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Testis Cancer

Differential
Differential of a scrotal mass:
History: Time course, associated pain,
constitutional symptoms, exacerbating factors,
etc

Past medical history: undescended testis, h/o
contralateral tumor
Evaluation of Scrotal Mass
Physical exam:
Vitals
Pain, redness, heat, reducibility, orientation of testis
Phrens sign
Transillumination
Cremasteric reflex
UA, urine culture
Ultrasound
Differential: Hydrocele
Differential: Epididymo-orchitis
Epididymitis is most common
Usually an ascending infection thru vas
deferens
Age predicts causative organism
>35 yrs: coliform bacteria
12-35 yrs: chlamydia, gonorrhea
<12: coliform, ?viruses
Differential: Spermatocele/
Epididymal cyst
Differential: Varicocele

Differential: Testicular Torsion
Differential: Hernia
Reducible or incarcerated
Usually does not transilluminate
Swells with valsalva

Differential: benign testicular lesions
Very rare. Ultrasound may be suggestive
epidermoid cysts
fibromas
fibroadenomas
adenomatoid tumors
lipomas

Differential: testis tumor
Physical exam

?gynecomastia (found in 5%)
adenopathy
abdominal mass
Burden of Illness

Incidence rose from 3.5 to 6.5/100,000 over
30 years
About 6,000 cases/yr
Survival is > 90%
For all males, lifetime probability of dying of
testes cancer is 0.02%

Testicular Cancer: Is Screening
Accurate
Can screen via:

Testicular self exam: Low specificity: about 8% of
men with a lump found to have a tumor
Buetow J, Med Screen. 1996
Testicular ultrasound: Highly sensitive and
specific
Does Screening Improve Outcomes?
US Preventative Services Task Force 4/2004
Review
No evidence of decreased mortality
5 yr survival is >90% without screening
Risk of false positives with TSE
Cannot recommend screening
Diagnosis
Diagnosis
Diagnosis
Ultrasound is highly specific (hypoechoic lesion),
but diagnosis is made at radical orchiectomy

Microlithiasis- not a risk factor

Biopsy contraindicated



Histologic types
Germ cell tumors:
Seminoma versus Non seminomatous germ cell tumors
(NSGCT)

Non-germ cell tumors (rare, <5%)
Leydig cell tumors (precocious puberty)
Sertoli cell tumors
Mixed sex chord-stromal tumors
NSGCT
Choriocarcinoma
(elevated b-Hcg)
Embryonal cell
Teratoma (mature and immature)
Yolk sac
(elevated AFP)
Seminoma
Rarely make hcg

Generally favorable prognosis when seen in
older men
Tumor markers
AFP levels are elevated 50%-70% NSGCT
hCG levels are elevated in 40%-60%.
AFP has a half-life of 5-7 days
hCG has a half-life of 36 hours.
Important to follow response after
orchiectomy
LDH is non-specific measure of tumor burden
Treatment
Staging CT scan miss microscopic disease in 1
in 3 to 1 in 5 men

% embryonal cell, LV invasion, T stage can be
predictive or RP disease

Dilemma: overtreat or undertreat?
Treatment
Seminoma
Stage IA and B:
radiation therapy vs surveillance (? Chemo)
NSGCT
Stage IA
retroperitoneal lymph node dissection vs surveillance
Stage IB
retroperitoneal lymph node dissection vs surveillance vs
chemotherapy

Higher stages-chemo, f/b surgery as needed
Retroperitoneal Lymph Node
Dissection
chemotherapy
Usually 2 cycles of BEP
Well tolerated
? Late effects
Effects on fertility
Surveillance
NCCN guidelines
CT q 2-3 months for first year or two
Then q4, q6
Labs, CXR q month for year one, then q 2
months, etc

Issues are compliance, anxiety

Quality of Surveillance for Stage I Testis Cancer in the Community

401, 96, and 541 patients received surveillance, RPLND and XRT, respectively.
Mean follow up was 23, 24 mo, and 23 months, respectively.
100% of surveillance patients had at least one follow up test in the first year, but 8-16% of patients had no follow tests of any kind in years 2-5.
Compliance with recommended follow up was generally poor.
Compliance with follow up was higher in RPLND patients.






