testicular%20cancer
TESTICULAR CANCER

Testicular cancer is a rare neoplasm that arises from the testis. It commonly presents as a painless testicular mass.

It has high prevalence in young and middle-aged men in the age of 15-40 years old.

It is a highly treatable disease with a high cure rate.

Testicular primary germ cell tumors coming from the malignant transformation of primordial germ cells make up 95% of all testicular cancer.

 

Classification

Classification of Germ Cell Tumors

Seminoma

  • Comprises approximately 50% of testicular germ cell tumors
  • Peak incidence is in the fourth decade of life & more likely to manifest w/ localized disease
  • Not as rapidly growing as nonseminomas & is radiation therapy sensitive
  • Though may present w/ elevated hCG, it is usually not marked by increases in the level of serum tumor markers at presentation or w/ disease recurrence
    • Seminomas do not produce AFP 
  • Pure type is composed of 100% seminoma - nonseminomatous elements are absent
    • When a tumor has both components of seminoma & nonseminoma, management is guided by the more aggressive nonseminoma

Nonseminoma

  • Most frequent in the third decade of life & tend to metastasize to retroperitoneal lymph nodes & lung parenchyma
  • More resistant to radiation therapy & has elevated levels of tumor markers especially AFP
  • Nonseminomatous testicular tumors have the following histologies: Choriocarcinoma, embryonal carcinoma, teratoma, yolk sac tumor, & mixed germ cell tumor
    • All other tumors, including those that have both seminoma & nonseminoma components, are considered as nonseminomas

Staging

Staging of Testicular Cancer

  • May be clinical which includes physical examination, evaluation of tumor markers & imaging studies or pathologic which is defined by a surgical procedure
  • Determine post-orchiectomy serum levels of AFP, hCG, & LDH
    • Persistently elevated levels may indicate residual or metastatic disease or possibly a second germ cell tumor in the remaining testis while level normalization does not rule out metastasis
    • Increased level of AFP is seen only w/ nonseminoma; thus, a seminomatous tumor w/ an elevated AFP level may indicate an occult nonseminomatous component and that patient should receive treatment for a nonseminomatous GCT
  • Perform abdominal/pelvic CT scan for evaluation of the retroperitoneal lymph nodes
    • Abdominal/pelvic CT scan has a 70-80% sensitivity in the determination of retroperitoneal nodes
    • A CT scan of the chest is done if the abdominal/pelvic CT or chest x-ray is positive or in case of a nonseminoma
  • MRI of the central nervous system may be done in advanced stage of the disease, eg choriocarcinoma, elevated hCG, or patients manifesting cerebral symptoms; or when results are inconclusive w/ CT or ultrasound
  • Other tests, eg bone scan, liver ultrasound, may be performed in patients w/ symptoms or suspicion for metastases

TNM Classification for Testicular Cancer According to the American Joint Committee on Cancer (AJCC) (2010, 7th ed)

pT Primary tumor
pTX Primary tumor cannot be assessed
pT0 Primary tumor not evident, eg histological scar in testis
pT1 Tumor limited to testis & epididymis w/o vascular/lymphatic invasion; tumor may invade tunica albuginea but not tunica vaginalis
pT2 Tumor limited to testis & epididymis w/ vascular/lymphatic invasion, or tumor extending through tunica albuginea involving tunica vaginalis
pT3 Tumor invades spermatic cord w/ or w/o vascular/lymphatic invasion
pT4 Tumor invades scrotum w/ or w/o vascular/lymphatic invasion
Regional lymph nodes
N Clinical
NX Regional lymph nodes cannot be assessed
N0 No metastasis to regional lymph node
N1 Metastasis w/ a lymph node mass ≤2 cm in greatest dimension or multiple lymph nodes, none >2 cm in greatest dimension
N2 Metastasis w/ a lymph node mass >2 cm but not >5 cm in greatest dimension, or multiple lymph nodes, any one mass >2 cm but not >5 cm in greatest dimension
N3 Metastasis w/ a lymph node mass >5 cm in greatest dimension
pN Pathologic
pNX Regional lymph nodes cannot be assessed
pN0 No metastasis to regional lymph node
pN1 Metastasis w/ a lymph node mass ≤2 cm in greatest dimension & ≤5 positive nodes, none >2 cm in greatest dimension
pN2 Metastasis w/ a lymph node mass >2 cm but not >5 cm in greatest dimension; or >5 positive nodes, none >5 cm; or evidence or extranodal extension of tumor
pN3 Metastasis w/ a lymph node mass >5 cm in greatest dimension

