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
