Testicular Cancer

Most testicular cancers are germ cell tumours and occur in young men.

They are divided into:

Seminoma

and

Nonseminomatous germ cell tumour

including:

• Embryonal carcinoma
• Yolk sac tumour
• Choriocarcinoma
• Teratoma

Mixed tumours are managed according to the nonseminomatous component.

Testicular cancer is highly curable even when metastatic.

Risk factors include:

• Cryptorchidism
• Previous contralateral testicular cancer
• Testicular dysgenesis
• Family history

Typical presentation is:

• Painless testicular mass
• Testicular enlargement
• Heaviness

Pain occurs in a minority and can lead to erroneous treatment as epididymitis.

Metastatic disease can produce:

• Back pain from retroperitoneal nodes
• Cough or dyspnoea
• Gynaecomastia
• Neurological symptoms

Every persistent intratesticular mass should be regarded as malignant until proven otherwise.

Scrotal ultrasound: confirms an intratesticular lesion.

Measure tumour markers before orchiectomy:

• AFP
• Beta hCG
• LDH

Pure seminoma does not produce AFP.

An elevated AFP means the tumour must be managed as nonseminomatous germ cell cancer even when biopsy appears predominantly seminomatous.

Stage using CT of:

• Chest
• Abdomen
• Pelvis

MRI can substitute for abdominal imaging in selected surveillance pathways where expertise exists.

Radical inguinal orchiectomy

Standard initial treatment is radical inguinal orchiectomy.

Clamp and divide the spermatic cord at the internal ring and remove:

• Testis
• Epididymis
• Cord structures

Do not perform routine transscrotal biopsy or scrotal orchiectomy because this alters lymphatic drainage and contaminates the scrotum.

Offer sperm banking before chemotherapy or radiotherapy where future fertility is important.

Stage I seminoma

After orchiectomy, surveillance is preferred for most compliant patients.

Adjuvant options include:

Carboplatin AUC 7 IV for one cycle

in selected patients.

Routine adjuvant radiotherapy is used much less often because of long term second malignancy and cardiovascular concerns.

Stage I nonseminoma

Risk is strongly influenced by lymphovascular invasion.

Options are:

• Surveillance
• One cycle BEP

A high risk stage I patient can be offered one cycle BEP or surveillance after counselling.

BEP regimen

A standard 5 day BEP cycle uses approximately:

Bleomycin 30 units IV on days 1, 8 and 15

Etoposide 100 mg/m² IV days 1 to 5

Cisplatin 20 mg/m² IV days 1 to 5

Cycle repeats every 21 days.

Good prognosis metastatic nonseminoma is generally treated with:

BEP × 3 cycles

while intermediate or poor prognosis disease generally requires:

BEP × 4 cycles.

When bleomycin is contraindicated, use an established alternative such as EP or VIP according to tumour category.

Residual mass

After chemotherapy for nonseminoma:

Resect residual retroperitoneal masses greater than approximately 1 cm when markers have normalised or are normalising because residual tissue may contain:

• Teratoma
• Viable cancer
• Necrosis.

Residual seminoma is managed differently, often using functional imaging for larger persistent masses rather than automatically resecting every residual lesion.