Testicular cancer

All suspected cases must be thoroughly investigated and referred to a urologist

Treatment frequently requires multidisciplinary therapy that may include the GP

Most patients will survive, hence the importance of long-term regular follow-up

Scrotal lump

Genital trauma

Pain (pain occurs in only 10-15% of testicular cancers)

History of subfertility or undescended testis

Sexual activity/history of urine or sexually transmitted infection

Perform a clinical examination of the testes and general examination to rule out enlarged nodes or abdominal masses

On clinical examination it can be difficult to distinguish between testicular and epididymal cysts. Lumps in the epididymis are rarely cancer. Lumps in the testis are nearly always cancer

Organise ultrasound of the scrotum to confirm testicular mass (urgent, organise within 1-2 days)

Always perform in young men with a retroperitoneal mass

Advice on next steps for investigation and treatment

Urgent referral to urologist (seen within 2 weeks)

CT scan of chest, abdomen and pelvis

Serum tumour markers (AFP, hCG, LDH) before orchidectomy: may be ordered by GP prior to urologist consultation

Semen analysis and hormone profile (testosterone, FSH, LH): may be ordered before chemotherapy

Discuss sperm banking with all men prior to treatment

Fine needle aspiration: scrotal biopsy or aspiration of testis tumour is not appropriate or advised

Recurrence

Monitoring the contralateral testis by physical examination

Management of complications, including fertility

Seminoma
Non-seminoma (NSGCT)
– Embryonal carcinoma
– Yolk sac tumour
– Choriocarcinoma
– Teratoma

Histopathological type

Tumour size (> 4 cm)

Invasion of the rete testis

Vascular/lymphatic invasion or peri-tumoural invasion

Percentage embryonal carcinoma > 50%

Proliferation rate (MIB-1) > 70%

Primary location

Elevation of tumour marker levels (AFP, hCG, LDH)

Presence of non-pulmonary visceral metastasis

Only clinical predictive factor for metastatic disease in seminoma

pTX Primary tumour cannot be assessed

pT0 No evidence of tumour

pTis Germ cell neoplasia in situ

pT1 Tumour limited to testis (including rete testis invasion) without vascular/lymphatic invasion (LVI)

T1a Pure seminoma < 3 cm in size

T1b Pure seminoma [> =] 3 cm in size

pT2 Tumour limited to testis (including rete testis invasion) with LVI, or tumour invading hilar soft tissue or epididymis or penetrating visceral mesothelial layer covering the external surface of tunica albuginea with or without LVI

pT3 Tumour invades spermatic cord with or without LVI

pT4 Tumour invades scrotum with or without LVI

NX Regional lymph nodes were not assessed

N0 No positive regional nodes

N1 Metastasis with a lymph node mass ≥ 2 cm in greatest dimension, or multiple lymph nodes, none more than 2 cm in greatest dimension

N2 Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension or multiple lymph nodes, any one mass more than 2 cm but not more than 5 cm in greatest dimension

N3 Metastasis with a lymph node mass > 5 cm in greatest dimension

*Clinical (based on clinical examination and histological assessment) or Pathological (based on histological examination post-orchidectomy) lymph node classifications may be made, denoted by the prefix ‘c’ or ‘p’, respectively (e.g. pN1, cN2)

MX Distant metastasis cannot be assessed

M0 No distant metastasis

M1 Distant metastasis

M1a Non-retroperitoneal nodal or pulmonary metastases.M1b Non-pulmonary visceral metastases

Sx  Serum markers not available or not performed

S0 Serum marker study levels within normal limits

S1 Lactate dehydrogenase (LDH) < 1.5 x Normal* and human chorionic gonadotrophin (hCG) < 5000 mIU/mL and alpha fetoprotein (AFP) < 1000 ng/mL

S2 LDH 1.5-10 x Normal or hCG 5000-50,000 mIU/mL or AFP 1000-10,000 ng/mL

S3 LDH > 10 x Normal or hCG > 50,000 mIU/mL or AFP > 10,000 ng/mL

Surveillance is recommended (if facilities are available and the patient willing and able to comply)

Carboplatin-based chemotherapy decreases recurrence rates by 75% or 90%, for one or two courses, respectively

Adjuvant treatment not recommended for patients at very low risk (< 4 cm size, absence of rete testis invasion)

Radiotherapy is not recommended as adjuvant treatment, although it remains a treatment option

