Testicular Cancer

Incidence

Estimates for testicular cancer based on the American Cancer Society report for 2012:

  • total estimated new cases: 8,590
  • total estimated deaths: 360

Risk Factors

  • Undescended testicle (i.e. cryptorchidism)
  • Prior history of testicular cancer
  • Family history of testicular cancer
  • Gonadal dysgenesis
  • Androgen insensitivity syndrome
  • Intratubular Germ Cell Neoplasia (ITGCN) (i.e. carcinoma in-situ)

Pathology

Types of lesions:

  • Germ Cell Tumors
    • Seminoma

      • Classic
      • Spermatocytic
    • Nonseminoma

      • Embryonal
      • Yolk sac tumor
      • Choriocarcinoma
      • Teratoma
    • Tumors with mixed types

  • Other types: Lymphoma, Leydig cell tumor, Sertoli cell tumor, Granulosa cell tumor, other

Route of Spread

Testicular Cancer spreads by:

  • Local invasion
  • Hematogenous spread (i.e. to metastatic sites through the blood by way of vascular channels)
  • Lymphatic spread (i.e. by way of lymphatic channels to lymph nodes)

Clinical Features

  • Painless testicle mass or swelling
  • Pain +/- mass or swelling of the testicle
  • Sign or symptoms related to metastasis
  • History of trauma
  • Gynecomastia or breast tenderness
  • Incidental finding

Usual Work-up

  • Scrotal ultrasound
  • Serum tumor markers (i.e. AFP, bHCG, LDH)
  • Imaging for staging (i.e CT scan)

Staging (TNM)

Primary Tumor (T):

  • TX-primary tumor cannot be assessed
  • T0-No evidence of primary tumor (e.g. histologic scar in testis)
  • Tis-Intratubular germ cell neoplasia (carcinoma-in-situ)
  • T1-Tumor limited to the testis and epididymis without vascular/lymphatic invasion; tumor may invade into the tunica albuginea but not the tunica vaginalis
  • T2-Tumor limited to the testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis
  • T3-Tumor invades the spermatic cord with or without vascular/lymphatic invasion
  • T4-Tumor invades the scrotum with or without vascular/lymphatic invasion

Regional Lymph Nodes (N):

  • Nx-Lymph nodes cannot be assessed
  • cN0/pN0-No regional lymph node metastasis
  • cN1-metastasis with a lymph node mass 2cm or less in greatest dimension; or multiple lymph nodes, none more than 2cm in greatest dimension. pN1-Metastasis with a lymph node mass 2cm or less in greatest dimension and less than or equal to five nodes positive, none more than 2cm in greatest dimension.
  • cN2-metastasis with a lymph node mass, more than 2cm, but not more than 5cm in greatest dimension; or multiple lymph nodes, any one mass greater than 2cm but not more than 5cm in greatest dimension. pN2-Metastasis with a lymph node mass more than 2cm but not more than 5cm in greatest dimension; or more than 5nodes positive none more than 5cm; or evidence of extranodal extension of tumor.
  • cN3-metastasis with a lymph node mass more than 5cm in greatest dimension. pN3-metastasis with a lymph node mass more than 5cm in greatest dimension.

Distant Metastasis (M):

  • Mx-Distant metastasis cannot be assessed
  • M0-No distant metastasis
  • M1-distant metastasis (m1a=nonregional nodal or pulmonary metastasis, m1b=distant metastasis at site other than nonregional lymph nodes or lung)

Serum Tumor Markers (S):

  • Sx-Marker studies not available or not performed
  • S0-Marker study levels within normal limits
  • S1-LDH < 1.5 x N and hCG < 5000 and AFP < 1000
  • S2-LDH 1.5-10 x N and hCG 5000-50,000 and AFP 1000-10,000
  • S3-LDH >10 x N and hCG >50,000 and AFP >10,000

Stage Grouping

  • Stage 0: TisN0M0S0; premalignant lesions, no disease outside the testicle
  • Stage 1: T1-4N0M0S0; disease confined to the testicle
  • Stage 1s: Tx-4N0M0S1-3; no evidence of disease outside of the testicle on staging images, but continued elevation of tumor markers after orchiectomy
  • Stage 2: Tx-4N1-3M0S0-1; evidence of regional lymphatic nodal involvement on staging imaging with or without S1 tumor marker elevation after orchiectomy, regardless of T stage
  • Stage 3: Tx-4N0-3M0-1S0-3; evidence of metastatic disease outside of regional lymph nodes or limited to regional lymph nodes with S2-3 tumor marker elevation after orchiectomy, regardless of T stage

Treatment Options

Treatment is based on tumor type and stage

  • Seminoma
    • Stage 1: low dose radiation, chemotherapy, or active surveillance
    • Stage 1s (i.e. continued tumor marker elevation despite no evidence of disease on staging imaging): chemotherapy
    • Stage 2a/b: Standard dose radiation or chemotherapy
    • Stage 2c/3: chemotherapy
    • Recurrence or incomplete treatment may require more chemotherapy, surgery, or a combination of chemotherapy and surgery.
  • Nonseminoma
    • Stage 1: surgery (RPLND), chemotherapy, or active surveillance
    • Stage 1s (i.e. continued tumor marker elevation despite no evidence of disease on staging imaging): chemotherapy
    • Stage 2a/b: Standard dose radiation or chemotherapy
    • Stage 2a/b: surgery (RPLND) or chemotherapy
    • Stage 2c/3: chemotherapy
    • Recurrence or incomplete treatment may require more chemotherapy, surgery, or a combination of chemotherapy and surgery.

Prognostic Factors

  • Level of tumor marker elevation
  • Lymphatic or vascular invasion
  • Size of primary tumor
  • Rete testis invasione
  • Majority of embryonal cell carcinoma present
  • Absence of yolk sac elements
  • Higher T stage
  • Amount of disease present
  • Lymph node or visceral metastasis

Survival

Cisplatin-based chemotherapy has made a huge difference in the treatment of testicular cancer. Prior to current chemotherapy regimens, advanced testicular cancer was associated with only a 5-10% cure rate. However, after introduction of current chemotherapy regimens, advanced testicular cancer is now associated with an 80-90% cure rate.

Recommended Follow-up

Depending on treatment, patients are followed at different time periods with tumor markers and follow-up imaging to monitor for recurrent or persistent disease.