Urology Info - Testicular Cancer

Testicular Cancer

Page updated Winter 2021.

Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable sources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to take or administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original sources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.

Basics and Diagnosis

Epidemiology

Germ cell tumor is the most common solid malignancy among males age 20 to 40 years.

Risk factors

Germ cell neoplasia in situ, history of UDT, family or personal history of testis cancer.

Diagnosis

Solid testicular mass

Any solid mass in the testis identified by physical exam or imaging should be treated as a malignant tumor until proven otherwise.

Scrotal ultrasound

With doppler

CT scan/ MRI of the abdomen and pelvis

With IV contrast

Chest imaging

Serum tumor markers before orchiectomy

AFP, hCG, and LDH

Serum tumor markers after orchiectomy

If serum markers are elevated before orchiectomy, we measure them again after orchiectomy.

Radical Orchiectomy

Radical inguinal orchiectomy is the first step in managing these patients.

Risks Associated with Radical Orchiectomy

Risks of anesthesia

Bleeding into the scrotum

Infection

Damage to nearby nerves, and structures

Inguinal hernia

Infertility

Changes in testosterone levels

Notice: Cancer may recur and spread even after this procedure. Further surveillance and/or treatments are required for all patients.

Sperm Banking

We discuss sperm banking before treatment.

Staging

TNM staging: click here.

AJCC staging: click here.

Risk Classification-Non Seminoma

Good prognosis

Testicular/retroperitoneal primary

No nonpulmonary visceral metastases

AFP <1000 ng/mL

HCG <5000 IU/L

LDH <1.5 × upper limit of normal (N)

Intermediate prognosis

Testicular/retroperitoneal primary

No nonpulmonary visceral metastases

AFP ≥1000–10,000 ng/mL

HCG ≥5000–50,000 IU/L

LDH ≥1.5 × N and ≤10 × N

Poor prognosis

Mediastinal primary or Nonpulmonary visceral metastases or

AFP >10,000 ng/mL or

HCG >50,000 IU/L (10,000 ng/mL) or

LDH >10 × upper limit of normal

Risk classification-Seminoma

Notice: AFP is normal in pure seminoma.

Good prognosis

No nonpulmonary visceral metastases

Intermediate prognosis

Nonpulmonary visceral metastases

Germ Cell Neoplasm In Situ

Germ cell neoplasm in situ is a precursor lesion for germ cell tumor and is associated with a 50% risk of developing an invasive germ cell tumor within 5 years.

Radical orchiectomy or low-dose (≥ 20 Gy) RT is an effective treatment for germ cell neoplasm in situ.

Seminoma

Serum HCG is elevated in about 15% of patients with metastatic seminoma. Unlike non-seminoma, serum tumor marker levels are not used to guide treatment.

Stage I Treatment options after orchiectomy are:

Surveillance (preferred), carboplatin x 1, RT (20 Gy)

Stage IS Perform CT chest/abdomen/pelvis

Stage IIA RT (30 Gy) or Chemotherapy (BEP X 3 or EP X 4)

Stage IIB with a LN ≤3cm

Chemotherapy (BEP X 3 or EP X 4) or RT (36 Gy)

Stage IIB Seminoma with a LN >3 cm

BEP X 3 or EP X 4

Stage IIC and III Good Risk

BEP X 3 or EP X 4

Stage III Intermediate Risk (Nonpulmonary Visceral Metastases)

BEP X 4 or VIP X 4

Residual Masses > 3 cm after First-line Chemotherapy

FDG-PET will be done. Patients with PET positive residual masses should undergo surgical resection.

Residual masses that are PET-negative or less than 3 cm can be safely observed after chemotherapy.

Teratoma at Metastatic Sites

This is less common in seminoma compared to non-seminoma but should be considered in patients who fail to respond to chemotherapy.

Non Seminoma

Stage I

Surveillance or RPLND or BEP X 1

RPLND: stage I non-seminoma who had teratoma with malignant transformation at orchiectomy.

