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Testicular Cancer

OVERVIEW
Testicular cancer is 1-1.5% of male cancers and about 5% of urological tumors. (7,8,9)  It is one of the most curable solid malignancies with 99%-100% of stage I and 70% to 80% of stage II and III diseases cured. (1)  The majority of patients presenting with stage I disease will require surgery and surveillance with no chemotherapy or radiation. (2) Presentation is most commonly painless testicular mass, although 25% present with pain. (3) 2-3% of patients develop a contralateral tumor during follow up. (4) 

Most experts and guidelines strongly recommend patients with disseminated disease be treated at centers of excellence with extensive experience (1) 

EXTRAGONADAL TUMORS
Germ cell tumors (GCT) outside of the gonads are rare (<5%) but can occur, usually in the mediastinum or retroperitoneum (5) and rarely in the pineal gland of adolescents.  Prognosis for mediastinal nonseminomas is worse than gonadal GCT's and  (1)

SMALL INCIDENTAL TESTICULAR MASSES
Small testicular masses are common and found in nearly 3% of scrotal US. A study of 120 men with incidental small testicular masses (<1cm) found on ultrasound for fertility workup found 15% eventually underwent surgery with 6 of the original 120 diagnosed with seminoma, all of which were >5mm and vascular on initial US. (6)  A retrospective study of masses <2cm found 14% malignant. (10)

HIGH YIELD NOTES
  • nonseminoma don't operate if tumor markers elevated unless from a teratoma-
  • seminoma >200 b-HCG, consider advanced treatment (chemo)
  • if applicable give 200mg IM testosterone, if hypogonadism is cause, this dose will suppress LH and then b-HCG will drop
  • b-hcg - 24 to 48hrs, AFP 5-7 days, 
  • liver disease can elevate AFP
  • GCNIS not present in spermatocytic, pediatric yolk cell, pediatric teratoma
  • nonseminoma - presence of lymphovascular invasion is highest predictor of relapse
  • h/o radiation is higher risk for 2nd malignancy than h/o chemo
  • some say immature teratoma can be considered NSGCT, has same prognosis as mature teratoma though
  1. Daneshmand, Siamak, and Dorff, Tanya. "Lesson 3: Update on Medical and Surgical Management of Advanced Testis Cancer. AUA Update Series." (2018)
  2. Nichols, Craig R., et al. "Active surveillance is the preferred approach to clinical stage I testicular cancer." Journal of Clinical Oncology 31.28 (2013): 3490-3493.
  3. Medical Treatment of Urologic Malignancies. International Consultation on Medical Treatemtn of Urological Malignancies. Lisbon 2014. Edited by C Stief, K Fizazi and C Evans. Arnhem, The Netherlands:ICUD-EAU 2015.
  4. Albers, Peter, et al. "EAU guidelines on testicular cancer: 2011 update." European urology 60.2 (2011): 304-319.
  5. Oosterhuis, J. Wolter, et al. "Why human extragonadal germ cell tumours occur in the midline of the body: old concepts, new perspectives." International journal of andrology 30.4 (2007): 256-264.
  6. Bieniek, J. M., Juvet, T., Margolis, M., Grober, E. D., Lo, K. C., & Jarvi, K. A. (2018). Prevalence and Management of Incidental Small Testicular Masses Discovered on Ultrasonographic Evaluation of Male Infertility. The Journal of Urology, 199(2), 481–486.​
  7. La Vecchia, Carlo, et al. "Cancer mortality in Europe, 2000–2004, and an overview of trends since 1975." Annals of Oncology 21.6 (2010): 1323-1360.
  8. Curado, Maria-Paula, et al. Cancer incidence in five continents, Volume IX. IARC Press, International Agency for Research on Cancer, 2007.
  9. ​Engholm, Gerda, et al. "NORDCAN–a Nordic tool for cancer information, planning, quality control and research." Acta oncologica 49.5 (2010): 725-736.
  10. Gentile, Giorgio, et al. "Testis sparing surgery of small testicular masses: retrospective analysis of a multicenter cohort." The Journal of Urology 203.4 (2020): 760-766.
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