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

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

3. 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

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

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

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

7. 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

8. 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

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

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

11. 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 ;356(18):

12. 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

13. 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

14. 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).

15. 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

16. 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)

17. 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

18. 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

19. 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!!

20. 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

21. 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

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

23. 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

24. 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

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

26. Question 3 The following statements are false, save
Testicular cancer is the most common cancer of infancy
There are more men aged 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

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

28. 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