Testicular Cancer

Diagnosis of testicular cancer

Complete history and physical Laboratory: CBC w/differential Liver function panel Chest x-ray CT of abdomen and pelvis Baseline tumor markers β-hCG, α-FP, LDH

Testicular cancer Tumor Markers β-hCG

Increased 10-20% seminomas Increased in 40-60% nonseminomas

Testicular cancer Tumor Markers LDH

Non-specific tumor marker Related to disease burden Increased in 80% seminomas and 60% nonseminomas

Testicular cancer Tumor Markers α-fetoprotein

Serum protein of fetus Increased in 40-60% nonseminomas Not seen in seminomas

Prognosis of testicular cancer Nonseminoma Low risk

Tumor markers β-hCG < 5,000 IU/ml α -FP <1,000 ng/ml LDH < 1.5 x normal Non-mediastinal primary No non-pulmonary visceral mets

Poor Risk assessment for testicular Nonseminoma cancer

Tumor markers β-hCG > 50,000 IU/ml α -FP>10,000 ng/ml LDH >10x normal Mediastinal primary site Nonpulmonary visceral mets present

Initial Treatment: Nonseminomatous

BEP Every 3 weeks x 3-4 cycles or EP Every 3 weeks x 4 cycles BEP (Bleomycin, Etoposide, Cisplatin) or EP (Etoposide + Cisplatin) Cisplatin SHOULD NOT be substituted by Carboplatin

Testicular chemo options

Chemotherapy options are platinum based BEP/EP

Risk Factors of testicular cancer

Cryptorchidism Previous history of testicular cancer Family history Klinefelter's syndrome HIV Seminoma

Testicular cancer Epidemiology

Most common cancer in men ages 15-34 Incidence higher in Caucasians 5:1 (Caucasian:African American)

Stage IIB: Initial treatment

Orchiectomy + BEP x 3 or EP x 4 Especially if tumor markers are positive BEP (Bleomycin, Etoposide, Cisplatin) or EP (Etoposide + Cisplatin)

Stage IIA initial treatment

Orchiectomy + RPLND + 2 cycles adjuvant chemotherapy Increased RR but no difference in overall survival BEP (Bleomycin, Etoposide, Cisplatin) x 3 or EP (Etoposide + Cisplatin) x 4 if tumor markers are positive

Initial Treatment: Nonseminomatous Stage I:

Orchiectomy + nerve sparing retroperitoneal lymph node dissection (RPLND)

Histology of testicular cancer

Over 95% of testicular tumors are germ cell

Clinical Presentation (S&S) of testicular cancer

Painless, firm mass Enlargement/swelling of testicle Systemic symptoms ~ 10% patients Back and/or bone pain Shortness of breath Cough Abdominal fullness Altered mental status (or other CNS symptoms) Breast tenderness or gynecomastia (~ 5%)

Prevention and Screening of testicular cancer

Prevention and Screening, No studies have been done to determine whether self-examination or examination during routine physicals can help reduce the number of deaths caused by testicular cancer

Each testicle tumor spreads like a road map

Right testicle: right inter-aortocaval → precaval → preaortic lymph nodes Left testicle: left para-aortic → preaortic → inter-aortocaval nodes

Staging of testicular cancer

Stage I is Confined to testis,epididymis, or spermatic cord Stage II has Lymph node involvement, disease spread retroperitoneum Stage III is (Disseminated disease) Distant spread of disease (lung, liver, bone)

Cancer cure rate

Testicular cancer has high cure rate even with higher stage disease No stage 4

First site of dissemination in testicular cancer

retroperitoneal lymph nodes