Testicular Cancer
Page updated Winter 2021.
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Basics and Diagnosis
Epidemiology
Germ cell tumor is the most common solid malignancy among males age 20 to 40 years.
Risk factors
Germ cell neoplasia in situ, history of UDT, family or personal history of testis cancer.
Diagnosis
Solid testicular mass
Any solid mass in the testis identified by physical exam or imaging should be treated as a malignant tumor until proven otherwise.
Scrotal ultrasound
With doppler
CT scan/ MRI of the abdomen and pelvis
With IV contrast
Chest imaging
Serum tumor markers before orchiectomy
AFP, hCG, and LDH
Serum tumor markers after orchiectomy
If serum markers are elevated before orchiectomy, we measure them again after orchiectomy.
Radical Orchiectomy
Radical inguinal orchiectomy is the first step in managing these patients.
Risks Associated with Radical Orchiectomy
Risks of anesthesia
Bleeding into the scrotum
Infection
Damage to nearby nerves, and structures
Inguinal hernia
Infertility
Changes in testosterone levels
Notice: Cancer may recur and spread even after this procedure. Further surveillance and/or treatments are required for all patients.
Sperm Banking
We discuss sperm banking before treatment.
Staging
TNM staging: click here.
AJCC staging: click here.
Risk Classification-Non Seminoma
Good prognosis
Testicular/retroperitoneal primary
No nonpulmonary visceral metastases
AFP <1000 ng/mL
HCG <5000 IU/L
LDH <1.5 × upper limit of normal (N)
Intermediate prognosis
Testicular/retroperitoneal primary
No nonpulmonary visceral metastases
AFP ≥1000–10,000 ng/mL
HCG ≥5000–50,000 IU/L
LDH ≥1.5 × N and ≤10 × N
Poor prognosis
Mediastinal primary or Nonpulmonary visceral metastases or
AFP >10,000 ng/mL or
HCG >50,000 IU/L (10,000 ng/mL) or
LDH >10 × upper limit of normal
Risk classification-Seminoma
Notice: AFP is normal in pure seminoma.
Good prognosis
No nonpulmonary visceral metastases
Intermediate prognosis
Nonpulmonary visceral metastases
Germ Cell Neoplasm In Situ
Germ cell neoplasm in situ is a precursor lesion for germ cell tumor and is associated with a 50% risk of developing an invasive germ cell tumor within 5 years.
Radical orchiectomy or low-dose (≥ 20 Gy) RT is an effective treatment for germ cell neoplasm in situ.
Seminoma
Serum HCG is elevated in about 15% of patients with metastatic seminoma. Unlike non-seminoma, serum tumor marker levels are not used to guide treatment.
Stage I Treatment options after orchiectomy are:
Surveillance (preferred), carboplatin x 1, RT (20 Gy)
Stage IS Perform CT chest/abdomen/pelvis
Stage IIA RT (30 Gy) or Chemotherapy (BEP X 3 or EP X 4)
Stage IIB with a LN ≤3cm
Chemotherapy (BEP X 3 or EP X 4) or RT (36 Gy)
Stage IIB Seminoma with a LN >3 cm
BEP X 3 or EP X 4
Stage IIC and III Good Risk
BEP X 3 or EP X 4
Stage III Intermediate Risk (Nonpulmonary Visceral Metastases)
BEP X 4 or VIP X 4
Residual Masses > 3 cm after First-line Chemotherapy
FDG-PET will be done. Patients with PET positive residual masses should undergo surgical resection.
Residual masses that are PET-negative or less than 3 cm can be safely observed after chemotherapy.
Teratoma at Metastatic Sites
This is less common in seminoma compared to non-seminoma but should be considered in patients who fail to respond to chemotherapy.
Non Seminoma
Stage I
Surveillance or RPLND or BEP X 1
RPLND: stage I non-seminoma who had teratoma with malignant transformation at orchiectomy.
We recommend active treatment (RPLND or chemotherapy) to those with lymphovascular invasion and/or embryonal carcinoma predominance.
