The GP’s role
GPs are typically the first point of contact for men who have noticed a testicular lump, swelling or pain.
The GP’s primary role is assessment, referral and follow-up.
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All suspected cases must be thoroughly investigated and referred to a urologist
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Treatment frequently requires multidisciplinary therapy that may include the GP
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Most patients will survive, hence the importance of long-term regular follow-up
Note on screening: There is little evidence to support routine screening. However, GPs may screen men at higher risk, including those with a history of previous testicular cancer, undescended testes, infertility or a family history of testicular cancer.
Overview
Benign cysts
Epididymal cysts, spermatocele, hydatid of Morgagni and hydrocele are all non-cancerous lumps that can be found in the scrotum.
![Table: Benign cysts](https://wp.healthymale.org.au/wp-content/uploads/2024/05/table-benign-cysts-1024x618.jpg)
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Epididymal cysts
Common fluid-filled cysts which feel slightly separate from the testis and are often detected when pea-sized. Should be left alone when small but can be surgically removed if they become symptomatic
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Spermatocele
Fluid-filled cysts containing sperm and sperm-like cells. These cysts are like epididymal cysts except they are typically connected to the testis
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Hydatid of Morgagni
Small common cysts located at the top of the testis. They are moveable and can cause pain if they twist. These cysts should be left alone unless causing pain
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Hydrocele
A hydrocele is a swelling in the scrotum caused by a buildup of fluid around the testes. Hydroceles are usually painless but gradually increase in size and can become very large. Hydroceles in younger men may be a warning of an underlying testis cancer, albeit rarely. In older men, hydroceles are almost always a benign condition, but a scrotal ultrasound will exclude testicular pathology
Diagnosis and management
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Medical history
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
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Physical examination
Perform a clinical examination of the testes and general examination to rule out enlarged nodes or abdominal masses
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Clinical notes
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
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Ultrasound
Organise ultrasound of the scrotum to confirm testicular mass (urgent, organise within 1-2 days)
Always perform in young men with a retroperitoneal mass
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Investigation and referral
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
Clinical notes
The urologist will form a diagnosis based on inguinal exploration, orchidectomy and en bloc removal of testis, tunica albuginea, and spermatic cord.
Organ-sparing surgery can be attempted in specific cases (solitary testis or bilateral tumours) in specialist referral centres.
Prosthesis may be considered at time of orchidectomy but may also be placed later.
Follow-up
Patient follow-up (in consultation with treating specialist) for:
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Recurrence
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Monitoring the contralateral testis by physical examination
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Management of complications, including fertility
Classification and risk factors
There are three categories of testicular epithelial cancer. Germ cell tumours account for 90-95% of cases of testicular cancer.
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Germ cell tumours
Seminoma
Non-seminoma (NSGCT)
– Embryonal carcinoma
– Yolk sac tumour
– Choriocarcinoma
– Teratoma -
Sex cord stromal tumours
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Non-specific stromal tumours
Prognostic risk factors
Pathological (pT1-pT4)
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Histopathological type
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For seminoma
Tumour size (> 4 cm)
Invasion of the rete testis
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For non-seminoma
Vascular/lymphatic invasion or peri-tumoural invasion
Percentage embryonal carcinoma > 50%
Proliferation rate (MIB-1) > 70%
Clinical (for metastatic disease)
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Primary location
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Elevation of tumour marker levels (AFP, hCG, LDH)
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Presence of non-pulmonary visceral metastasis
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Only clinical predictive factor for metastatic disease in seminoma
Staging of testicular tumours
The Tumour, Node, Metastasis (TNM) system is recommended for classification and staging purposes. The IGCCCG staging system is recommended for metastatic disease.
American Joint Committee on cancer staging of testicular cancer
pT – Primary Tumour*
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pTX Primary tumour cannot be assessed
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pT0 No evidence of tumour
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pTis Germ cell neoplasia in situ
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pT1 Tumour limited to testis (including rete testis invasion) without vascular/lymphatic invasion (LVI)
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T1a Pure seminoma < 3 cm in size
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T1b Pure seminoma [> =] 3 cm in size
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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
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pT3 Tumour invades spermatic cord with or without LVI
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pT4 Tumour invades scrotum with or without LVI
Regional lymph nodes*
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NX Regional lymph nodes were not assessed
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N0 No positive regional nodes
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N1 Metastasis with a lymph node mass ≥ 2 cm in greatest dimension, or multiple lymph nodes, none more than 2 cm in greatest dimension
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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
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N3 Metastasis with a lymph node mass > 5 cm in greatest dimension
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*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)
Distant metastasis
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MX Distant metastasis cannot be assessed
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M0 No distant metastasis
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M1 Distant metastasis
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M1a Non-retroperitoneal nodal or pulmonary metastases.M1b Non-pulmonary visceral metastases
Serum markers
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Sx Serum markers not available or not performed
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S0 Serum marker study levels within normal limits
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S1 Lactate dehydrogenase (LDH) < 1.5 x Normal* and human chorionic gonadotrophin (hCG) < 5000 mIU/mL and alpha fetoprotein (AFP) < 1000 ng/mL
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S2 LDH 1.5-10 x Normal or hCG 5000-50,000 mIU/mL or AFP 1000-10,000 ng/mL
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S3 LDH > 10 x Normal or hCG > 50,000 mIU/mL or AFP > 10,000 ng/mL
Treatment options for localised testicular cancer
Orchidectomy cures almost 85% of stage I seminoma patients and 70-80% of stage I non-seminomatous germ cell tumour (NSGCT) patients.
