Tumours of the Urinary System - Testicular Cancer

Question 1

What is the presentation of testicular cancer?

Answer 1

• Painless lump

Less often:
• Tender inflamed swelling
• History of trauma (trauma not a risk factor)
• Symptoms of nodal or distant metastasis: para-aortic lymph nodes, chest, bone

Question 2

What is the aetiology of testicular cancer?

Answer 2

• Caucasians
• Testicular maldescent, infertility, atrophic testis and previous cancer in contralateral testis
• Testicular Germ Cell Neoplasia In-Situ

Question 3

What are the tumour markers?

Answer 3

Blood for tumour markers is taken immediately before and serially after surgery

Types:
• AFP (alpha-fetoprotein) - teratoma
• BHCG (human chorionic gonadotrophin) - seminoma
• LDH (lactate dehydrogenase) - non-specific marker of tumour)

Question 4

What are the investigations used t diagnose testicular cancer?

Answer 4

• Lump in testis = testicular tumour until proven otherwise
• Differential diagnoses:
    - infection (i.e. epididymo-orchitis)
    - epididymal cyst
    - missed testicular torsion
• MSSU
• Testicular ultrasound scan and CXR
• Tumour markers

Question 5

What are the treatment options for testicular cancer?

Answer 5

Radical orchidectomy is essential

Occasionally may need biopsy of ‘normal’ contralateral testis if high risk for tumour (no biopsy of effected testis)

Further treatment depends on tumour type, stage (TNM) and grade

Question 6

For testicular cancer, the main lymphatic spread to regional lymph nodes occurs in which group of lymph nodes?

a. Scrotal lymph nodes
b. Inguinal lymph nodes
c. Pelvic lymph nodes (i.e. internal iliac chain)
d. Mediastinal lymph nodes
e. Para-aortic lymph nodes

Answer 6

E

Question 7

Where is the incision made for radical inguinal orchidectomy for testicular cancer?

Answer 7

In the groin, to remove the testes and surround fascia, with spermatic cord (which contains BV and lymphatics which are routes for spread)

Question 8

Describe the pathology of testicular cancer

Answer 8

• Germ cell tumour (GCT)

* Non-GCT (sex cord/stomal)

Question 9

Describe the different types of Germ Cell Tumour (GCT)

Answer 9

Seminomatous
• Classicial, spermatohytic or analplastic

Non-seminomatous
• Teratoma, yolk sac, choriocarcinoma, mixed GCT

Question 10

What is the grading dependent on?

Answer 10

Histological assessment of differentiation (aggressiveness)
• Low grade = well differentiated
• High grade = poorly differentiated

Question 11

How can the cancer spread?

Answer 11

Spread occurs in 3 ways:
• Local spread (i.e. local invasion to adjacent structures)
• Regional spread (lymphatic invasion)
• Distant spread (lungs, bone, liver)

Stage using TNM system

Question 12

What investigation are used for staging?

Answer 12

• Local staging (via pathological assessment of orchidectomy specimen)
• Nodal staging (via CT scan)
• Distant staging (chest, abdomen and pelvis) (via CT scan)
• Tumour markers also provide staging and prognostic information

Question 13

Describe the different stages of testicular cancer

Answer 13

Stage I - disease is confined to the testis
Stage II - Infradiaphragmatic nodes involved
Stage III - Supradiaphragmatic nodes involved
Stage IV - extralymphatic disease

Question 14

What is the treatment in testicular cancer for a low stage tumour and negative markers?

Answer 14

Orchidectomy, followed by:
• Surveillance; or
• Adjuvant radiotherapy (SGCT only); or
• Prophylactic chemotherapy

Question 15

What is the treatment in testicular cancer with nodal disease, persistent tumour markers or relapse on surveillance?

Answer 15

• Combination chemotherapy (BEP); or

* Lymph node dissection (NSGCT only)

Question 16

What is the treatment in testicular cancer with metastases?

Answer 16

• First-line chemotherapy

* Second-line chemotherapy