Testicular cancer

Epidemiology

• Most common malignancy in males aged 15-44 yo
• 10% occur in undescended testes, even after orchidopexy

Risk factors:

• Cryptorchidism
• infertility
• family history
• Klinefelter’s syndrome
• mumps orchitis

Classification

Classification of Testicular tumour

Presentation:

• Usually painless lump
• Painful lump if bleeds inside or infection
• Rarely, changes in testicular volume or consistency
• Longer history in seminoma pt than non-seminoma
• Signs of metastasis
  • supraclavicular lymph node
  • Dyspnoea from pulmonary mets

Investigations:

• Bloods: AFP, B-hCG, Lactate dehydrogenase
• Imaging
  • 1st line: Ultrasound colour Doppler
  • Other: CT abdomen and chest for staging

Seminomous Germ cell tumour

• Older patients (avg. 40 years)
• 25% metastasise at presentation
• Excellent prognosis even with advanced disease (5 year survival of 73%)
• Tumour marker not typically raise: AFP normal, ↑ HCG (10%), ↑LDH (10%)
• Strong association with cryptorchidism
• May present with mass in the undescended testes in the inguinal region or the abdomen

Non-seminomatous germ cell tumours

• Younger patients (20-30 year olds)
• Advanced disease = poor prognosis (48% at 5 years)
• Biomarkers
  • Embryonal carcinoma: ↑AFP /↑B-hCG
  • Yolk sac tumour: ↑AFP characteristic
  • Choriocarcinoma:↑B-hCG characteristic
  • Teratoma: ↑AFP /↑B-hCG

Sex cord-stromal tumour

• Arise from supportive connective tissue around germ cells
• Rare, less than 5% of testicular cancer
• Excellent prognosis after surgical resection
• Two types of tumour: Leydig cell tumour, Sertoli cell tumour

Lymphoma

• Most common cause of a testicular mass in males > 60 years old; often bilateral
• Usually of diffuse large B-cell type

Staging

• Stage 1: No evidence of metastasis
• Stage 2: Infradiaphragmatic node involvement (spread via para-aortic nodes)
• Stage 3: Supradiaphragmatic node involvement
• Stage 4: Lung involvement (haematogenous)

Management

• SGCT
  • Orchidectomy (via inguinal approach to prevent lymphatic spread)
  • Extremely radiosensitive
  • NOTE: orchidectomy and radiotherapy cures 95% in stage 1
• NSGCT
  • Orchidectomy (inguinal approach)
  • 3 cycles of Bleomycin + Etoposide + Cisplatin
• Follow-up
  • Do close follow up using biomarkers, reviews and self-examination