lymphatic system to be removed.

Sperm abnormalities and Leydig cell dysfunction are frequently found in patients with testicular cancer prior to orchiectomy. Furthermore, chemotherapy and radiation treatment can additionally impair fertility. Therefore, in patients in the reproductive age group, pre-treatment fertility assessment should be performed, and semen analysis and cryopreservation offered accordingly.

Non-Seminomatous Germ Cell Tumours
Stage 1 NSGCTs will require orchidectomy then further managed dependent on their risk score. Low risk patients without any evidence of vascular invasion can routinely enter just surveillance, whilst high risk patients or those with vascular invasion require adjuvant chemotherapy (typically cisplatin, etoposide, bleomycin) and then surveillance

Metastatic NSGCTs management is also dependent on risk scoring. Cases with intermediate prognosis should be treated with cycles of chemotherapy, whilst those with poor prognosis should be treated with one cycle of chemotherapy before reassessment (those with marker decline should have continued chemotherapy cycles, whilst those with unfavourable decline should have their chemotherapy intensified).

Seminomas
Stage 1 seminoma can often be managed with orchidectomy alone and surveillance monitoring. Patients have a high relapse risk are often considered for chemotherapy.

For metastatic seminoma, stage IIA can be treated with either radiotherapy or chemotherapy, whilst higher stage disease will require primary chemotherapy and treated similar to metastatic NSGCTs (as above).

Question 7

Complications

Answer 7

Radiotherapy and chemotherapy often carry an associated risk of secondary malignancies, such as leukaemia.

Prognosis of the disease depends on the tumour type and stage. However, fortunately the condition overall has a high rate of complete remission.

Question 8

Key points

Answer 8

Testicular cancer is most common cancer in males aged 20-40yrs
Patients will present with a unilateral painless testicular lump
Diagnosis is made through combination of tumour markers and imaging
Management is dependent on tumour subtype, disease stage, and risk scoring