Ashray Gunjur Intern, Royal Melbourne Hospital Testicular Cancers Ashray Gunjur Intern, Royal Melbourne Hospital

Did you know? That the words testify, testimonial and testament are derived from... The ancient roman practice of cupping your testicle when you spoke

Anatomy http://www.aboutcancer.com/testicle_anatomy1.jpg For clinical exams of the testes, the important landmarks are 1) the tunica vaginalis, anterior-inferior double layer- potential space where fluid may accumulate 2) epidydymis, posterio-superiorio-lateral structure 3) superficial inguinal ring, with spermatic cord connecting to epidydymis http://www.aboutcancer.com/testicle_anatomy1.jpg

Differentials HISTORY? * Pain?? * Time course of symptoms? PHYSICAL EXAM? * pain? * reducibility? * Lie of teste?

Differentials Toronto Notes 2010 Phren’s sign- lifting testicle relieves pain of epididymitis = positive Toronto Notes 2010

Differentials 1) Hydrocele A collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis, due to secretions > reabsorptions.

Differentials 2) Epidydymal cyst/Spermatocele - Cysts usually located in the head of the epidydymis, generally asymptomatic - spermatocele = cyst >2cm. Always superior to the testis, distinct

Differential 3) Varicocele Dull, aching, left scrotal pain, typically noticeable when standing and relieved by recumbency Testicular atrophy, believed to be secondary to loss of germ cell mass by induction of apoptosis (programmed cell death) initiated by the associated slightly increased scrotal temperature Decreased fertility

Typical case Young man with painless growth of unilateral teste On examniation, firm nontender, non-transilluminating mass in one of the testes

Epidemiology Relatively rare- 1-2% of men, but.. Most common malignancy in age 20-40 Three peak model: infancy, 30-34 years, >60 years

Risk factors Cryptorchidism- 4-8x risk of germ cell tumour Risk still increased after orchiopexy in pt <6yrs old- 2.23x* Risk still increased in contralateral testis- 5-20% of malignancy in normal descended testis! Prior testicular cancer- 500x Approx 1-2% of testicular cancer patients will develop a second primary contralaterally... *Pettersson A, Richiardi L, Nordenskjold A, Kaijser M, Akre O. Age at surgery for undescended testis and risk of testicular cancer. N Engl J Med. May 3 2007;356(18):1835-41

Risk factors Genetics Diethylstilbestrol (DES) exposure in utero E.g. Klinefelter syndrom (47XXY)- germ cell tumours Diethylstilbestrol (DES) exposure in utero E.g. ‘Agent Orange’, Industrial occupation

Diagnosis Best first test hypoechoic lesion Can distinguish intrinsic from extrinsic testicular lesions with high degree of accuracy Can detect lesions as small as 1mm in testis! Seminomas- tend to be well defined hypoechoic lesions without cystic areas Nseminomas- inhomogenous with calcs, cystic areas, indistinct margins

Diagnosis Gold standard? - inguinal orchidectomy!! Although the fear of scrotal violation may be surgical ‘dogma’- a review in 1995 J Urol systematically reviewing all series with scrotal violation found local recurrence rates to be small 2.9 vs. 0.4%, and no statistically different overall survival without any additional local adjuvant treatment (potentially morbid or disfiguiring).

Histologic types Germ cell tumors (>95%): Seminoma (40%) versus Non seminomatous germ cell tumors (NSGCT) (40%) vs. mixed (15%) Non-germ cell tumors (rare, <5%) Leydig cell tumors (precocious puberty) Sertoli cell tumors Mixed sex chord-stromal tumors

Germ cell tumours Seminoma (40%) Non-seminoma (40%) (elevated AFP) Generally favourable prognosis, tend to be in older men Rarely make B-HCG (15%), no aFP (0%) Non-seminoma (40%) Choriocarcinoma (elevated b-HCG (50%), haematogenous spread) Embryonal cell Teratoma (mature and immature) Yolk sac (elevated AFP)

Tumour markers AFP levels are elevated 50%-70% NSGCT hCG levels are elevated in 40%-60% NSGCT. AFP has a half-life of 5-7 days hCG has a half-life of 36 hours. Important to follow response after orchiectomy LDH is non-specific measure of tumor burden

Risk stratification Good-risk nonseminoma Testicular or retroperitoneal primary tumor, and No nonpulmonary visceral metastases, and Good markers; all of:Alpha-fetoprotein (AFP) < 1,000 ng/mL, and Human chorionic gonadotropin (hCG) < 5,000 IU/mL (1,000 ng/mL), and Lactate dehydrogenase (LDH) < 1.5 times the upper limit of normal Intermediate-risk nonseminoma Intermediate markers; any of:AFP 1,000 to 10,000 ng/mL, or hCG 5,000 IU/L to 50,000 IU/L, or LDH 1.5 to 10 times the upper limit of normal Poor-risk nonseminoma Mediastinal primary, or Nonpulmonary visceral metastases, or Poor markers; any of:AFP > 10,000 ng/mL, or hCG > 50,000 IU/mL (10,000 ng/mL), or LDH > 10 times the upper limit of normal

Risk stratification Good-risk seminoma Any primary site, and No nonpulmonary visceral metastases, and Normal AFP, any hCG, any LDH Intermediate-risk seminoma Nonpulmonary visceral metastases, and Poor-risk seminoma No such thing!!

Treatment Post Orchidectomy… Seminoma Stage IA and B: radiation therapy vs surveillance (? Chemo) NSGCT Stage IA retroperitoneal lymph node dissection vs surveillance Stage IB retroperitoneal lymph node dissection vs surveillance vs chemotherapy Higher stages-chemo, f/b surgery as needed

Retroperitoneal Lymph Node Dissection RPLND is the only reliable way to identify nodal micromets- high false negative rate with CT scans. - accurate path staging of retroperitoneum to guide ?chemotherapy in low radiologically staged NSGCT

Why? Non-seminomas are more aggressive than seminomas RPLND is used to guide chemotherapy No of +ive nodes correlates to cycles of chemo

Surveillance NCCN guidelines CT q 2-3 months for first year or two Then q4, q6 Labs, CXR q month for year one, then q 2 months, etc Issues are compliance, anxiety

Question 1 The most common presenting complaint for a testicular cancer is: a) a painless swelling of a single teste b) a red, painful scrotum c) haematuria d) back pain

Question 2 All of the following are a risk factor for testicular cancers, save Cryptorchidism Maternal DES exposure Caucasian race Repeated testicular trauma

Question 3 The following statements are false, save Testicular cancer is the most common cancer of infancy There are more men aged 15-25 diagnosed with testicular cancer than >50 Unilateral surgical orchidectomy precludes the chance of testicular cancer recurring Unilateral surgical orchidectomy is the gold standard diagnostic procedure for testicular cancer

Question 4 Routine workup and staging of diagnosed testicular cancer should include: a-FP B-HcG CT A/P + C PET scan

Question 5 The following are incorrect about Seminomas, save Ultrasound features often involve heterogenous cystic components aFP is often raised and used for prognostication Para-aortic radiotherapy is often indicated Patients with metastatic disease have a poor prognosiss