Stage I Testis Cancer Compliance With Surveillance Follow Up Guidelines for Seminoma





N*

COMPLIANCE



Abdominal Imaging

Chest Imaging

Labs / Tumor Markers

100%

50%

0%

100%

50%

0%

100%

50%

0%

Surveillance
For
Seminoma

1

397

39.5%

14.9%

22.4%

56.7%

17.4%

25.9%

41.8%

10.3%

27.5%
2

227

15.9%

17.2%

39.6%

40.1%

20.3%

39.6%

30.4%

11.9%

34.8%
3

110

3.6%

19.1%

45.5%

21.8%

30.9%

47.3%

25.5%

17.3%

39.1%
4

61

6.6%

31.1%

62.3%

42.6%

NA

57.4%

27.9%

23.0%

49.2%
5

19

0%

36.8%

63.2%

42.1%

NA

57.9%

21.1%

21.1%

57.9%

Surveillance
For NSGCT

1

397

23.7%

30.7%

22.4%

12.3%

28.5%

25.9%

21.4%

20.4%

27.5%
2

227

5.3%

27.8%

39.6%

3.1%

20.3%

39.6%

13.2%

17.2%

34.8%
3

110

3.6%

19.1%

45.5%

3.6%

18.2%

47.3%

13.6%

29.1%

39.1%
4

61

6.6%

31.1%

62.3%

3.3%

8.2%

57.4%

11.5%

16.4%

49.2%
5

19

36.8%

NA

63.2%

10.5%

31.6%

57.9%

21.1%

21.1%

57.9%

Post -
RPLND

1

96

68.8%

22.9%

8.3%

60.4%

33.3%

0%

57.3%

16.7%

14.6%
2

61

62.3%

NA

37.7%

27.9%

37.7%

14.8%

23.0%

29.5%

26.2%
3

28

60.7%

NA

39.3%

17.9%

28.6%

28.6%

25.0%

14.3%

32.1%
4

14

50.0%

NA

50.0%

14.3%

28.6%

14.3%

14.3%

21.4%

42.9%
5

7

28.6%

NA

71.4%

0%

14.3%

85.7%

28.6%

42.9%

28.6%

Post - XRT

1

541

19.8%

30.1%

11.8%

28.8%

27.2%

15.3%

43.6%

16.5%

23.3%
2

309

19.7%

38.5%

41.7%

32.7%

36.2%

31.1%

41.1%

27.2%

31.7%
3

155

45.2%

NA

54.8%

59.4%

NA

40.6%

59.4%

NA

40.6%
4

76

35.5%

NA

64.5%

51.3%

NA

48.7%

57.9%

NA

42.1%
5

23

13.0%

NA

87.0%

30.4%

NA

69.6%

60.9%

NA

39.1%


FOLLOW
UP YEAR


N*


COMPLIANCE



Abdominal Imaging


Chest Imaging


Labs / Tumor Markers


100%


50%


0%


100%


50%


0%


100%


50%


0%


1


397


39.5%


14.9%


22.4%


56.7%


17.4%


25.9%


41.8%


10.3%


27.5%


2


227


15.9%


17.2%


39.6%


40.1%


20.3%


39.6%


30.4%


11.9%


34.8%


3


110


3.6%


19.1%


45.5%


21.8%


30.9%


47.3%


25.5%


17.3%


39.1%


4


61


6.6%


31.1%


62.3%


42.6%


NA


57.4%


27.9%


23.0%


49.2%


5


19


0%


36.8%


63.2%


42.1%


NA


57.9%


21.1%


21.1%


57.9%


Quality of Surveillance for Stage I Testis Cancer in the Community


The use of surveillance for testis cancer is widely accepted in the community.
Compliance rates with recommended follow up care are poor .
Compliance among RPLND patients appear to be superior, possibly due to
greater selection for motivated patients.
Surveillance protocols developed at referral centers are not being followed in
the community; further work is needed to understand the impact of this
apparent quality of care problem on oncologic outcomes in men treated in the
community with surveillance protocols.

Testicular Cancer outcomes
5 year survival for stage I is >95%

Focus is on reducing treatment side effects (e.g.
retrograde ejaculation)

Concern over late effects of treatment

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