Testicular tumours Flashcards
If a testicular mass is palpated, what not-cancerous pathology could it be?
- Torsion
- Epididymo-orchitis
- Scrotal hernia
- Hydrocele
- Haematoma
- Spermatocele
- Intratesticular benign cyst
- Syphilitic gumma
Discuss germ cell tumours
- Most common cancers in men aged 15-35
- Much less common in women
Discuss the types of germ cell tumours in men
a) Seminomas
b) Non-seminoma (previously teratoma, comprised of both mature and immature cells, teratoma now refers to the mature components
What are the clinical features of testicular cancer?
- Testicular mass +/- pain
- Metastasis to the para-aortic LNs
- Back pain
- Gynaecomastia if the tumour is B-hCG secreting
What are the investigations for testicular cancer?
- Ultrasound or MRI
- Assay of serum tumour makers: a-fetoprotein, lactase dehydrogenase and b-hCG
- CT or MRI to look for distant mets
Discuss alpha-fetoprotein
- Normally made by the liver and yolk sac of a fetus
- Levels should fall by the age of 1
- Healthy adults should have very low levels
- High levels occur due to liver cancer and non-seminoma germ cell cancer
Discuss seminomas
- Germ cell tumour of the testicle
- Malignant
- Account for 50% of testicular germ cell cancers
- One of the most treatable and curable cancers with a >95% survival rate
Where can germ cell tumours be found?
Gonads mainly, specifically testicles in males
Can also develop in non-gonadal sites such as the pituitary, mediastinum and retroperitoneum
What is the treatment for testicular cancer?
Orchidectomy via the inguinal approach to avoid spillage of highly metastatic tumour in the scrotum
Discuss management of semnomas
- Very radio and chemosensitive
- Associated with raised serum LDH (very rarely b-hCG and never raised a-fetoprotein)
- Adjuvant therapy with chemotherapy is preferred as it leads to a >95% cure in early stage disease
What is the chemotherapy regimen of choice for seminomas?
Carboplatin because it is convenient, it causes reduced acute side effects and doesn’t run the risk of causing secondary malignancy as with xRT
What is BEP?
Combination chemotherapy
- Cisplatin
- Etoposide
- Bleomycin
- Cures 95% of people with metastatic seminoma disease
What is cisplatin?
Alkylating agent
1) attachment of alkyl groups to DNA bases, resulting in the DNA being fragmented by repair enzymes in their attempts to replace the alkylated bases
2) DNA damage via the formation of cross-links (bonds between atoms in the DNA) which prevents DNA from being separated for synthesis or transcription
3) the induction of mispairing of the nucleotides leading to mutations
What is etoposide?
Topoisomerase II inhibitor
Cell cycle dependent and phase specific, affecting mainly the S and G2 phases of cell division.
What is bleomycin?
An antibiotic that has anti-tumour activity
Main mode of action is the inhibition of DNA synthesis with some evidence of lesser inhibition of RNA and protein synthesis
Major effects in G2 and M phases
Discuss management of non-seminomas (teratomas)
- Risk of relapse with stage 1 disease varies from 5-50%
- Mets commonly involves para-aortic LNs and lung but can spread quickly, especially if b-hCG secreting
- 80% of seminomas will express either b-hCG or a-fetoprotein
- Almost all metastatic disease is associated with an elevation in LDH
What is a rapid test for non-seminoma testicular cancer?
- pregnancy test (b-hCG +)
- presence of gynaecomastia
What is the most established treatment for non-seminomas?
BEP (3-4 cycles)
Discuss fertility and testicular cancer
20% will be infertile at time of diagnosis but the majority of men who are not infertile, will retain their fertility
Discuss testicular cancer
- Most common malignancy in young men (20-34yrs)
- Highly curable when diagnosed early
- Most common are seminomas followed by teratomas
Discuss the epidemiology of testicular cancer
• UK: ~1400 new cases each year with the highest incidence in those aged 25-35
• Relatively rare, accounts for ~1% of all cancers and accounts for <1% of cancer deaths in males
• Most common solid tumours diagnosed in men aged 20-34
White men have, by far, he highest incidence compared to African and Asian men
What are the risk factors of testicular cancer?
• Cryptorchidism (failed descent of one or both tested) - relative risk of 2-17x for malignancy
- 50-10% of patients with cryptorchidism develop cancer in the contralateral, normally descended testicle
- Seminomas tend to be the predominant tumour type associated with undescended testis
• Family hx
• Testicular atrophy: due to trauma, hormones and viral orchitis (mumps)
• Being white
HIV 5x the risk in men with HIV compared to age matched controls
Which side do the majority of testicular masses occur?
Right (55%)
How do testicular cancers present?
