Diagnosis

Testicular cancer

Etiology

Cause [wfe]

• Unknown

• Genetic factor: isochromosome on chromosome 12

Pathophysiology [wfe]

1. Seminomas: transformed germ cells that are blocked in their differentiation

2. Intratubular germ-cell neoplasia: gonocytes fail to differentiate into spermatogonia

3. Hormonal changes during puberty --> cancer attain invasive potential

4. Classification:

   1. Germ Cell Tumors: Germ cell neoplasia in situ

   2. Derived from Germ Cell Neoplasia In Situ

      Seminoma, Embryonal carcinoma, Yolk sac tumor, post-pubertal type, Trophoblastic tumor, Teratoma, Mixed germ cell tumors

   3. Germ Cell Tumors Unrelated to GCNIS

      Spermatocytic tumor, Yolk sac tumor, Mixed germ cell tumor

   4. Sex Cord/Stromal Cell Tumors

      Leydig cell tumor, Sertoli cell tumor, Granulosa cell tumor, Thecoma/fibroma, Other sex cord/gonadal stromal tumors, Gonadoblastoma

   5. Miscellaneous Non-specific Stromal Cell Tumors

      Ovarian epithelial tumors, Tumors of paratesticular structures, Cystadenoma of the epididymis, Papillary cystadenoma, Adenocarcinoma of the epididymis, Mesenchymal tumors of the spermatic cord and the testicular adnexa

Risk factors [wfe]

• Cryptorchid (undescended) testes

• Intraabdominal testes

• First-degree relatives

• Infections (HPV, EBV, CMV, HIV, Parvovirus B-19)

• Testicular trauma

Complications [wfe]

• Metastatic complications

• Venous thromboembolism

• Complications secondary to the treatment

  • Hypogonadism

  • Peripheral neuropathy (cisplatin)

  • Hearing loss (cisplatin)

  • Tinnitus (cisplatin)

  • Raynaud phenomenon (cisplatin)

  • Secondary malignancies

  • Cardiovascular disease

  • Infertility

  • Infections

  • Surgical complications(antegrade ejaculation failure, small bowel obstruction)

Epidemiology

Incidence per 100.000 [vwu][ify][vbf][ios][ns2][554]

Approach

• Blood test: AFP, β-hCG, and LDH

• Ultrasound testis

• CT abdomen/pelvis

Treatment

According to the IGCCCG risk classification [wfe]

1. Stage 0:  GCNIS

   • Surveillance with ultrasonography

   • Radical inguinal orchiectomy

   • Radiotherapy + testosterone replacement therapy

2. Stage I: Orchiectomy

   • Seminoma:

     • 15% to 18% will relapse after orchiectomy without adjuvant treatment

     • Surveillance (CT scans and tumor markers) or carboplatin chemotherapy for high-risk patients (rete-testis invasion and tumor size >4cm)

     • Alternative: radiotherapy to the retroperitoneum

   • Non-seminoma: more aggressive than seminoma

     • 14% to 22% risk of relapse without adjuvant treatment in tumors without lymphovascular invasion

     • Active surveillance (CT scans) without adjuvant therapy

     • Alternative: adjuvant chemotherapy (bleomycin, etoposide, and cisplatin)

   • Stage IIA and IIB: Orchiectomy

     • Seminoma:

       • Chemotherapy with three cycles of BEP

       • Alternative: Radiotherapy

     • Non-seminoma: 

       • Chemotherapy with three cycles of BEP --> if residual retroperitoneal disease of >1cm --> salvage resection

       • Alternative: Retroperitoneal lymph node dissection + surveillance (N1) or chemotherapy with two cycles of BEP (N2-N3)

3. Stage IIC and III: Chemotherapy and surveillance with CT scans and tumor markers

   • BEP: bleomycin, etoposide, and cisplatin

   • EP: etoposide, and cisplatin

   • Cisplatin-based chemotherapy:

     • VIP (etoposide, ifosfamide, cisplatin)

     • VeIP (vinblastine, ifosfamide, cisplatin)

4. Residual Lesions:

   • Seminoma: 95% responds well to chemotherapy

     • If residual tumor masses > 3cm --> PET CT --> Retroperitoneal lymph node dissection

   • Non-seminoma:

     • Residual tumor masses < 1cm --> surveillance with CT scans

     • Residual tumor masses > 1cm --> Retroperitoneal lymph node dissection

Differential diagnoses

Cancer origo incerta, Epididymitis, Hematoma, Hydrocele, Inguinal hernia, Leiomyosarcoma, Lipoma, Lung cancer, Lymphoma, Malignant melanoma, Orchitis, Prostate cancer, Rhabdomyosarcoma, Sarcoma, Spermatocele, Syphilis, Testicular torsion, Testicular tumor, Torsion of the appendix testis, Trauma, Tuberculosis, Varicocele