Urology: Testicular Cancer

Testicular Cancer

Types

  • Germ Cell Tumors (95%)
    • Seminoma (Most Common)
    • Nonseminomatous
      • Teratoma
      • Choriocarcinoma
      • Embryonal Carcinoma
      • Yolk Sac
  • Stromal Tumors (5%)
    • Leydig Cell Tumor (Most Common)
    • Sertoli Cell Tumor
    • Granulosa Cell Tumor
  • Other Tumors
    • Lymphoma
    • Carcinoid
    • Metastases

Risk Factors

  • Germ Cell Tumors:
    • Cryptorchidism
    • Infertility
    • Hypospadias
    • HIV
  • Stromal Tumors:
    • No Known Risk Factors

Prognosis

  • Most Common Solid Malignancy in Males Age 15-35
  • High Survival Rate Due to Modern Advances – Previously was the Most Common Cancer-Related Death in Males Age 25-35
  • Seminomas are Exquisitely Sensitive to Radiation Therapy with a Favorable Prognosis
  • Embryonal Carcinomas are Aggressive with High Rates of Metastases

Presentation

  • Painless Nodule/Mass
  • Heavy Sensation
  • Dull Ache
  • Gynecomastia from hCG Production
  • Symptoms from Metastases
  • Leydig Cell Tumors May Present with Precocious Puberty, Virializing or Feminizing Due to Testosterone Production

Diagnosis

  • Initial Evaluation: US & Serum Tumor Markers
    • Serum Tumor Markers: AFP, Beta-HCG & LDH
    • Check Hormonal Markers if Stromal Tumor Suspected: Testosterone, LH & FSH
    • CT of Chest/Abdomen/Pelvis for Staging
  • Definitive Diagnosis: Pathology on Orchiectomy
    • Do Not Biopsy – Risk for Tumor Seeding to Scrotal Sac & Metastatic Spread to Inguinal Nodes

Serum Tumor Markers

  • Seminoma: Beta-HCG & LDH May Be High
    • AFP Not Elevated
  • Nonseminomatous Germ Cell Tumors: AFP, Beta-HCG & LDH May Be High
  • Stromal Tumors: Negative Tumor Markers
    • May See Elevation of Hormonal Markers

Seminoma, Testicle Opened After Resection 1

Embryonal Carcinoma, Testicle Opened After Resection 2

Seminoma US 3

TNM Staging – AJCC 8

  • TNM
 TNM
IConfined to Testicle1-5 LN ≤ 2 cmMets+
IIInvaded Blood Vessels, Lymphatics, Epididymis, Fatty Tissue or Tunica Vaginalis> 5 LN or 2-5 cm 
IIIInvaded the Spermatic CordLN > 5 cm 
IVInvaded the Scrotum  
  • Stage
 TNM
IAny TN0M0
IIAny TN1M0
IIIAny TAny NM1
  • Staging Subgroups Include Serum Tumor Markers (S) – LDH, Beta-HCG & AFP

Treatment

  • Primary Treatment: Radical Orchiectomy by Inguinal Incision
    • Inguinal Incision Avoids the Lymphatics of a Scrotal Approach
    • May Consider Partial Orchiectomy if Polar Mass ≤ 2 cm & Abnormal or Absent Contralateral Testicle
  • Retroperitoneal Lymph Node Management:
    • Seminoma: Radiation Therapy
    • Nonseminomatous or Stromal Tumor: Retroperitoneal Lymph Node Dissection (RPLND)
    • *Consider Active Surveillance Alone for Stage I with Low Risk for Recurrence
  • Advanced Disease: Chemotherapy

Radical Orchiectomy – Procedure

  • Inguinal Incision & Incise External Oblique Fascia (Similar to Inguinal Hernia)
  • Mobilize Cord (Preserve Ilioinguinal Nerve)
  • Divide External Spermatic Fascia & Cremasteric Fibers
  • Deliver Testicle by Gentle Cephalad Traction
  • Mobilize Cord to Level of Internal Ring
  • Individually Dissect, Ligate & Divide the Vas Deferens & Gonadal Vessels
    • High-Ligation at Level of Internal Inguinal Ring (Key Step)
  • Closure

References

  1. Agrawal S, Bajpai R, Agrawal RK, Gupta TC. Bilateral synchronous seminoma with bilateral cryptorchidism of the testis. Indian J Urol. 2010 Oct;26(4):587-9. (License: CC BY-NC-SA-3.0)
  2. Barmon D, Kataki AC, Sharma JD, Hafizur R. Embryonal carcinoma in androgen insensitivity syndrome. Indian J Med Paediatr Oncol. 2011 Apr;32(2):105-8. (License: CC BY-NC-SA-3.0)
  3. Dieckmann KP, Anheuser P, Sattler F, Von Kügelgen T, Matthies C, Ruf C. Sequential bilateral testicular tumours presenting with intervals of 20 years and more. BMC Urol. 2013 Dec 9;13:71. (License: CC BY-2.0)