Testicular cancer: current views

Dr. M. Mangala

MD (Kin); FRCS (Ireland); MMed (Wits); FCS (SA) Urology

38th BMA CONGRESS

Background

1% and 1.5% male neoplasms 5% all urological tumors Prevalence 2-3/100000

In the 15-34 y.o 62/100000 5% cases bilateral Duplication of the short arm of X12

Isochromosome 12p or I(12p)

Diagnosis

Scrotal USSensitivity 100%

MRISensitivity 100% and Specificity 95-100%High cost: not justified

Diagnosis

Serum tumour markersAFP produced by yolk sac: T1/2 5-7 dayshCG expression of trophoblasts: T1/2 2-3 days

B subunit specific

LDH marker of tissue destruction (bulk) Inguinal exploration and orchidectomy

Radical orchidectomy

Diagnosis

False AFP elevationCancers: Hepatobiliary, pancreatic, gastric, lungBenign: Liver conditions

False elevation hCGCancers: Lung, hepatobiliary, gastric, pancreatic,

multiple myeloma

Tumour marker by histological type

hCG (%) AFP (%)

Seminoma 7 0

Teratoma 25 38

Teratocarcinoma 57 64

Embryonal 60 70

Choriocarcinoma 100 0

On orchidectomy

Organ-sparing surgery In suspicion of a benign-lesion In synchronous, bilateral testicular tumours In metachronous, contralateral tumours In a tumour in a solitary testis

The tumour should be less than 30% of the testicular volume.

Staging and clinical classification

To determine the presence of metastatic or occult diseaseTumour markersNodal pathway screenedVisceral metastasis excluded

Abdominal, supra-clavicular nodes, liverStatus of mediastinal and lung metastasisStatus of brain and bone if suspicion

Staging and clinical classification Abdominal, pulmonary, extra-pulmonary,

mediastinal node assessed by CT Supraclavicular nodes. PE and CT Retroperitoneal nodes CT MRI as CT but cost limit its use. FDG-PET: F/U of Residual mass seminoma post

CRxWW or active treatment?

Classification

TNMpTX: Primary tumour can’t be assessedpT0 : No evidence of primary tumourpTis: Intratubular germ cell neoplasiapT1: Tumour limited to testis and epidydimis

without vascular/lymphatic invasion

_ pT2: same with invasion

Classification

TNMpT3: Invasion of the spermatic cordpT4: Tumour invades scrotum with or without

vascular/lymphatic invasion Serum markers

Sx, S0, S1, S2, S3 according to level of LDH, hCG, AFP.

Classification

Stage I: Confined to the testisStage IA: pT1, N0, M0, S0Stage IB: pT2, N0, M0, S0Stage IS: pT/Tx, N0, M0, S1-3

Stage II: Retroperitoneal involvement IIA nodes < 2cm, IIB nodes > 2cm

Stage III: Nodes visceral or supradiaphragmatic

Treatment: Seminoma

Low-stage: I,IIA Surgery, DXT to retroperitoneum

High-stage: IIB, III (Bulky and elevated AFP)Primary CRx (Sensitivity to platinum)Residual mass Mx controversial

Treatment: NSGCT

Low-stageRPLNDSurveillance

Tumour within tunica albuginea Normal tumour markers after orchidectomyNo vascular invasionNo sign of disease on imagingReliable patient

Treatment: NSGCT

SurveillanceMonthly visit 1/12 for 2 yearsBimonthly third yearTumour markers each visitCXR, CT Scan q 3/12

Treatment: NSGCT

High-stagePrimary CRx

Tumour marker stable If residual mass excision

Tumour marker raised Salvage CRx

Follow-up

Labour intensive Don’t forget to palpate

Remaining testisAbdomenLymph node area