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TESTICULAR CANCER
  • primary or secondary cancers

  • primary cancers are germ cell tumors

  • secondary tumors of the testes may due to spread from adenocarcinoma of the prostate, lung carcinoma and malignant melanoma

Germ cell tumors (GCT)

  • common in men between the ages of 15 and 35

  • carries a potential cure rate in excess of 80%

  • appropriate diagnostic and treatment regimen started in a timely manner is important

  • the main histologic divisions are as follows:

  1. seminoma: this accounts for 40% of all cases

  2. non-seminomas: 60% of all GCT

  3. mixed germ cell tumor

Extragonadal GCT: these are germ cell tumors primarily found outside the gonads e.g. mediastinum, sacrococcygeal region and the retroperitoneum

GCT in children : usually of yolk sac tumor variety

GCT in the elderly : usually of spermatic seminoma variety

  • it follows an indolent course

  • metastasis is not common

  • affects both testicles at a slightly higher frequency

Stromal cell tumors

  • usually benign but about 10% of cases will spread

  • treatment is with orchiectomy alone

  • no need for RPLND ( retroperitoneal lymph node dissection)

Associated risk factors

  • cryptorchidism and undescended testes

  • testicular atrophy and increased FSH (follicle stimulating hormone)

  • testicular feminization syndrome

  • chromosome 12 abnormalities : the most important of which is isochromosome 12 abnormality , i12p.

  • nonseminomatous extragonadal GCT is associated with klinefelters syndrome

  • the significance of trauma, orchitis and irradiation is not known

 

Signs and symptoms

  • testicular swelling, usually painless

  • testicular pain may be sudden if there is associated torsion of the testicle or there is hemorrhage into the tumor

  • gynecomastia in patients with sertoli and leydig cell tumor varieties

  • back pain is very common in patients with retroperitoneal involvement

  • the testicular masses are firm to hard

  • varicocele

  • symptoms attributable to spread to other organs e.g. persistent cough and bloody sputum production, headaches, seizures, nausea, vomiting, blurred vision and abdominal and bone pains

 

Diagnosis

  • careful history and physical examination

  • testicular ultrasound

  • Radical transinguinal ultrasound of the affected testicle should be performed if any of the above tests are suggestive

  • CT scans of the chest abdomen and pelvis with contrasts

  • full blood count, chemistry, lactate dehydrogenase (LDH) level is suggestive of tumor bulk

  • tumor markers, alphafetoprotein (AFP) and b HCG (human chorionic gonadotrophin) levels to be asssesed before and after orchiectomy is done

  • alphafetoprotein : this is never produced by pure seminomas and choriocarcinomas

  1. half life of AFP is 4 to 6 days

  2. increased level of AFP also found in pregnant women and hepatitis

HCG (human chorionic gonadotrophin)

  • also found in normal patients , pregnant women, marijuana users, tumors of the bladder, prostate, kidney and ureters.

  • Half life is 24 hours

Nonseminomas may have either or both AFP and HCG elevation

 

TREATMENT OF GCT

Stage I ( tumor confined to the testis)

  • seminoma: patient may undergo radiation, observation or ?experimental chemotherapy

  • nonseminoma: observation versus nerve sparing RPLND ( retroperitoneal lymph node resection)

Stage I I ( lymph node involvement)

Seminoma:

  • intraabdominal lymph node enlargement up to 10cm. requires radiation therapy

  • if the lymph nodes are greater than 10cm, chemotherapy is indicated

 

Nonseminoma:

- retroperitoneal lymph node dissection (RPLND) followed by observation in patients with microscopic lymph node involvement

  • chemotherapy to be reserved for relapsed cases

  • cure rates identical in both instances

  • chemotherapy definitely indicated in patients with bulky lymph nodes

 

Advanced GCT

  • treatment requires the use of platinum-based chemotherapeutic regimen

  • aggressive treatment of advanced seminoma is less

  • in good prognosis cases 3 cycles of PEB ( platinum, etoposide and bleomycin) is equivalent to 4 cycles of EP (etoposide and platinum)

  • in poor prognosis cases, 4 cycles of BEP required

  • any residual masses ( except in seminomas with a mass less than 3cm.) must be resected

  • if markers are negative after treatment, observe and do follow up examinations and levels of tumor markers

  • if markers are positive , salvage therapy with VIP (vinblastine, ifosfamide and cisplatin)

  • high-dose chemotherapy with autologous bone marrow transplant may be given after 2 cycles of standard regimen ( PEB or PVB) in patients with poor prognostic risks or after failure of salvage therapy

  • poor prognostic cases to be enrolled in clinical trials.