Testicular Cancer

Aetiology

  • Most common solid cancer in men 20-45
  • Seminomatous - 35-45 years
  • Non-seminomatous (teratoma) - < 35 years

Risk factors

  • White Caucasians
  • Previous TC - increased risk in contralateral testicle
  • Cryptorchidism
  • HIV
  • Family history

Pathophysiology

  • Germ cell tumours, 2 main types:

Seminoma

  • Arise from seminiferous tubules
  • Cure rate 95%, extremely responsive to radiotherapy even if relatively advanced

Teratoma

  • Often far more aggressive and can metastasize
  • Very chemosensitive even with metastasis
  • Less common
  • Rarely exist as 'pure' tumours; usually associated with other non-seminomatous cell types (e.g. yolk sac, embryonal, choriocarcinoma)
  • Prognosis dependent on sub-types present and the relative proportion

Other types

  • Yolk sac tumour - can produce alpha feto protein
  • Embryonal cell carcinoma - aggressive form, looks high grade and is associated with frequent metastasis
  • Choriocarcinoma - positive for beta HCG, positive pregnancy test

Clinical presentation

Symptoms

  • Scrotal lump
  • Delayed presentation occasionally seen
  • Acute pain due to bleeding
  • Symptoms of advanced disease: weight loss, neck lumps, chest symptoms or bone pain

Signs

  • Asymmetry or slight scrotal discolouration
  • Hard, non-tender, irregular mass mostly intratesticular
  • Assess involvement of epididymis, spermatic cord and scrotal skin
  • Secondary hydrocele
  • Abdominal mass, lymphadenopathy - advanced disease

Investigations

  • Imaging - US testicle, CT chest abdomen for staging
  • Bloods:
    • Tumour markers
      • Alpha-fetoprotein may be raised in teratomas (not seminomas)
      • Beta-hCG may be raised in teratomas and seminomas, but more often in teratomas
      • Lactate dehydrogenase
    • FBC
    • LFTs
    • Renal function tests

Management

  • Generally a good prognosis even at an advanced stage
  • Radical inguinal orchidectomy
    • Offer sperm preservation
  • Re-check tumor markers 1 week post-op if they are elevated pre-op
  • Check CT staging
  • Further followup by oncologist
    • Chemotherapy as adjuvant treatment even in non-metastatic cases