Adjuvant treatments may reduce the risk of metastases in those not cured by orcidectomy, but this comes at the cost of possible adverse effects.
Surveillance is another management option. A risk-adapted approach is now used to determine subsequent management.
pT1 Seminoma
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Surveillance is recommended (if facilities are available and the patient willing and able to comply)
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Carboplatin-based chemotherapy decreases recurrence rates by 75% or 90%, for one or two courses, respectively
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Adjuvant treatment not recommended for patients at very low risk (< 4 cm size, absence of rete testis invasion)
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Radiotherapy is not recommended as adjuvant treatment, although it remains a treatment option
pT1 Non-Seminomatous Germ Cell Tumour (NSGCT)
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Low risk (No Lymphovascular invasion, Proliferative index < 70%)
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
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High risk (Lymphovascular invasion, Embryonal component, pT2-pT4)
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
Treatment of metastatic disease (pT2-pT4)
The treatment of metastatic germ cell tumours depends on:
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The histology of the primary tumour and
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Prognostic groups as defined by the International Germ Cell Cancer Collaborative Group (IGCCCG).
Seminoma
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Radiotherapy (30Gy), or chemotherapy (BEP) can be used with the same schedule as for the corresponding prognostic groups for NSGCT
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Any pT, N3 seminoma is treated as “good prognosis” metastatic tumour with three cycles of BEP or four cycles of EP
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PET scan plays a role in evaluation of post-chemotherapy masses larger than 3 cm
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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
NSGCT
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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
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Metastatic NSGCT with a good prognosis, primary treatment three courses of BEP
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Metastatic NSGCT with intermediate or poor prognosis, four courses of BEP and inclusion in clinical trial recommended
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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
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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
IGCCCG Prognostic- based staging system for metastatic germ cell cancer
![Table: IGCCCG Prognostic- based staging system for metastatic germ cell cancer](https://wp.healthymale.org.au/wp-content/uploads/2024/05/IGCCCG-prognostic-based-staging-system-for-metastatic-germ-cell-cancer-1024x689.jpg)
Additional investigations
Serum tumour markers
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Post-orchidectomy half-life kinetics of serum tumour markers
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
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Other examinations (Assessment of abdominal and mediastinal nodes and viscera (CT scan) and supraclavicular nodes (physical examination)
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
Treatment
The first stage of treatment is usually an orchidectomy: removal of the diseased testis via an incision in the groin, performed under general anaesthetic. Men can be offered a testicular prosthesis implant during or following orchidectomy.
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Further treatment depends on the pathological diagnosis (seminoma vs non-seminoma and the stage of disease) and may include surveillance, chemotherapy or radiotherapy
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
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If a man has a bilateral orchidectomy (rare) he will require ongoing testosterone replacement therapy
Patient support
Diagnosis and treatment can be extremely traumatic for the patient and family.
Regular GP consultations can offer patients a familiar and constant person with whom to discuss concerns (e.g. about treatment, cancer recurrence, and the effects of testis removal on sexual relationships and fertility).
Referral to a psychologist may be required.
Patient follow-up
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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%)
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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
Semen storage
Men with testicular cancer often have low or even absent sperm production even before treatment begins. Chemotherapy or radiotherapy can, but does not always, lower fertility further.
All men wanting to maintain fertility should have a discussion regarding pre-treatment semen analysis and storage as semen can be stored long-term for future use in fertility treatments.
Men who have poor sperm counts may need to visit the sperm-banking unit on 2 or 3 occasions or, in severe cases, an Andrology referral may be required.
Surgical removal of one testis does not affect the sperm-producing ability of the remaining testis.
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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
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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
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Refer the patient to a fertility specialist or a local infertility clinic. These clinics usually offer long-term sperm storage facilities
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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)
Clinical review
Professor Nathan Lawrentschuk, University of Melbourne, Royal Melbourne Hospital & Epworth Healthcare