testicular cancer

Question 1

definition of testicular cancer

Answer 1

malignant tumour of the testes

Question 2

pathology of testicular cancer

Answer 2

main types:

• seminomas (50%, peak 30-40yr),
• nonseminomatous germ-cell tumours or teratomas (30%, peak 20-30yrs),
• mixed germ cell tumour (12%),
• lymphoma

Seminomas are pale, cream-white solid and well-circumscribed tumours. contain sheets of uniform, tightly packed cells that vary from well-differentiated spermatocytes to anaplastic.

Teratomas are cystic in appearance with haemorrhagic and necrotic areas. - can contain tissue from yolk sac, trophoblastic and embryonal cell elements with varying differentiation, and are classified on the relative proportions.

spread locally to tunica vaginalis and along the spermatic cord

lymphatic spread to para-aortic nodes, then mediastinal and supraclavicular nodes

blood borne spread to lungs and liver

Question 3

staging of testicular cancer

Answer 3

Royal Marsden Hospital staging:

I – Limited to testis

II – Abdominal lymphadenopathy (infradiaphragmatic ie para-aortic nodes, not inguinal nodes) A:<2 cm, B: 2–5 cm, C:>5cm

III – Nodal involvement above the diaphragm; A, B, C as above

IV – Liver/lung metastases (cannonball metastases in lungs)

Question 4

aetiology of testicular cancer

Answer 4

unknown, likely gene mutation in germ cells

testicular maldescent (cryptorchid testes) or ectopic testes increase risk 40x - 10% occur in undescended testes even after orchidopexy

contralateral testicular tumour - found in 5%

atrophic testes

infant hernia

infertility

first degree relatives (male)

Question 5

epidemiology of testicular cancer

Answer 5

uncommon

1% male malignancies

most common malignancy in 18-35yrs

lifetime risk 1/500

peak incidence of seminoma 30-40yrs

peak of lymphoma >65yrs

Question 6

sx of testicular cancer

Answer 6

swelling or discomfort of the testes

backache due to para-aortic lymph node enlargement

resp symptom: SOB, haemoptysis from lung met

dragging feeling in groin

non-tender

Question 7

signs of testicular cancer

Answer 7

painless hard testicular mass (may be a secondary hydrocoele)

found after trauma/infection +- haemospermia, pain

lymphadenopathy (abdo mass) eg supraclavicular, para-aortic

signs of pleural effusion

gynaecomastia resulting from tumour HCG production

5% of seminomas & 50% of NSGCTS present with metastases.

solid on US

Question 8

Ix for testicular cancer

Answer 8

bloods:

• FBC
• U&E
• LFT
• tumour markers, they also help monitor treatment
  
  • a-fetoprotein indicates teratomatous elements (>3IU/mL), produced by yolk sac (endodermal sinus) components and embryonal carcinomas and teratomas
  • B-HCG - germ cell tumours (seminoma and teratoma) produce HCG with a and B subunits normally secreted by placental syncytiotrophoblasts, and or the B unit in isolation. HCG produced by 100% of choricarcinomas
  • LDH - low specificity, LDH-1 mopst frequently elevated, LDH elevated in 40-60% men with germ cell tumours. Suggest bulky disease and rising levels = recurrence
• high placental alkaline phosphtase (PLAP) - seminomatous component present

Uncommonly teratomas can contain areas of choriocarcinomatous (trophoblastic) differentiation and these produce high levels of human chorionic gonadotrophin (HCG).

urine pregnancy test - positive if produces B-HCG

CXR - lung met/pleural effusion

testicular US - tumours seen in testicle, hydrocoele may be associated

CT abdo/thorax - for disease staging, or brain if extensive disease

excision biopsy

Question 9

teratoma on US

Answer 9

variegated gross appearance with both solid and cystic areas,

Question 10

mx of testicular cancer

Answer 10

• inguinal orchidectomy
• testis sparing surgery
• +- carboplatin
• +- external beam radiotherapy
• +- lymph node dissection

Question 11

complications of testicular cancer

Answer 11

Question 12

px of testicular cancer

Answer 12

most seminoma are cured
ie good px
strict surveillance program followed to detect recurrent disease