CLINICAL UPDATE
Testicular cancer
By Dr Jerard Ghossein, Urologist, Mt Lawley. Tel 9224 2185
T
esticular cancer represents just over 1% of all male neoplasms (706 new cases in Australia during 2010), the most common solid (i.e. non haematogenous) cancer in men aged 18 to 39, of which 90-95% are seminomas and non-seminomatous germ cell tumours (NSGCT). Most are Stage 1 at the time of diagnosis. Testicular tumours show excellent cure rates. This is due to early diagnosis, careful staging and treatment with a combination of surgery, chemotherapy and radiotherapy to which testicular tumours are extremely sensitive. Testicular cancer is uncommon in boys under 15 and in men over 60, with the incidence of NSGCT peaking in the third decade of life, and pure seminoma in the fourth decade. Infants and boys below 10yo may develop yolk sac tumours and 50% of men over 60 with testicular tumours will have lymphoma rather than a tumour of testicular origin. Benign stromal tumours of the testis make up less than 5% of adult testicular tumours.
Risk factors Regular testicular self-examination and yearly scrotal ultrasound is recommended for men with risk factors. These include a history of cryptorchidism, Klinefelter’s syndrome, familial history of testis cancer in first-grade relatives, presence of contra lateral tumour and infertility. (A possible association between testicular microlithiasis and cancer has not been confirmed, so routine surveillance is not recommended for microlithiasis.)
Diagnosis Patients usually present with a painless testicular mass, often detected following
Q Non-seminomatous tumour replacing almost the entire testis.
a history of minor trauma, for which a thorough examination should include examining for lymphadenopathy and abdominal masses. A scrotal ultrasound should be performed for a suspected testicular tumour – a malignancy generally appears as a hypoechoic mass. Serum tumour markers (AFP, HCG, and LDH) are used in both the diagnosis and follow up – their initial values and kinetics pre and post op are important for staging and prognostic purposes. If a combination of clinical and ultrasound findings suggests a testicular tumour then urgent referral for review is recommended.
Treatment depends on staging If a testicular tumour is suspected then an inguinal orchidectomy would be performed with en bloc removal of the testis and the spermatic cord on the affected side. Frozen section is seldom used due to a high false negative rate. Further treatment depends on the type and stage of tumour. Testicular tumour staging uses the TNM system, which takes account of: the degree of local extension (pT stage) on histopathology of any orchidectomy specimen; retroperitoneal and mediastinal lymphadenopathy on CT imaging; and tumour markers.
Q Ultrasound scan of right testis showing hypoechoic testicular lesion suspicious of primary testicular malignancy. 38
Stage 1 seminoma: Retroperitoneal recurrence risk is 15-20%, for which cisplatin chemotherapy or para-aortic radiotherapy may be considered. An alternative is continued surveillance with regular CT scanning, depending on available facilities and patient compliance with the strict follow-up regime. Chemotherapy and radiotherapy for disease recurrence or
progression past Stage 1 disease has very good outcomes. Stage 1 NSGCT: Risk stratification is according to histopathology that includes evidence of vascular invasion. For low risk patients (no vascular invasion, no significant embryonal element) close, long term followup is recommended. For patients unwilling to comply, adjuvant chemotherapy or nerve sparing retroperitoneal lymph node dissection can be considered. In higher risk patients (vascular invasion) two courses of BEP chemotherapy (bleomycin, etoposide, cisplatin) are recommended. For higher grade tumours of these types, adjuvant treatment is chemotherapy (most common in Australia) or retroperitoneal lymph node dissection. Treatment for other types of testicular cancer would be dependent on tumour type and staging.
Fertility and follow up Aside from the effect of orchidectomy on fertility, patients who may be candidates for post-operative chemotherapy are advised to consider sperm banking because of the high incidence of oligo and azoospermia following chemotherapy. Improvement in sperm count post chemotherapy occurs in up to 80% of patient after five years, and the probability of a normal sperm count at five years is around 58%. Follow up is rigorous, comprising physical examination, tumour markers, and imaging. Their frequency and timing depends on tumour type, stage and prior treatment. Patients unwilling or unable to comply may be offered more aggressive/alternative treatment initially. O Author competing interests – no relevant disclosures
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