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.