- 85% are painless
- Found by man or partner
- Bilateral in 2% of cases
Discuss extra-testicular manifestation of testicular cancer
• 5-10% of patients have extra-testicular manifestations at the time of presentation with or without evidence of a tumour in the testicles
• Bone pain (skeletal metastasis), lower extremity swelling (venous occlusion), supraclavicular LNs, symptoms of hyperthyroidism and gynaecomastia
Spinal cord and cerebral metastasis may cause neurological symptoms
Discuss investigations of testicular tumours
• Ultrasound of testis: sensitivity near 100%, if the scan does not confirm a mass but suspicion is high – proceed to CT scan of the pelvis and abdomen
• CT scan (abdo and pelvis): used to assess extra testicular metastasis
• Serum beta-hCG: elevated in all cases of choriocarcinoma (non-seminomatous germ cell tumour – rarest of all testicular cancers). Upper limit reference range for men under 50 is 0.7U/L
• Serum alpha-fetoprotein (AFP): raised in some testicular cancers >25 microgram/L indicates cancer
Serum lactate dehydrogenase (LDH): elevated in 50% of all cases of testicular cancer. Has a high false-positive rate >25 U/L
Discuss serum markers of testicular tumours
Serum concentrations of a-fetoprotein and/or b-hCG are elevated in most men with teratomas and are used to assess response to treatment
B-hCG is elevated in a minority of men with seminomas and AFP is not elevated in men with pure seminomas
Discuss additional tests for testicular masses
• CT chest if CT abdo+pelvis is +
Biopsies are not advised in the evaluation of a testicular mass – diagnosis is established by removing and examining the testicle
Discuss primary tumour staging of testicular tumours
Tis = germ-cell neoplasm in situ (original place) T1 = confined to testis without LN invasion T2 = confined to testis with LN involvement or beyond tunica albuginea T3 = invades spermatic cord T4 = invades scrotum
Discuss regional LN staging of testicular tumours
NX = LNs can't be assessed N0 = no LN mets N1 = regional LN mets <2cm N2 = regional LN mets 2-5cm N3 = regional LN mets >5cm
Discus staging of testicular cancers
- Stage I = confined to testis • Stage II = any pT/TX, N1-3, M0, SX • Stage IIA = any pT/TX, N1, M0, S0/S1 • Stage IIB = any pT/TX, N2, M0, S0/S1 - Stage IIC = any pT/TX, N3, M0, S0/S1
What is a direct access ultrasound?
When a test is performed and primary care retain clinical responsibility throughout, including acting on the result
What is a hydrocele?
Fluid within the tunica vaginalis
Primary or secondary
Primary: associated with a patent processus vaginalis which typically resolves during first year of life, more common in younger men, larger and can resolve spontaneously
Secondary: testes trauma, tumour or infection
What is epididymoorchitis?
Inflammation of epididymis
Caused by chlamydia, E.coli, mumps, gonorrhoea, TB
Sudden onset, tender, swelling, dysuria
What is a varicocele?
- Dilated veins of pampiniform plexus
- Left side more commonly affected
- Can be visible bag of worms
- Patient may complain of dull ache
What is a haematocele?
Blood in tunica vaginalis, usually occurs due to trauma, needs draining
Differentials for testicular cancer
- Testicular torsion
- Epididymo-orchitis
- Scrotal hernia
- Hydrocele
- Epididymal cyst
- Haematoma
- Spermatocele
- Intratesticular benign cyst
- Syphilitic gumma (A gumma is a soft, non-cancerous growth resulting from the tertiary stage of syphilis. It is a form of granuloma)
Types of testicular tumours
- Seminoma (55%)
- Non-seminomatous germ cell tumour (33%)
- Mixed germ cell tumour (12%)
What is a germ cell tumour?
Neoplasm derived from germ cells
Can be benign or malignant
Mainly occur inside gonads
Clinical features of testicular cancer
- Testicular mass +/- pain
- Metastases to the para-aortic LNs
- Back pain
- Gynaecomastia if the tumour is hCG secreting
Investigation of testicular tumours
- Ultrasound or MRI
- Assay of serum tumour markers: a-fetoprotein, lactase dehydrogenase (LDH) and B-hCG
- Pregnancy tests on men in A&E have saved the lives of men with metastatic germ cell cancer
- CT or MRI to look for distant mets
Treatment of testicular cancer
Orchidectomy via the inguinal approach to avoid spillage of highly metastatic tumour in the scrotum
Epidemiology of testicular cancer
- UK: ~1400 new cases each year with the highest incidence in those aged 25-35
- Relatively rare, accounts for ~1% of all cancers and accounts for <1% of cancer deaths in males
- Most common solid tumours diagnosed in men aged 20-34
- White men have, by far, he highest incidence compared to African and Asian men
Risk factors for testicular cancer
- Cryptorchidism (failed descent of one or both tested) - relative risk of 2-17x for malignancy
- 50-10% of patients with cryptorchidism develop cancer in the contralateral, normally descended testicle
- Seminomas tend to be the predominant tumour type associated with undescended testis
- Family hx
Testicular atrophy: due to trauma, hormones and viral orchitis (mumps)
Being white
HIV 5x the risk in men with HIV compared to age matched controls
1st order investigations for testicular cancer
- Ultrasound of testis: sensitivity near 100%, if the scan does not confirm a mass but suspicion is high – proceed to CT scan of the pelvis and abdomen
- CT scan (abdo and pelvis): used to assess extra testicular metastasis
- Serum beta-hCG: elevated in all cases of choriocarcinoma (non-seminomatous germ cell tumour – rarest of all testicular cancers). Upper limit reference range for men under 50 is 0.7U/L
- Serum alpha-fetoprotein (AFP): raised in some testicular cancers >25 microgram/L indicates cancer
- Serum lactate dehydrogenase (LDH): elevated in 50% of all cases of testicular cancer. Has a high false-positive rate >25 U/L
