Testicular cancer: current views Dr. M. Mangala MD (Kin); FRCS (Ireland); MMed (Wits); FCS (SA) Urology 38 th BMA CONGRESS

Background  1% and 1.5% male neoplasms  5% all urological tumors  Prevalence 2-3/  In the y.o 62/  5% cases bilateral  Duplication of the short arm of X12  Isochromosome 12p or I(12p)

Diagnosis  Scrotal US  Sensitivity 100%  MRI  Sensitivity 100% and Specificity %  High cost: not justified

Diagnosis  Serum tumour markers  AFP produced by yolk sac: T1/2 5-7 days  hCG expression of trophoblasts: T1/2 2-3 days  B subunit specific  LDH marker of tissue destruction (bulk)  Inguinal exploration and orchidectomy  Radical orchidectomy

Diagnosis  False AFP elevation  Cancers: Hepatobiliary, pancreatic, gastric, lung  Benign: Liver conditions  False elevation hCG  Cancers: Lung, hepatobiliary, gastric, pancreatic, multiple myeloma

Tumour marker by histological type hCG (%)AFP (%) Seminoma70 Teratoma2538 Teratocarcinoma5764 Embryonal6070 Choriocarcinoma1000

On orchidectomy  Organ-sparing surgery  In suspicion of a benign-lesion  In synchronous, bilateral testicular tumours  In metachronous, contralateral tumours  In a tumour in a solitary testis The tumour should be less than 30% of the testicular volume.

Staging and clinical classification  To determine the presence of metastatic or occult disease  Tumour markers  Nodal pathway screened  Visceral metastasis excluded  Abdominal, supra-clavicular nodes, liver  Status of mediastinal and lung metastasis  Status of brain and bone if suspicion

Staging and clinical classification  Abdominal, pulmonary, extra-pulmonary, mediastinal node assessed by CT  Supraclavicular nodes. PE and CT  Retroperitoneal nodes CT  MRI as CT but cost limit its use.  FDG-PET: F/U of Residual mass seminoma post CRx  WW or active treatment?

Classification  TNM  pTX: Primary tumour can’t be assessed  pT0 : No evidence of primary tumour  pTis: Intratubular germ cell neoplasia  pT1: Tumour limited to testis and epidydimis without vascular/lymphatic invasion _ pT2: same with invasion

Classification  TNM  pT3: Invasion of the spermatic cord  pT4: Tumour invades scrotum with or without vascular/lymphatic invasion  Serum markers  Sx, S0, S1, S2, S3 according to level of LDH, hCG, AFP.

Classification  Stage I: Confined to the testis  Stage IA: pT1, N0, M0, S0  Stage IB: pT2, N0, M0, S0  Stage IS: pT/Tx, N0, M0, S1-3  Stage II: Retroperitoneal involvement  IIA nodes 2cm  Stage III: Nodes visceral or supradiaphragmatic

Treatment: Seminoma  Low-stage: I,IIA  Surgery, DXT to retroperitoneum  High-stage: IIB, III (Bulky and elevated AFP)  Primary CRx (Sensitivity to platinum)  Residual mass Mx controversial

Treatment: NSGCT  Low-stage  RPLND  Surveillance  Tumour within tunica albuginea  Normal tumour markers after orchidectomy  No vascular invasion  No sign of disease on imaging  Reliable patient

Treatment: NSGCT  Surveillance  Monthly visit 1/12 for 2 years  Bimonthly third year  Tumour markers each visit  CXR, CT Scan q 3/12

Treatment: NSGCT  High-stage  Primary CRx  Tumour marker stable  If residual mass excision  Tumour marker raised  Salvage CRx

Follow-up  Labour intensive  Don’t forget to palpate  Remaining testis  Abdomen  Lymph node area