Mark Browning, M.D. ‘77 IUSME 2.29.16 Testicular Cancer Mark Browning, M.D. ‘77 IUSME 2.29.16

Testis

Testicular Cancer Germ Cell tumor in ages 15-45 > ½ occur Cure rate is 95% 99% confined to testis 96% spread to retroperitoneum 75% spread to other sites 8400 men diagnosed in 2015 380 deaths > Age 65 Lymphoma noted

Germ Cell Cancer 95% are of germ cell origin 5% arise from stromal tissue or Leydig cells Germ cell tumors may arise from Testicle (90%) Extragonadal Sites Anterior Mediastinum (1/4 Ts) Retroperitoneum

Mediastinal Germ Cell Cancer Malignant Transformation of germinal elements distributed during embryogenesis Rare (<500 cases/year) Associated with Klinefelter’s Syndrome

Epidemiology & Risk Factors Rare Cancer but most common among men ages 15-35 Associated with testicular dysgenesis & oligospermia Cryptorchidism 10% of testicular cancers ¼ of these patients have it occur in the contralateral, descended testis Brothers have higher risk factor 2% chance of opposite testis if previous diagnosis

Presentation of Testis Cancer Painless Scrotal Mass Gynecomastia Swelling in one or both legs & +/- blood clot Back Pain secondary to retroperitoneal adenopathy Pulmonary symptoms secondary to lung mets Associated low sperm count >80% are oligospermic at presentation

Diagnostic/Clinical Work-Up Scrotal Ultrasound Trans-scrotal biopsy is Contraindicated AFP & BHCG CT of Chest, abdomen & pelvis PET Scan is not helpful in diagnosing & Staging but can be helpful in seminomas with masses that have not completely resolved MRI only if Brain or Bone involved

Pathology Seminoma vs. Non-Seminoma If AFP is elevated is Non-Seminoma Most Tumors are “mixed”; if there is any non-seminoma component it is treated as a non-seminoma Non-Seminoma consists of Choriocarcinoma Embryonal carcinoma Yolk sac tumor teratoma

Tumor Markers Seminoma Choriocarcinoma: b-HCG elevated Usually normal marker levels Occassionally b-HCG elevated AFP is NEVER elevated Choriocarcinoma: b-HCG elevated Yolk sac tumor: AFP elevated Embryonal Carcinoma: both elevated Teratoma: neither elevated

Prognostic Variables Testicular Cancer is highly curable (>90%) Small subset of patients have a poor prognosis is still AFP > 10,000 B-HCG > 50,000 Non-pulmonary visceral mets (bone, brain, liver) Primary mediastinal non-seminomatous GCT

Clinical Presentations Embryonal carcinoma, choriocarcinoma & yolk sac tumors spread via lymphatics & hematogenously Pulmonary mets are common Less common are bone, brain & liver Teratoma does not spread hematogenously, but grows by local extension Can be carried to distant sites by other components of cancer (e.g.. Embryonal) Can transform into other cancers (sarcomas, neural tumors, carcinomas)

Treatment Surgery…Radical Orchiectomy Surveillance. Frequently with CTs & markers Radiation Rx possibly for Seminoma Chemotherapy for higher than stage 1 seminoma and non-seminoma Cis platinum, Bleomycin & Etoposide