 

M Distant metastasis
M0 No distant metastasis
M1 Distant metastasis
M1a Non-regional lymph node/s or lung
M1b Other sites
S Serum tumor markers
SX Serum marker studies not available or performed
S0 Serum marker study levels w/in normal limits
  LDH (U/I) hCG (mIU/mL) AFP (ng/mL)
S1 <1.5 x N1 & <5000 & <1000
S2 1.5 - 10 x N1 or 5000 - 50,000 or 1000 - 10,000
S3 >10 x N1 or >50,000 or >10,000

Anatomic Stage/Prognostic Group for Testicular Cancer

Stage 0

pTis

N0

M0

S0

Stage I

pT1-T4

N0

M0

SX

Stage IA

pT1

N0

M0

S0

Stage IB

pT2-T4

N0

M0

S0

Stage IS

Any pT/TX

N0

M0

S1-3

Stage II

Any pT/TX

N1-3

M0

SX

Stage IIA

Any pT/TX

N1

M0

S0-1

Stage IIB

Any pT/TX

N2

M0

S0-1

Stage IIC

Any pT/TX

N3

M0

S0-1

Stage III

Any pT/TX

Any N

M1

SX

Stage III A

Any pT/TX

Any N

M1a

S0-1

Stage III B

Any pT/TX

N1-3

M0

S2

Any pT/TX

Any N

M1a

S2

Stage III C

Any pT/TX

N1-3

M0

S3

Any pT/TX

Any N

M1a

S3

Any pT/TX

Any N

M1b

Any S

1N: Upper limit of normal for LDH assay

History

  • Patient notes painless swelling or nodule in one testicle, occasionally an enlargement of a previously small atrophic testis
  • Some patients complain of a heavy sensation or a dull ache in the lower abdomen, scrotum, or perianal area; scrotal pain may be present in up to 27% of patients
  • Other presentations include symptoms due to metastases: Back or flank pain from retroperitoneal metastasis, dyspnea or cough from pulmonary metastasis, neck mass from supraclavicular lymph node metastasis, gastrointestinal hemorrhage, nausea, or vomiting from retroduodenal metastasis, bone pain from skeletal metastasis, central or peripheral nervous system symptoms from involvement of the cerebrum, spinal cord or peripheral nerve roots, unilateral or bilateral swelling of lower extremities from iliac or caval venous obstruction
  • Gynecomastia can result from elevated serum levels of hCG

Physical Examination

  • Bimanually examine scrotal contents & compare w/ the normal contralateral testis
  • Suspicious finding would be a firm, hard or fixed area w/in the tunica albuginea
  • Evaluation also includes abdominal palpation for the presence of nodal disease or visceral involvement, assessment of the supraclavicular lymph nodes for adenopathy & the chest for gynecomastia or thoracic involvement

Laboratory Tests

  • Include a complete blood count, creatinine, electrolytes, & liver enzymes
  • Measurement of serum tumor markers alpha fetoprotein (AFP), human chorionic gonadotropin (hCG), & lactate dehydrogenase (LDH) is important and is done before & after treatment & during the follow-up period as these are prognostic factors that contribute to the diagnosis, staging & management of the disease
    • Elevated tumor markers support the diagnosis of testicular cancer & levels should be assessed prior & 5-7 days after orchiectomy until normalization or lack of any further decline; however, negative levels do not rule out a germ cell tumor
    • Tumor marker levels are also determined immediately before initiating each new cycle of chemotherapy

Imaging

  • Eg testicular ultrasound, chest x-ray
    • Testicular ultrasound is indicated for persistent or painful swelling of the testes or when a testicular malignancy is being considered
      • The contralateral testis is also examined for its size & presence of any structural changes

Fertility

  • Sperm abnormalities are often present in patients w/ testicular tumors
    • Azoospermia &/or oligospermia are found at diagnosis in at least 50% of patients w/ testicular GCT
  • Infertility is a significant consequence of GCT therapy
    • Radical lymph node dissection (RPLND) is associated w/ ejaculatory dysfunction, chemotherapy w/ Cisplatin-containing regimens may lead to germ cell damage, & radiation scatter to the remaining testicle from radiation therapy can cause fertility problems 
  • It is recommended that patients undergo semen analysis & cryopreservation of sperm in a sperm bank before diagnosis & staging to prevent exposure of sperm during the course of therapy & to preserve fertility
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