Stage IS BEP X 3 or EP X 4
Stage IIA with Normal Post-Orchiectomy AFP & HCG
RPLND or chemotherapy
Stage IIA S1 BEP X 3 or EP X 4
Stage: IIB BEP X 3 or EP X 4 . RPLND may be done in highly selected patients.
Stage IIB S1 BEP X 3 or EP X 4
IIC, and IIIA BEP X 3 or EP X 4
IIIB and IIIC BEP X 4 or VIP X 4
Post RPLND Management
pN0: surveillance
pN1: surveillance (preferred) or BEP X 2 or EP X 2
pN2: BEP X 2 or EP X 2
pN2: BEP X 3 or EP X 4
pN1-3 pure teratoma: surveillance is preferred.
Post-chemo Residual Masses with Normal Tumor Markers
Resect if ≥ 1 cm and tumor markers are negative.
Next step is going to be per resected pathology:
Teratoma or necrosis: surveillance
Other germ cells: 2 cycles of EP or TIP or VIP or VeIP
Post-chemo Residual Masses with Elevated Tumor Markers
Mildly elevated and normalizing: manage like masses with normal tumor markers.
Elevated but stable: Close surveillance.
Elevated and rising: Second line therapy
Second Line Therapy
If relapse occurs <2 years: consider chemo. Surgery is an option for a single mass.
Conventional chemotherapy regimen: TIP or VeIP
High dose chemo: Carboplatin/ etoposide or P-ICE
Relapse occurs > 2 years: consider surgery, if respectable.
RPLND
Cephalad extent of the dissection
Level of the renal arteries.
Caudal extent of the dissection
The crossing of the ureter over the ipsilateral common iliac artery.
Right modified template
We omit the para-aortic lymph nodes below the inferior mesenteric artery
Left modified template
We omit paracaval, precaval, and retrocaval lymph nodes.
Full bilateral template dissection
We recommend this if there is suspicious lymph nodes on CT, or during the surgery or when the primary tumor is teratoma.
Nerve-sparing
Is appropriate for selected patients who want to preserve their ejaculation.
Gonadal vessels
Ipsilateral ones should be removed.
Retrocrural Dissection
May be considered at the time of RPLND.
Nephrectomy
It is the most common auxiliary procedure.
Major Vascular Reconstruction
In some series, 15% of patients needed vascular procedures.
This included aortic resection, cavotomy/caval resection, iliac resection, and renovascular resection with repair.
Primary reconstruction of the IVC is preferred if possible.
Small vessel wall injuries may be repaired via patch venoplasty or with bovine/porcine pericardial grafts.
PTFE or Dacron grafts may be used.
Liver Resection
RPLND in patients with liver involvement is usually done after first, second or third-line chemotherapy.
All lesions including residual liver masses should be resected at this time.
Thoracic Masses
These masses should be addressed after RPLND is done.
All masses > 1 cm should be considered for resection unless the retroperitoneum only had fibrosis.
Brain Metastases
Primary chemo ± RT ± Surgery
Brain metastases are associated with choriocarcinoma and should be suspected in any patient with a very high serum HCG level.
Patients with choriocarcinoma of the brain are at risk of bleeding and should be monitored for this when chemotherapy is started.
Chemotherapy Regimens
BEP
Bleomycin + etoposide + cisplatin
EP
Etoposide + cisplatin
VIP
Etoposide + Ifosfamide + Cisplatin
TIP
Paclitaxel + ifosfamide + cisplatin
VeIP
Vinblastine + ifosfamide +cisplatin (Platinol).
Carboplatin + etoposide
P-ICE
Paclitaxel + ifosfamide + carboplatin + etoposide
Testicular Microlithiasis
Incidentally detected microlithiasis should not undergo further evaluation.
Men with risk factors and testicular microlithiasis should be counseled about the potential increased risk of germ cell tumor. They need to perform periodic self-examination, and be followed by a urologist.