Testicular Cancer Flashcards
Epidemiology
Most common cancer in males aged 20-40y
Caucasian and Northern European at highest risk
Categories
Germ cell tumours (95%) and non-germ cell tumours (NGCTs, 5%)
GCT divisions
Seminomas
Non-seminomatous GCTs
Both are usually malignant
NGCTs division
Usually benign
Leydig cell tumours (oestrogen)
Sertoli cell tumours (testosterone)
Positive thing about seminomas
Tend to remain localised until late and have a very good prognosis
NSGCT division
Yolk sac tumours
Choriocarcinomas
Embryonal carcinomas
Teratomas
Often metastasise early and have worse prognosis than seminomas
Risk factors
Cryptoorchidism 4-10x higher risk of GCTs
Previous testicular malignancy
+ve FH
Kleinfelter’s syndrome
Clinical features
Unilateral painless testicular lump
Irregular, firm, fixed
Doesnt transilluminate
Metastasis might show weight loss, back pain or dyspnoae
Lymphatic drainage of the testes
Para-aortic nodes
This means that localised lymphadenopathy may not be present even in metatstaic disease
Differentials
Epididymal cyst
Haematoma
Epididymitis
Hydrocoele
Investigations
Tumours markers
beta-HCG in 60% of NSGCTs and 15% of seminomas
AFP can be raised in some NSGCTs as well
LDH can also be a marker for tumour volume
Imaging
Scrotal ultrasound
Staging by CT chest-abdo-pelvis with contrast
When should trans-scrotal percutaneous biopsy be done?
Shouldnt be done
It can cause seeding
Staging of testicular cancer
Royal Marsden Classification
Explain Royal Marsden
I - Disease confined to testis
II - Infra-diaphragmatic LN involvement
III - Supra and infra-diaphragmatic LN involvement
IV - Extralymphatic metastatic spread
General management
Specialist MDT
Either surgery, radiotherapy or chemo or a combination of them.
Treatment of Stage I NSGCTs
Orchidectomy and further management dependent on risk score.
Low risk with no vascular invasion -> Surveillance
High risk -> Adjuvant chemo of cisplatin, etoposide, bleomycin and then surveillance.
Treatment of metastatic NSGCTs
Dependent on risk scoring
Cycles of chemotherapy if intermediate
Poor prognosis -> One cycle of chemo before reassessment, might need intensification.
Treatment of stage 1 seminomas.
Often with orchidectomy alone and surveillance
If there is a high risk of relapse consider doing chemo.
Treatment of metastatic seminoma.
Stage IIA can be treated either with radiotherapy or chemotherapy
Higher stage require primary chemo and treated similar to metastatic NSGCTs
What should be done before orchidectomy?
Since sperm abnormalities and Leydic cell dysfunction can ensue you should do a pre-treatment fertility assessment.
Semen analysis
Cryopreservation should be offered as well
Complications
Risk of secondary malignancies like leukaemia from radiotherapy and chemo.
