Testicular%20cancer Diagnosis

Classification of Germ Cell Tumors

Pure Seminoma

• Comprises approximately 55-60% of testicular germ cell tumors
• Peak incidence is in the fourth decade of life and more likely to manifest with localized disease
• Not as rapidly growing as nonseminomas and is radiation therapy sensitive
• Though may present with elevated hCG, it is usually not marked by increases in the level of serum tumor markers at presentation or with 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 and nonseminoma, management is guided by the more aggressive nonseminoma

Nonseminomatous Germ Cell Tumor (NSGCT)

• Include nonseminoma tumors, mixed seminoma and nonseminoma tumors, and seminoma tumors with increased serum AFP levels
• Most frequent in the third decade of life and tend to metastasize to retroperitoneal lymph nodes and lung parenchyma
• More resistant to radiation therapy and has elevated levels of tumor markers especially AFP
• Nonseminomatous testicular tumors have the following histologies: Choriocarcinoma, embryonal carcinoma, teratoma, yolk sac tumor, and mixed germ cell tumor

• May be clinical which includes physical examination, evaluation of tumor markers and imaging studies or pathologic which is defined by a surgical procedure
• Determine post-orchiectomy serum levels of AFP, hCG, and 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 with nonseminoma; thus, a seminomatous tumor with 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 and chest scan or X-ray for evaluation of the retroperitoneal lymph nodes metastatic disease
  
  • Recommended within 4 weeks before initiation of chemotherapy to confirm staging
  • 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 scan 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 (>5000 IU/L) or AFP (>10,000 ng/mL), with extensive lung metastasis or non-pulmonary visceral metastases, or patients manifesting cerebral symptoms; or when results are inconclusive with CT scan or ultrasound
• Other tests, eg bone scan, liver ultrasound, may be performed in patients with symptoms or suspicion for metastases

TNM Classification for Testicular Cancer According to the American Joint Committee on Cancer (AJCC) (2017, 8th ed)

Anatomic Stage/Prognostic Group for Testicular Cancer

¹N: Upper limit of normal for LDH assay

• 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

• Bimanually examine scrotal contents and compare with the normal contralateral testis
• Suspicious finding would be a firm, hard or fixed area within 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 and the chest for gynecomastia or thoracic involvement

• Include a complete blood count, creatinine, electrolytes, and liver enzymes
• Measurement of serum tumor markers alpha fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) is important and done before and after treatment and during the follow-up period as these are prognostic factors that contribute to the diagnosis, staging and management of the disease
  
  • Elevated tumor markers support the diagnosis of testicular cancer and levels should be assessed prior and 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

• 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 and presence of any structural changes

• Sperm abnormalities are often present in patients with testicular tumors
  
  • Azoospermia and/or oligospermia are found at diagnosis in at least 50% of patients with testicular GCT

• Infertility is a significant consequence of GCT therapy
  
  • Radical lymph node dissection (RPLND) is associated with ejaculatory dysfunction, chemotherapy with Cisplatin-containing regimens may lead to germ cell damage, and radiation scatter to the remaining testicle from radiation therapy can cause fertility problems 

• It is recommended that patients undergo semen analysis and cryopreservation of sperm in a sperm bank before diagnosis and staging to prevent exposure of sperm during the course of therapy and to preserve fertility