testicular cancer
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Etiology
risk factors
- undescended testes (cryptorchidism)
- Klinefelter's syndrome
- family history
Epidemiology
- white race
- ages 15-40 & > 60 years
- most common cancer in males age 15-35 years
Pathology
- seminoma (40%)
- embryonal carcinoma
- teratoma
- choriocarcinoma
- yolk sac tumors
- endodermal sinus tumors
- often an admixture of several cell types
- metastasis: pulmonary
Genetics
Clinical manifestations
- patients usually present with unilateral scrotal mass or testicular swelling[2]
- generally painless until advanced
- dull pain in the pelvis, perianal region or scrotum
- hard lump on the testicle is generally 1st sign
- a heavy feeling in the groin may be noted
- symptoms may develop related to metastasis, i.e.
- weight loss
Laboratory
- complete blood count (CBC)
- comprehensive chemistry panel[5]
- includes serum lactate dehydrogenase
- serum beta-chorionic gonadotropin (serum beta-hCG)
- increased in 10% of seminomas
- may be increased in non-seminomas[8]
- 5000-50,000 U/L intermediate prognosis
- > 50,000 U/L poor prognosis
- correlates with trophoblasts within tumor
- serum alpha-fetoprotein
- NEVER increased in pure seminomas
- 85% of non-seminomas have elevated serum alpha-fetoprotein or serum beta-hCG
- 1000-10,000 ng/mL intermediate prognosis
- > 10,000 ng/mL poor prognosis
- serum beta-hCG & serum alpha-fetoprotein before & after inguinal orchiectomy for staging & prognosis[2]
- do NOT biopsy[2]
- see ARUP consult[7]
Radiology
- ultrasound of testicles
- heterogeneous, hypoechoic testicular mass most likely testicular cancer
- chest X-ray (screening for pulmonary metastases)
- computed tomography (CT)[2]
- magnetic resonance imaging may be useful[5]
- PET scan
Staging
- stage 1: confined to testes
- stage 2: nodal metastases below diaphragm (retroperitoneal)
- stage 3: spread beyond retroperitoneal lymph nodes
Complications
- complications of combination chemotherapy[2][10]
- metabolic syndrome
- cardiovascular disease[2]
- chronic kidney disease
- peripheral neuropathy
- chronic pulmonary disease
- secondary malignancy (years after completion of therapy)
- sexual dysfunction, infertility
- complications of radiation therapy
Management
- semen cryopreservation for all men diagnosed with testicular cancer prior to therapy
- orchiectomy
- radical (inguinal) orchiectomy
- definitive procedure to pathologic diagnosis & local control
- scrotal orchiectomy
- do NOT biopsy[2]
- radical (inguinal) orchiectomy
- if serum AFP is elevated or histopathology shows any component of non-seminoma, treat as non-seminoma
- treatment by stage & type AFTER orchiectomy
- stage 1
- seminoma:
- orchiectomy usually curative[2]
- active surveillance recommended for stage I seminoma diagnosed after radical inguinal orchiectomy[2]
- 2 cycles of carboplatin chemotherapy is an option[2]
- non-seminoma: observation
- 1 cycle of cisplatin chemotherapy is an option[2]
- seminoma:
- stage 2
- seminoma: radiation (seminomas are radiosensitive)
- cisplatin-based chemotherapy with greater lymph node involvement
- non-seminoma: cisplatin-based chemotherapy
- seminoma: radiation (seminomas are radiosensitive)
- stage 3 (& stage 2c)
- stage 1
- chemotherapy
- indications:
- stage 2 or 3 non-seminoma
- stage 3 seminoma
- increasing tumor markers after orchiectomy
- metastatic disease
- up to 85% cure rate for metastatic disease (excludes brain metastases)
- cisplatin usually with etoposide + bleomycin[2]
- indications:
- retroperitoneal masses are common after chemotherapy, if tumor markers have normalized:
- retroperitoneal lymph node dissection for CT-identified residual disease after chemotherapy for non-seminoma[2]
- follow-up PET scan-computed tomography (PET-CT) for seminoma
- chemotherapy if several lymph nodes or lymph node(s) > 5 cm or if positive tumor markers (serum alpha-fetoprotein, serum beta-hCG)[2]
- prognosis:
- cure rates generally good
- seminomas have low mortality, relapse rates without adjuvant chemotherapy < 15-20%
- non-seminomas have poorer prognosis than seminomas, but may still be curable
- non-seminomas with low risk feature have cure rates of 90-95%
- non-seminomas with poor prognostic signs have cure rates of ~50%[2]
- USPSTF recommends against screening[6]
More general terms
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 30
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 676-677
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 602-605
- ↑ 5.0 5.1 5.2 Torpy JM et al, Testicular Cancer, Patient Information Page JAMA 2008, 299:718
- ↑ 6.0 6.1 Lin K and Sharangpani R Screening for Testicular Cancer: An Evidence Review for the U.S. Preventive Services Task Force Annals of Internal Medicine 2010 153:396 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20855803 <Internet> http://www.annals.org/content/153/6/396.abstract
- ↑ 7.0 7.1 ARUP Consult: Testicular Cancer The Physician's Guide to Laboratory Test Selection & Interpretation https://arupconsult.com/content/testicular-cancer
- ↑ 8.0 8.1 Motzer RJ, Bolger GB, Boston B et al Testicular cancer. Clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2006 Nov;4(10):1038-58. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17112452
- ↑ van den Belt-Dusebout AW, de Wit R, Gietema JA et al Treatment-specific risks of second malignancies and cardiovascular disease in 5-year survivors of testicular cancer. J Clin Oncol. 2007 Oct 1;25(28):4370-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17906202
- ↑ 10.0 10.1 Willemse PM, Burggraaf J, Hamdy NA et al Prevalence of the metabolic syndrome and cardiovascular disease risk in chemotherapy-treated testicular germ cell tumour survivors. Br J Cancer. 2013 Jul 9;109(1):60-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23660945
- ↑ Tandstad T, Smaaland R, Solberg A et al Management of seminomatous testicular cancer: a binational prospective population-based study from the Swedish norwegian testicular cancer study group. J Clin Oncol. 2011 Feb 20;29(6):719-25. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21205748
- ↑ Rosenfield K, Ghoshhajra BB, Dudzinski DM, Stone JR. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 9-2016. A 29-Year-Old Man with Dyspnea and Chest Pain. N Engl J Med. 2016 Mar 24;374(12):1178-88. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27007962 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMcpc1512452
- ↑ NEJM Knowledge+. Question of the Week. Jan 17, 2017 http://knowledgeplus.nejm.org/question-of-week/958/
- ↑ Hanna NH, Einhorn LH Testicular Cancer - Discoveries and Updates. N Engl J Med 2014; 371:2005-2016. November 20, 2014 http://www.nejm.org/doi/full/10.1056/NEJMra1407550
- ↑ Mir MC, Pavan N, Gonzalgo ML. Current Clinical Applications of Testicular Cancer Biomarkers. Urol Clin North Am. 2016 Feb;43(1):119-25. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26614034
- ↑ Lance Amstrong Foundation http://www.livestrong.org