About 99% of testicular tumours are malignant & although they make up only about 1-2% of malignant tumours in men, they are one of the most common form of cancer in the young male adult. A testicular tumour often escapes detection until after it has metastasized.
Mode of Spread of Testicular Cancer
1) Metastases first develop in retroperitoneal nodes. Rt sided tumour metastasize primarily to the inter aortocaval region just below the renal vessels & left sided tumour to the left para aortic area.
2)Distant spread is to the supraclavicular areas( left, primarily) & the lungs.
3)Inguinal lymph nodes are affected only if the scrotal skin is involved.
Pathological classification of Testicular Tumour
- Germ cell tumours : 90%
– Seminoma – Spermatocytic seminoma
– Embryonal carcin – Yolk sac tumour.
– Choriocarcinoma. – Teratoma : Mature
: Malignant transf.
– Embryonal carcinoma + Teratoma.
– Other combination.
- Sex cord-stromal tumour : 5%.
– Leydig cell tumour.
– Sartoli cell tumour
– Granulosa cell tumour.
Clinical features of Testicular Cancer
- Patients may not seek advice for several months of noticing a testicular lump.
- A painless firm mass within the testicular substance.
- Often pain, when there is spontaneous bleeding.
- Gynocomastia, when have increased hCG (teratoma).
- Abdominal pain, anorexia, wt loss, epigastric lump in abdominal metastasis.
- May have chest pain, dyspnoea, haemoPatientsysis in late stage.
- On examination : Testis is enlarged, smooth, firm & heavy, one or more protuberance may be palpable & thickening of spermatic cord.
Investigation for Testicular Cancer
- Serum tumour markers :
- A) Beta-hCG : 65% of non seminomatous.
10% of seminoma.
- B) AFP : 70% of non seminomatous.
Not elevated in seminoma.
- C) LDH : 60% 0f Patients.
Approximately 85% of Patients demonstrate elevation of one of these markers at presentation. Serum level decrease when tumour is completely removed or regress. Markers are used mainly to follow tumour regression or predict recur.
- Chest X-Ray
- Abdominal CT scan :
Stage 1 = Testis lesion only- no spread.
Stage 2 = Nodes below the diaphragm only.
Stage 3 = Nodes above the diaphragm only.
Stage 4 = Pulmonary or hepatic metastasis.
Treatment of Testicular Cancer
# Seminomas are radiosensitive, so Patients should be treated with external beam radiation therapy to the abdomen following orchidectomy.In the presence of bulky abdomen, disease or distant
# In the presence of bulky abdomen, disease or distant metastasis, adjuvent chemotherapy may be given Patients with substantial residual tumour ( > 3cm ) may be benefited from surgical removal.
Teratoma / Non seminomatous tumours
# Patients with non seminematous cell type who have extensive retroperitoneal or chest metastasis are best treated by multi agent chemotherapy by cisplatin, methotraxate, bleomycin & vincristine.In stage-1disease, watch the level of serum markers & by
# In stage-1disease, watch the level of serum markers & by repeated CT.
# Retroperitoneal lymph node dissection be with held in Patients with normal serum marker & no enlarged of these nodes.
Bailey & Love’s Short Practice of Surgery