TESTICULAR CANCER

Michael D. Strub, M.D.

April 24, 2000

 

Testicular Carcinoma:

Most common malignancy in males 15-35 years of age

One of the most curable solid malignancies; a model for multimodal therapy

Mortality: 1970 = 50% 1996 = <10%

 

Histology:

Testis covered with tunic during descent from genital ridge in peritoneum, passes through inguinal canal to scrotum

Tunica vaginalis, internal spermatic fascia, cremasteric fascia, external spermatic fascia, dartos tunic, scrotal skin

Testes covered by tunica albuginea

Seminiferous tubules of 2 cell types

Sertoli - support cells

Spermatogonia - germinal cells

Between tubules are Leydig interstitial cells that produce testosterone

90.9% testis tumors arise from germinal elements

Frequency of Histology:

Seminoma 40%

Embryonal Carcinoma 20-25%

Teratocarcinoma 25-30%

Teratoma 5-10%

Pure Choriocarcinoma 1%

Mixed tumors more common

Testis Blood Supply:

Originates from genital ridge. Internal spermatic artery from aorta below renal arteries

Passes through spermatic cord to testis accompanied by artery of the vas

Veins: pampiniform plexus to spermatic vein to vena cava (Rt.): Left renal vein on left

Epidemiology:

Incidence: 55,000 new cases annually

American white male lifetime 1:500

Age peak 20-40 years, >60 years and 0-10 years

Seminoma rare <10 and >60; most common 35-39

Yolk sac most common infants and children

Malignant lymphoma >50 years

Racial: American Blacks 1/3 incidence of American White, but 10x incidence of African Blacks

Higher risk in professional men

Genetic: 1/3 genetically predisposed with homozygous recessive inheritance

Laterality: R>L; same as cryptorchidism

Etiology:

Cryptorchidism

Dysgensis

Heredity

Chemical carcinogens

Trauma

Orchitis

Congenital Causes:

Cryptorchidism (undescended testicle) 7-10% with cancer

0.7% of adults

3-14X normal expected incidence of testis cancer

Acquired Causes:

trauma - not causative

Hormones - exogenous

Atrophy - nonspecific or mumps orchitis leads to postulated hormone imbalance

Natural History:

Approximately 1/2 patients with nonseminomatous tumors present with disseminated disease

Involvement of epididymus or cord may lead to pelvic and inuinal node metastasis

Tumor confined to testis proper spreads to retroperitoneal nodes

 

Generalizations:

Complete spontaneous regression is rare

All germinal testis tumor in adults should be regarded as malignant

Tunica albuginea is natural barrier to expansile local growth

Lymphatic metastasis is common to all forms of germinal testis tumors: pure chorio spreads by vascular invasion also

Clinical Generalizations:

Survival in patients with germ cell tumors is related to stage at presentation

The need clearly exists for patients education

This enforces the need for testicular self exam

Signs and Symptoms:

Painless nodule or swelling of one gonad

10% have acute pain as presenting symptom

10% have metastatic lesion as presenting symptom

Physical Exam:

· Bimanual exam of scrotal contents

· Ultrasound of scrotum is rapid/reliable technique to exclude hydrocele or epididymitis, best test to delineate solid vs. cystic mass

Differential Diagnosis:

· Testis torsion

· Epididymitis

· Hydrocele

· Hernia

· Hematoma

· Spermatocele

· Syphilitic gumma

Sites of Metastasis:

· Rt. testicle primary site is inter-aortal caval nodes with spread to left para-aortic R to L

· Lt. Testicle primary site is Lt. para-aortic nodes with spread to pre-aortic nodes

· Inguinal mets if tunica albuginea invaded or previous surgery as inguinal hernia repair, orchiopexy has altered normal lymphatic flow

 

Templates:

· Right side: renal hilum bilaterally to level of left ureter or gonadal vein

· Left inferior mesenteric artery to right side, down aorta to iliac artery

· Bilaterally above inferior mesenteric artery and unilaterally above IMA

Staging:

· Boden/Gibb

1. Confined to testicle

2. Spread to regional nodes

3. Spread beyond regional nodes

· MSKCC

1. Confined to testicle

a. Nodes < 5 cm

b. Nodes > 5 cm

c. Nodes > 10 cm

2. Spread beyond regional nodes

Imaging Studies:

· Chest X-ray PA/Lat

· Chest CT

· Abdominal pelvic CT scan

Tumor Markers:

· Alpha feto protein (AFP) from trophoblastic cells of neoplasm. Normally in fetal yolk sac, liver, GI tract

1. Low levels after 1st year of life

2. Half life 5-7 days

3. Seen in pure embryonal, teratocarcinoma, yolk sac or combined.

4. Not seen in pure chorio or pure seminoma

· Beta Human Chorionic Gonadotropin (BHCG) produced by syncytiotrophoblasts of germ cell tumors

1. Normally secreted by placenta

2. Half life 24-36 hours

3. Seen in 5-10% of pure seminoma

4. All patients with chorio and 40-60% embryonal cancer

Treatment General:

· Multimodal therapy credited with treatment success

· Accuracy of staging/ability to recognize early failure keeps success high

· Radical orchiectomy for local control

Seminoma:

· Low stage = orchiectomy and radiation therapy

· Advanced stage = chemotherapy (vinblastin, cisplatin, bleomycin) followed by surgery vs. RT

Seminoma Histology:

· Embryonal-small rounded irregular mass. Necrosis and hemorrhage and poorly defined capsule

· Pure chorio-need synctiotrophoblast and sytotrophoblast. Small lesion can give advanced mets

· Teratoma-germ cell with different levels of maturation. Mature has 3 germinal layers present

Treatment NSGCT:

· Radical orchiectomy

· Retroperitoneal lymph node dissection with concern for future fertility. Ejaculation and emission affected by sympathetic nerves. Use of template.

 

NSGCT Treatment Considerations:

· Radiation therapy rarely successful

· Surveillance for low stage disease rarely done

· Chemo PVB or BEP

· High dose chemo and bone marrow transplant

 
Last modified: March 25, 2001 01:45 PM
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