GenSurg.nz

Testicular tumours

Section: Urology Curriculum: Curriculum, page 6

Incidence

  • 3.7/100,000
  • More common NZ, less common Africa/Asia
  • Peak incidence 15-35
  • Teratoma 20-30
  • Seminoma 30-40
  • Yolk sac younger (90% < 15)
  • Bilateral tumours 5%

Classification

  • Germ cell 85%
    • Seminoma
    • Non-Seminoma
      • Teratoma (has cells from more than one germ cell layer)
      • Choriocarcinoma -Syncytiotrophoblasts and Cytotrophoblasts
      • Embryonal
      • Yolk Sac
  • Sex cord-stromal tumours
    • Sertoli cell tumour
    • Leydig cell tumour
    • Granulosa cell tumour
    • Mixed types e.g. sertoli-leydig cell tumour
    • Unclassified
  • Mixed germ cell and stromal tumours
    • Gonadoblastoma
  • Adnexal and paratesticular tumours
    • Adenocarcinoma of the rete testis
    • Adenocarcinoma of the epididymis
    • Mesothelial neoplasms
    • Malignant mesothelioma
    • Adenomatoid tumour
  • Miscellaneous tumours
    • Carcinoid
    • Lymphoma
    • Metastatic tumours (prostate carcinoma is the most common)>)

Risk Factors

  • Cryptorchidism – orchidopexy does not stop risk
  • Genetic risk
  • Testicular dysgenesis, Kleinfelter’s, testicular feminization
  • Contralateral tumour – 5% cumulative risk

Clinical

  • Painless testicular mass, not separable from testis
  • 40% present with tenderness which may reflect small secondary hydrocele
  • Gynaecomastia
  • 30% present with metastatic disease

Pathology

  • Seminomas – Lymphatic spread to Retroperitoneal lymph nodes
  • Choriocarcinoma – haematogenous spread
FeatureSeminomaNSGCTs
PathologyUniform germ cells with clear cytoplasm, lymphocytic infiltrate.Includes embryonal carcinoma, teratoma, choriocarcinoma, and yolk sac tumors, showing diverse differentiation.
Age GroupCommon in men aged 30–40 years.Common in younger men aged 15–35 years.
Growth and SpreadRemains localised. Slow-growing; late lymphatic spread.Faster-growing; early metastasis to lymph nodes and distant organs.
Lymph Node SpreadRetroperitoneal lymph nodes.Retroperitoneal and distant lymphatic spread.
Hematogenous SpreadRare, occurs late.Common, especially in choriocarcinoma (lungs, liver, brain).
Tumor Markersβ-hCG (mildly elevated in ~10–15%); no AFP.70% = May have elevated AFP (yolk sac or mixed tumors), β-hCG (choriocarcinoma or mixed tumors).
Management- Stage I: Orchiectomy, surveillance, or carboplatin.
- Stage II-III: Radiation or BEP chemotherapy.		- Stage I: Orchiectomy, surveillance, or BEP chemotherapy.
- Stage II-III: BEP chemotherapy.
Radiation SensitivityHighly radiosensitive.Poorly radiosensitive; managed primarily with chemotherapy.
PrognosisExcellent; 5-year survival >95% in early stages.Variable; depends on type and stage, but generally more aggressive than seminomas.
Relapse RiskLower, particularly in early stages.Higher risk of recurrence, especially with mixed components.

Investigation

  • Blood tests – aFP (yolk sac cells), hCG (trophoblasts), LDH
  • USS to investigate testicle
    • Seminoma - well-defined hypoechoic lesions without cystic areas
    • Non-seminomatous germ cell tumours - non-homogenous hyperechoic lesions with calcs, cystic areas and indistinct margins
  • CT abdo/pelvis + CXR
  • DO NOT FNA (risk of disrupting lymphatics)

Staging

T1: Tumour limited to testis & epididymis, without LVI T2: Tumour as above but with LVI or extending through to tunica vaginalis T3: Tumour invades spermatic cord
T4: Tumours invades the scrotum

N1: LN mass < 2cm N2: LN mass 2-5cm N3: LN mass >5cm

M1 - distant nets

S0 - Markers within normal limits S1 - HCG <5,000, αFP <1,000, LDH <1.5x S2- HCG 5,000-50,000, aFP 1,000-10,000, LDH 1.5-10x S3- HCG >50,000, aFP >10,000, LDH >10x

M1a non-regional nodal or pulmonary M1b distant

Summary of staging

  • Stage 1 = no LN
  • Stage 2 = LN positive
  • Stage 3 = distant mets

Management

FeatureSeminomaNSGCTs
Stage 1Orϲhiеϲtоmy

+ Surveillance		Orchiectomy alone in low risk disease (no LVI, not embryonal carcinoma, >T2)

In high risk patients consider BEP or RPLND
Stage 2+ RTx or ChemoClinical

+ RPLND or BEP – BEP preferred in IIB/C

Pathological

BEP
Stage 3ChemoChemo

Principles of management

  • Resection of primary for local control, confirmation of histological diagnosis and prognostication
  • Then treatment based on stage
    • Seminoma
      • Most will receive radiotherapy
      • Consider chemotherapy
    • Non-seminoma
      • Most will receive RPLND
      • Consider chemotherapy

Inguinal orchidectomy

  • Diagnosis and prognostication
  • How to
    • 2cm skin incision superior and parallel to inguinal ligament
    • Through EO in line of fibres
    • ID and preserve ilioinguinal n
    • Dissect spermatic cord free along its length and isolate it at PT
    • Stretch cord opening and deliver the testicle
    • Divide the spermatic cord in 2 parts - vascular and vas, close to deep ring
    • Layered closure

Seminoma

  • Radiotherapy
    • Seminomas are more radiosensitive
    • Usually given to retroperitoneum
    • 30Gy to para-aortic and ipsilateral iliac LN
  • Chemotherapy Options
    • Always considered in stage 3 and some stage 2 disease

NSGCT

  • Prophylactic retroperitoneal LN dissection
  • Chemo
    • cisplatin/bleo regimes - 85% cure even with mets
  • Close F/U

Steps in management and MDM points

  • Confirmation of diagnosis - usually with radical orchidectomy
  • Risk stratification
    • Histo - seminoma vs non-seminoma
    • Mets or not
    • Serum tumour marker degree of elevation
  • Semen cryopreservation
    • Baseline sperm count and banking pre dx and staging
    • Infertility risk from all mx options (surgery, RTX) and the pathology
  • Specific management plans then differ based on the stage of disease and histology
  • This can include
    • Retroperitoneal lymphadenectomy
    • Chemotherapy
    • Radiotherapy

Follow-up

  • Self examination 3-6 monthly
  • Annual examination
  • Serum hCG and AFP useful for NSGCT but nothing required for seminoma

Natural history

  • Testicular GCTs are very curable with 95% 5 yr survival and often present with limited local disease (particularly seminoma)
  • When LN mets do occur it usually goes to para-aortic LNs so imaging needs to assess the retroperitoneal LNs
  • Mixed cancers get treated as NSGCT

Prognosis

  • LN neg disease = 100% 5 yr survival
  • Poor prognostic features
    • Markers
      • AFP >10000, hCG >50,000, LDH >10 (10x upper limit of normal)

Graph View

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