Testicular Cancer

Page updated Winter 2021.

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Basics and Diagnosis

Epidemiology


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


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.


Stage Grouping


IA: pT1


IB: pT2-4


IS: S1-3


IIA: N1


IIB: N2


IIC:N3


IIIA: M1a


IIIB: M1a S2, or N1-3 S2


IIIC: M1a S3, or N1-3 S3, M1b


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


Sperm Banking


We discuss sperm banking before treatment.


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


EP


Etoposide + cisplatin


VIP


Etoposide + Ifosfamide + Cisplatin


TIP


Paclitaxel + ifosfamide + cisplatin


VeIP


Vinblastine + ifosfamide +cisplatin (Platinol).


Carboplatin + etoposide


P-ICE


Paclitaxel + ifosfamide + carboplatin + etoposide