We recommend active treatment (RPLND or chemotherapy) to those with lymphovascular invasion and/or embryonal carcinoma predominance.

Stage IS BEP X 3 or EP X 4

Stage IIA with Normal Post-Orchiectomy AFP & HCG

RPLND or chemotherapy

Stage IIA S1 BEP X 3 or EP X 4

Stage: IIB BEP X 3 or EP X 4 . RPLND may be done in highly selected patients.

Stage IIB S1 BEP X 3 or EP X 4

IIC, and IIIA BEP X 3 or EP X 4

IIIB and IIIC BEP X 4 or VIP X 4

Post RPLND Management

pN0: surveillance

pN1: surveillance (preferred) or BEP X 2 or EP X 2

pN2: BEP X 2 or EP X 2

pN2: BEP X 3 or EP X 4

pN1-3 pure teratoma: surveillance is preferred.

Post-chemo Residual Masses with Normal Tumor Markers

Resect if ≥ 1 cm and tumor markers are negative.

Next step is going to be per resected pathology:

Teratoma or necrosis: surveillance

Other germ cells: 2 cycles of EP or TIP or VIP or VeIP

Post-chemo Residual Masses with Elevated Tumor Markers

Mildly elevated and normalizing: manage like masses with normal tumor markers.

Elevated but stable: Close surveillance.

Elevated and rising: Second line therapy

Second Line Therapy

If relapse occurs <2 years: consider chemo. Surgery is an option for a single mass.

Conventional chemotherapy regimen: TIP or VeIP

High dose chemo: Carboplatin/ etoposide or P-ICE

Relapse occurs > 2 years: consider surgery, if respectable.

RPLND

Cephalad extent of the dissection

Level of the renal arteries.

Caudal extent of the dissection

The crossing of the ureter over the ipsilateral common iliac artery.

Right modified template

We omit the para-aortic lymph nodes below the inferior mesenteric artery

Left modified template

We omit paracaval, precaval, and retrocaval lymph nodes.

Full bilateral template dissection

We recommend this if there is suspicious lymph nodes on CT, or during the surgery or when the primary tumor is teratoma.

Nerve-sparing

Is appropriate for selected patients who want to preserve their ejaculation.

Gonadal vessels

Ipsilateral ones should be removed.

Retrocrural Dissection

May be considered at the time of RPLND.

Nephrectomy

It is the most common auxiliary procedure.

Major Vascular Reconstruction

In some series, 15% of patients needed vascular procedures.

This included aortic resection, cavotomy/caval resection, iliac resection, and renovascular resection with repair.

Primary reconstruction of the IVC is preferred if possible.

Small vessel wall injuries may be repaired via patch venoplasty or with bovine/porcine pericardial grafts.

PTFE or Dacron grafts may be used.

Liver Resection

RPLND in patients with liver involvement is usually done after first, second or third-line chemotherapy.

All lesions including residual liver masses should be resected at this time.

Thoracic Masses

These masses should be addressed after RPLND is done.

All masses > 1 cm should be considered for resection unless the retroperitoneum only had fibrosis.

Brain Metastases

Primary chemo ± RT ± Surgery

Brain metastases are associated with choriocarcinoma and should be suspected in any patient with a very high serum HCG level.

Patients with choriocarcinoma of the brain are at risk of bleeding and should be monitored for this when chemotherapy is started.

Chemotherapy Regimens

BEP

Bleomycin + etoposide + cisplatin

Etoposide + cisplatin

VIP

Etoposide + Ifosfamide + Cisplatin

TIP

Paclitaxel + ifosfamide + cisplatin

VeIP

Vinblastine + ifosfamide +cisplatin (Platinol).

Carboplatin + etoposide

P-ICE

Paclitaxel + ifosfamide + carboplatin + etoposide

Testicular Microlithiasis

Incidentally detected microlithiasis should not undergo further evaluation.

Men with risk factors and testicular microlithiasis should be counseled about the potential increased risk of germ cell tumor. They need to perform periodic self-examination, and be followed by a urologist.