Transcript Testicular cancer

Testicular cancer
In a nutshell
• It metastasizes early but is highly curable even
in metastatic stage
• Tumor markers important in staging and
follow-up
Epidemiology
• occurs most often in men between the ages
of 15 and 40, where is also the most
frequent solid tumor
• it accounts for only 1% of all cancers in
men
• incidence highest among men living in the
United States and Europe and lowest
among men living in Africa or Asia
Risk factors
• Undescended testicle=cryptorchidism:
-Normally, the testicles descend from inside the abdomen
into the scrotum before birth. The risk of testicular cancer
is increased in males with a testicle that does not move
down into the scrotum
-Although most cancers develop in the undescended
testicle, about 1 out of 4 cases occur in the normally
descended testicle. Based on these observations it is
probable that cryptorchidism doesn't actually cause
testicular cancer but that there is something else that
leads to both testicular cancer and abnormal positioning
of one or both testicles.
• Family history of testicular cancer: the risk for
testicular cancer is greater in men whose brother or father
has had the disease. However, only about 3% of testicular
cancer cases are actually found to occur in families, most
men with testicular cancer do not have a family history of
the disease.
Risk factors
• Klinefelter's syndrome: Men with
Klinefelter's syndrome (a sex chromosome
disorder-47XXY-that is characterized by
low levels of androgens, sterility, breast
enlargement and small testes) are at
greater risk of developing testicular cancer.
• Race: The risk of testicular cancer among
white men is about 5 times that of black
men and 3 times that of Asian
• Carcinoma in situ of the testicle
• A previous testicular cancer
Risk factors
• NOT RISK FACTORS:
-trauma
-repetitive micro-trauma: bicycle or horseback
riding
Histology
A) From the testicular parenchyma (90%):
Germ cell tumors:
~50%/50% seminoma / non-seminomatous
germ cell tumor
Non-seminomatous germ cell tumors are subdivided in:
-Embryonal carcinoma
-Yolk sac tumors
-Teratoma etc.
B) From the testicular stroma (10%): stromal
tumors
Routes of dissemination
• Local invasion
• Lymphatic spread-early
-directly to para-aortic lymph nodes (because
embryonic origin of testes is intra-abdominal)
• Hematogenous metastases-early
-lung, liver, brain, bone
Clinical picture
• Most patients present with symptoms
consistent with infectious epididymitis and/or
orchitis
• only a minority of patients present with the
pathognomonic painless testicular mass
• Lumbar pain-in case of para-aortic lymph node
involvement
• Gynecomastia
a)
b)
Stromal tumors may secrete estradiol directly
βHCG secreted by the tumor acts like LH and increases testosterone,
which transforms in adipose tissue into estradiol
• Symptoms caused by metastases
Diagnosis
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History and physical
Inspection and palpation of the testicle
Testicular ultrasound
Palpation of inguinal lymph nodes
Abdominal CT for para-aortic and hepatic metastases
Tumor markers (βHCG, AFP, LDH), VSH
Chest radiography for lung metastases
Chest CT for lung metastases IF para-aortic lymph nodes positive or
chest radiograph abnormal
• Brain MRI for brain metastases IF clinical signs of brain metastases
• Bone scintigraphy IF bone pain
βHCG=human chorionic gonadotropin, beta subunit
AFP=alpha-fetoprotein
LDH=lactate dehydrogenase
Diagnosis-tumor markers
• Seminoma: AFP negative!!!, βHCG may be
positive, LDH may be increased
• Non-seminomatous germ cell tumor: AFP,
βHCG may be positive; LDH may be increased
Mnemonic: AFP-”fetal tissue growing in the
testis” in case of non-seminoma
Treatment
• If suspect for testicular cancer=>UNILATERAL
RADICAL INGUINAL ORCHIECTOMY
• NO BIOPSY BECAUSE THE RISK OF
DISSEMINATION !!!
Radical orchiectomy. Note the inguinal approach and the use
of the tourniquet.
Adjuvant treatment for seminoma
Stage I (=no lymphadenopathy on CT and no distant metastases):
Choice between:
-surveillance
-one cycle of chemotherapy
-para-aortic (“prophylactic”) radiotherapy (low dose: 25-30 Gy)
Stage II (=positive lymphadenopathy)
Choice between:
- para-aortic plus ipsilateral inguinal radiotherapy
- 4 cycles of chemotherapy
Stage III (=distant metastases or highly elevated tumor markers)
-4-6 cycles of chemotherapy
Adjuvant treatment for non-seminomatous germ
cell tumor
-para-aortic lymph node dissection or
chemotherapy (more complicated guidelines, too much
for student level)
Follow-up
• History and physical + chest X-ray + βHCG, AFP,
LDH
-every 2 months for year 1
- 3 mo/y 2
- 4 mo/y 3
- 6 mo/y 4
• Abdominal CT after 4 months of treatment
• PET-CT if suspicion of relapse
Follow-up for side effects of treatment
• RT favorizes gastric cancer
• RT may lead to retroperitoneal fibrosis with
ureteral obstruction
• Chemotherapy may lead to sterility (although
in general men with testicular cancer have low
fertility from the beginning due to
degenerative changes in the contralateral
testicle)
Etc.