Definition
Malignant lesion of the testis.
Key Points
- All newly discovered testicular lumps require investigation to exclude malignancy.
- Early tumours have an excellent prognosis with surgery alone.
- Late tumours have a good prognosis with surgery and medical therapy.
- Orchidectomy for tumour should be via a groin incision.
- Prognosis is generally good but depends on stage and histology.
Epidemiology
Age 20–35 years. Most common solid tumours in young males. The incidence of testicular cancer seems to be increasing.
Aetiology
- Crypto-orchidism – 40 to 50-fold increase in risk of developing testicular germ cell cancer. Risk is unaffected by orchidopexy.
- Exposure to high prenatal oestrogen levels, chemical carcinogens, trauma, orchitis.
- Higher incidence in white men.
Pathology
Classification of Testicular Tumours
- Germ-cell tumours (95%) (secrete AFP and β-HCG):
seminoma (SGCT) (40%)
non-seminoma (NSGCT) – embryonal carcinoma (25%), teratoma/teratocarcinoma (30%), choriocarcinoma (1%), yolk sac tumour (rare).
- Non-germ-cell tumours (stromal tumours) (5%):
Leydig cell
Sertoli cell
granulosa cell.
Non-germ-cell tumours are rare and only 10% of them are malignant.
- Metastatic tumours.
Staging
- Stage I: confined to scrotum.
- Stage II: spread to retroperitoneal lymph nodes below the diaphragm.
- Stage III: distant metastases.
Spread
- Germ-cell tumours to para-aortic nodes, lung and brain.
- Stromal tumours rarely metastasize.
Clinical Features
- Painless, hard swelling of the testis, often discovered incidentally or after trauma.
- Vague testicular discomfort common, bleeding into tumour may mimic acute torsion.
- Rarely evidence of metastatic disease or gynaecomastia (5%).
- Examination: hard, irregular, non-tender testicular mass.
Investigations
- Blood for tumour markers, i.e. AFP, β-HCG and LDH. Very useful in following success of treatment.
- AFP is elevated in 75% of embryonal and 65% of teratocarcinoma.
- AFP is not elevated in pure seminoma or choriocarcinoma. If an AFP elevation is noted in a pathologically diagnosed seminoma, the diagnosis should be changed to NSGCT.
- β-HCG is elevated in 100% choriocarcinoma, 60% embryonal carcinoma, 60% teratocarcinoma and 10% pure seminoma.
- Scrotal ultrasound: diagnosis is made by seeing a mass in the testis usually confined by the tunica albuginea.
- Chest X-ray to assess lungs and mediastinum: metastases.
- CT scan of chest and abdomen and pelvis: to detect lymph nodes and stage disease.
- Consider sperm banking for future fertility options.
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