Testicular cancer (URO)

Question 1

Who is testicular cancer common among?

Answer 1

Young adult men (20-34 years old)

Question 2

What is the most common type of testicular cancer?

Answer 2

Seminomas (germ cell tumour)

Question 3

What are the types of testicular cancer? (3)

Answer 3

• seminomas (germ cell tumour, most common)
• non-seminoma germ cell tumours (teratomas)
• non-germ cell tumours

Question 4

When do germ cell tumours begin (testicular cancer)?

Answer 4

Germ cell tumours start from foetal development –> carcinoma in situ (intratubular germ cell neoplasia unclassified) –> malignant growth (growth beyond basement membrane)

Question 5

What are the risk factors for testicular cancer? (8)

Answer 5

• cryptorchidism
• gonadal dysgenesis
• infertility
• age <45
• Fx / personal Hx
• testicular atrophy
• white ethnicity
• HIV

Question 6

Who is more likely to develop testicular cancer?

Answer 6

Infertile men 3x more likely to develop testicular cancer

Question 7

How does testicular cancer typically present?

Answer 7

Hard, painless nodule on one testis noticed by the patient or at regular clinic exam

Question 8

What are the clinical features of testicular cancer? (7)

Answer 8

• painless unilateral hard nodular testicular mass
• negative transillumination test (light does not shine through)
• gynaecomastia - due to seminoma/non-seminoma secreting hCG (increased oestrogen:androgen ratio)
• may be associated hydrocoele
• lymphadenopathy
• lower extremity swelling
• metastatic disease (cough, SOB, chest pain, bone pain - backache)

Question 9

What is the transillumination test like in testicular cancer?

Answer 9

Negative transillumination test (light does not shine through) - as opposed to positive in hydrocoele

Question 10

Why might we see gynaecomastia in testicular cancer?

Answer 10

Due to seminoma/non-seminoma germ cell tumour producing hCG –> increased oestrogen:androgen ratio

Question 11

What features of metastatic disease might we see in testicular cancer? (4)

Answer 11

• cough
• SOB
• chest pain
• bone pain (back pain)

Question 12

Which lymph nodes does testicular cancer typically spread to?

Answer 12

Para-aortic lymph nodes

Question 13

How will a hydrocoele differentiate from a testicular cancer? (3)

Answer 13

• transilluminates
• not separate to testis
• fluctuant

Question 14

What is the first-line principal investigation for testicular cancer?

Answer 14

Ultrasound with colour Doppler of testis - shows testicular mass

Question 15

Which tumour markers can you check for in testicular cancer? (3)

Answer 15

• alpha-fetoprotein (AFP)
• beta-hCG
• LDH

Question 16

What are tumour markers like in seminoma (testicular cancer)?

Answer 16

• normal AFP (vs raised in non-seminoma)
• raised beta-hCG sometimes
• raised LDH sometimes

Question 17

What are tumour markers like in non-seminoma germ cell tumours (testicular cancer)?

Answer 17

• raised AFP (vs normal in seminoma)
• raised beta-hCG
• normal LDH

Question 18

How can we stage testicular cancer and look for metastases? (2)

Answer 18

• CXR - check for lung mets
• CTAP - allows staging, enlarged retroperitoneal lymph nodes

Question 19

What confirms diagnosis of testicular cancer?

Answer 19

Histological examination of testicular mass post-orchiectomy (biopsy not advised before surgery for evaluation)

Question 20

How can testicular cancer cause paraneoplastic hyperthyroidism?

Answer 20

Alpha subunits of hCG and TSH are similar in shape –> tumour which causes excess hCG also stimulates TSH receptors of thyroid gland

Question 21

What are some differential diagnoses for testicular cancer? (8)

Answer 21

• testicular torsion (sudden, horizontal, rotated, high-riding testis, US shows hypoechogenicity and enlargement, blood flow occlusion)
• epididymo-orchitis (inflammation, shorter Hx, Doppler showss increased blood flow)
• scrotal hernia
• hydrocoele (transilluminating, testis cannot be palpated)
• epididymal cyst
• haematoma
• spermatocele
• intra-testicular benign cysts

Question 22

How would you manage a patient with testicular cancer prior to surgery?

Answer 22

Sperm cryopreservation - tumours associated with decreased fertility, and infertility can be a complication of treatment

Question 23

How can we surgically remove testicular cancer? (2)

Answer 23

Radical inguinal orchiectomy - involved testicle, spermatic cord and appendages removed

Or testis sparing surgery - for those wanting to preserve gonadal function with mass <2mm, those with negative tumour markers and unclear imaging, single functional testis, bilateral tumour

Question 24

How else is a patient with testicular cancer managed, outside of surgery?

Answer 24

Radiotherapy and chemotherapy

Question 25

What can we offer to patients with testicular cancer post-orchiectomy? (6)

Answer 25

• surveillance
• carboplatin chemotherapy (where f/u compliance is questionable)
• external beam radiation
• retroperitoneal lymph node dissection
• chemotherapy
• combination chemotherapy (if advanced/metastatic)

Question 26

What is a complication of testicular cancer?

Answer 26

Infertility - after orchiectomy, retroperitoneal LN dissection, chemotherapy and radiotherapy

Hence sperm banking advised/sperm cryopreservation

Question 27

What is the prognosis of testicular cancer like?

Answer 27

Excellent - high cure rate and 5y survival rates >95%