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.

 

Surgical Intervention

Radical Inguinal Orchiectomy

  • Performed once a testicular mass is detected on ultrasound
    • Inguinal approach prevents spread of cancer cells
  • Establishes the diagnosis of testicular malignancy & also serves as the primary treatment
  • Organ-sparing surgery may be done when tumor volume is <30% of the testicular volume in cases of metachronous contralateral tumors, synchronous bilateral tumors, or a tumor in a single testis w/ normal presurgical levels of testosterone
  • In case of a life-threatening metastatic disease, chemotherapy is started prior to orchiectomy
    • Orchiectomy after chemotherapy to remove the primary tumor is advisable
  • Inguinal biopsy of the contralateral testis may be considered if the following are present: Cryptorchid testis, pronounced atrophy, ultrasound findings suspicious for intratesticular abnormalities, eg macrocalcification or hypoechoic mass
    • Risk is high for TIN in the contralateral testis in patients age <40 yr & w/ testicular atrophy & patients w/ EGGCT
      • Treatment typically consists of radiation therapy, surveillance, or orchiectomy

 
Retroperitoneal Lymph Node Dissection (RPLND)

  • The standard surgical approach to nonseminomas in the primary & post-chemotherapy setting
  • It removes the lymph nodes draining the primary site & the nodal groups near the primary landing zone
  • Standard (modified bilateral) approach removes all node-bearing tissue up to the bifurcation of the great vessels including the ipsilateral iliac nodes
    • Long-term effect is retrograde ejaculation w/ resulting infertility 
  • Nerve-sparing RPLND can preserve anterograde ejaculation in approximately 90% of patients
  • RPLND results in the least number of patients at risk for chemotherapy’s late toxicities

Nonseminoma

Stage I

  • Nerve-sparing RPLND may be done if patient has contraindications to either chemotherapy or surveillance

Stage II

  • A modified, bilateral, nerve-sparing RPLND is performed in patients w/ post-orchiectomy negative tumor markers due to higher chance of bilateral disease w/ greater tumor burden

Postsurgical Management

  • Management of patients w/ stage I & II nonseminoma previously treated w/ primary nerve-sparing RPLND includes the following:
    • pN0: Surveillance
    • pN1: Surveillance (preferred) or chemotherapy w/ 2 cycles of EP or BEP
    • pN2: Chemotherapy w/ 2 cycles of EP or BEP (preferred) or surveillance
    • pN3: Chemotherapy w/ 4 cycles of EP or 3 cycles of BEP 
  • Surveillance may be done in patients w/ “low-volume” metastases, ie tumor nodes ≤2 cm in diameter & <6 nodes positive
  • Adjuvant chemotherapy is considered in “high-volume” metastases, ie any involved node >2 cm in largest diameter or >6 nodes positive or positive extranodal tumor extension
    • EP w/ or w/o Bleomycin given every 3 wk are well tolerated & effective
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