If the patient is able and willing to comply with a surveillance policy, long-term (at least 5 years) close follow-up should be recommended

In patients not willing (or unsuitable) to undergo surveillance, adjuvant chemotherapy or nerve-sparing retroperitoneal lymph node dissection (RPLND) are options

Increasingly, if the patient is able and willing to comply with an intensive surveillance policy, long-term (at least 5 years) close follow-up may be recommended understanding that some will relapse (40-60%) requiring chemotherapy with excellent response rates

Alternatively, adjuvant chemotherapy with one or two courses of bleomycin, etoposide and cisplatin (BEP) may be recommended with 97% non-relapse rates

If the patient is not willing to undergo chemotherapy or if chemotherapy is not feasible, nerve-sparing RPLND or surveillance with treatment at relapse (in about 50% of patients) are options

The histology of the primary tumour and 

Prognostic groups as defined by the International Germ Cell Cancer Collaborative Group (IGCCCG).

Radiotherapy (30Gy), or chemotherapy (BEP) can be used with the same schedule as for the corresponding prognostic groups for NSGCT

Any pT, N3 seminoma is treated as “good prognosis” metastatic tumour with three cycles of BEP or four cycles of EP

PET scan plays a role in evaluation of post-chemotherapy masses larger than 3 cm

Nerve-sparing retroperitoneal lymph node dissection (RPLND) as an option for primary treatment may be considered in very select cases as an alternative to chemotherapy

Low volume NSGCT with elevated markers (good or intermediate prognosis), three of four cycles of BEP; if no marker elevation, repeat staging at 6 weeks surveillance to make final decision on treatment

Metastatic NSGCT with a good prognosis, primary treatment three courses of BEP

Metastatic NSGCT with intermediate or poor prognosis, four courses of BEP and inclusion in clinical trial recommended

Surgical resection of residual masses after chemotherapy in NSGCT is indicated via a RPLND in case of visible residual mass and when tumour marker levels are normal or normalising

Nerve-sparing retroperitoneal lymph node dissection (RPLND) is an option for primary treatment where teratoma is suspected, and may be considered in select cases as an alternative to chemotherapy

The persistence of elevated serum tumour markers 6 weeks after orchidectomy may indicate the presence of metastases, while its normalisation does not necessarily mean an absence of tumour

Tumour markers should be assessed until they are normal, as long as they follow their half-life kinetics and no metastases are revealed on scans

Other examinations such as brain or spinal CT, bone scan or liver ultrasound should be performed if metastases are suspected

A chest CT scan should be performed routinely in patients diagnosed with germ cell tumours because in 10% of cases small. subpleural nodes are present that are not visible on plain chest X-ray

Men with early-stage seminoma have treatment options of surveillance, chemotherapy or radiotherapy. The treatment is based on patient and tumour factors

Men with early-stage non-seminoma have treatment options of surveillance, chemotherapy or further surgery. The treatment is again based on patient and tumour factors

Men with early-stage disease who relapse and men with advanced disease are generally referred for chemotherapy. If chemotherapy leaves residual masses, these may contain cancer and usually will need surgical removal

Regular follow-up is vital, and patients with testicular cancer should be watched closely for several years. The aim is to detect relapse as early as possible, to avoid unnecessary treatment and to detect asynchronous tumour in the contralateral testis (incidence 5%)

Plan follow-ups in conjunction with the urologist/oncologist. Follow-up schedules are tailored to initial staging and treatment, and can involve regular physical examination, tumour markers and scans to detect recurrence. The timing and type of follow-ups need to be determined for each patient in conjunction with the treating urologist/oncologist

Provide prompt fertility advice to all men considering chemotherapy or radiotherapy, to avoid delaying treatment. It is highly recommended that men produce semen samples for sperm storage prior to treatment

Sperm storage for teenagers can be a difficult issue requiring careful and delicate handling. Coping with the diagnosis of cancer at a young age and the subsequent body image problems following surgery can be extremely difficult. Fatherhood is therefore not likely to be a priority concern. Producing a semen sample by masturbation can also be stressful for young men in these circumstances

Refer the patient to a fertility specialist or a local infertility clinic. These clinics usually offer long-term sperm storage facilities

The timing of semen storage, if required, will vary with individual cases. The need for therapies may be prioritised ahead of banking (e.g., orchidectomy especially if a normal contralateral testis is present)