1. Testicular cancer

2. In a nutshell
It metastasizes early but is highly curable even in metastatic stage
Tumor markers important in staging and follow-up

3. Epidemiology
occurs most often in men between the ages of 15 and 40, where is also the most frequent solid tumor
it accounts for only 1% of all cancers in men
incidence highest among men living in the United States and Europe and lowest among men living in Africa or Asia

4. Risk factors Undescended testicle=cryptorchidism:
-Normally, the testicles descend from inside the abdomen into the scrotum before birth. The risk of testicular cancer is increased in males with a testicle that does not move down into the scrotum
-Although most cancers develop in the undescended testicle, about 1 out of 4 cases occur in the normally descended testicle. Based on these observations it is probable that cryptorchidism doesn't actually cause testicular cancer but that there is something else that leads to both testicular cancer and abnormal positioning of one or both testicles.
Family history of testicular cancer: the risk for testicular cancer is greater in men whose brother or father has had the disease. However, only about 3% of testicular cancer cases are actually found to occur in families, most men with testicular cancer do not have a family history of the disease.

6. Risk factors
Klinefelter's syndrome: Men with Klinefelter's syndrome (a sex chromosome disorder-47XXY-that is characterized by low levels of androgens, sterility, breast enlargement and small testes) are at greater risk of developing testicular cancer.
Race: The risk of testicular cancer among white men is about 5 times that of black men and 3 times that of Asian
Carcinoma in situ of the testicle
A previous testicular cancer

7. Risk factors NOT RISK FACTORS: -trauma
-repetitive micro-trauma: bicycle or horseback riding

8. Histology A) From the testicular parenchyma (90%): Germ cell tumors:
~50%/50% seminoma / non-seminomatous germ cell tumor
Non-seminomatous germ cell tumors are subdivided in:
-Embryonal carcinoma
-Yolk sac tumors
-Teratoma etc.
B) From the testicular stroma (10%): stromal tumors

9. Routes of dissemination
Local invasion
Lymphatic spread-early
-directly to para-aortic lymph nodes (because embryonic origin of testes is intra-abdominal)
Hematogenous metastases-early
-lung, liver, brain, bone

10. Clinical picture
Most patients present with symptoms consistent with infectious epididymitis and/or orchitis
only a minority of patients present with the pathognomonic painless testicular mass
Lumbar pain-in case of para-aortic lymph node involvement
Gynecomastia
Stromal tumors may secrete estradiol directly
βHCG secreted by the tumor acts like LH and increases testosterone, which transforms in adipose tissue into estradiol
Symptoms caused by metastases

11. Diagnosis History and physical
Inspection and palpation of the testicle
Testicular ultrasound
Palpation of inguinal lymph nodes
Abdominal CT for para-aortic and hepatic metastases
Tumor markers (βHCG, AFP, LDH), VSH
Chest radiography for lung metastases
Chest CT for lung metastases IF para-aortic lymph nodes positive or chest radiograph abnormal
Brain MRI for brain metastases IF clinical signs of brain metastases
Bone scintigraphy IF bone pain
βHCG=human chorionic gonadotropin, beta subunit
AFP=alpha-fetoprotein
LDH=lactate dehydrogenase

12. Diagnosis-tumor markers
Seminoma: AFP negative!!!, βHCG may be positive, LDH may be increased
Non-seminomatous germ cell tumor: AFP, βHCG may be positive; LDH may be increased
Mnemonic: AFP-”fetal tissue growing in the testis” in case of non-seminoma

13. Treatment
If suspect for testicular cancer=>UNILATERAL RADICAL INGUINAL ORCHIECTOMY
NO BIOPSY BECAUSE THE RISK OF DISSEMINATION !!!
Radical orchiectomy. Note the inguinal approach and the use of the tourniquet.

14. Adjuvant treatment for seminoma
Stage I (=no lymphadenopathy on CT and no distant metastases):
Choice between:
-surveillance
-one cycle of chemotherapy
-para-aortic (“prophylactic”) radiotherapy (low dose: Gy)
Stage II (=positive lymphadenopathy)
para-aortic plus ipsilateral inguinal radiotherapy
4 cycles of chemotherapy
Stage III (=distant metastases or highly elevated tumor markers)
-4-6 cycles of chemotherapy

15. Adjuvant treatment for non-seminomatous germ cell tumor
-para-aortic lymph node dissection or chemotherapy (more complicated guidelines, too much for student level)

16. Follow-up History and physical + chest X-ray + βHCG, AFP, LDH
-every 2 months for year 1
3 mo/y 2
4 mo/y 3
6 mo/y 4
Abdominal CT after 4 months of treatment
PET-CT if suspicion of relapse

17. Follow-up for side effects of treatment
RT favorizes gastric cancer
RT may lead to retroperitoneal fibrosis with ureteral obstruction
Chemotherapy may lead to sterility (although in general men with testicular cancer have low fertility from the beginning due to degenerative changes in the contralateral testicle)
Etc.