1. Mark Browning, M.D. ‘77 IUSME 2.29.16
Testicular Cancer
Mark Browning, M.D. ‘77
IUSME

2. Testis

3. Testicular Cancer Germ Cell tumor in ages 15-45 > ½ occur
Cure rate is 95%
99% confined to testis
96% spread to retroperitoneum
75% spread to other sites
8400 men diagnosed in 2015
380 deaths
> Age 65 Lymphoma noted

4. Germ Cell Cancer 95% are of germ cell origin
5% arise from stromal tissue or Leydig cells
Germ cell tumors may arise from
Testicle (90%)
Extragonadal Sites
Anterior Mediastinum (1/4 Ts)
Retroperitoneum

5. Mediastinal Germ Cell Cancer
Malignant Transformation of germinal elements distributed during embryogenesis
Rare (<500 cases/year)
Associated with Klinefelter’s Syndrome

6. Epidemiology & Risk Factors
Rare Cancer but most common among men ages 15-35
Associated with testicular dysgenesis & oligospermia
Cryptorchidism
10% of testicular cancers
¼ of these patients have it occur in the contralateral, descended testis
Brothers have higher risk factor
2% chance of opposite testis if previous diagnosis

7. Presentation of Testis Cancer
Painless Scrotal Mass
Gynecomastia
Swelling in one or both legs & +/- blood clot
Back Pain secondary to retroperitoneal adenopathy
Pulmonary symptoms secondary to lung mets
Associated low sperm count
>80% are oligospermic at presentation

8. Diagnostic/Clinical Work-Up
Scrotal Ultrasound
Trans-scrotal biopsy is Contraindicated
AFP & BHCG
CT of Chest, abdomen & pelvis
PET Scan is not helpful in diagnosing & Staging but can be helpful in seminomas with masses that have not completely resolved
MRI only if Brain or Bone involved

9. Pathology Seminoma vs. Non-Seminoma
If AFP is elevated is Non-Seminoma
Most Tumors are “mixed”; if there is any non-seminoma component it is treated as a non-seminoma
Non-Seminoma consists of
Choriocarcinoma
Embryonal carcinoma
Yolk sac tumor
teratoma

10. Tumor Markers Seminoma Choriocarcinoma: b-HCG elevated
Usually normal marker levels
Occassionally b-HCG elevated
AFP is NEVER elevated
Choriocarcinoma: b-HCG elevated
Yolk sac tumor: AFP elevated
Embryonal Carcinoma: both elevated
Teratoma: neither elevated

11. Prognostic Variables Testicular Cancer is highly curable (>90%)
Small subset of patients have a poor prognosis is still
AFP > 10,000
B-HCG > 50,000
Non-pulmonary visceral mets (bone, brain, liver)
Primary mediastinal non-seminomatous GCT

12. Clinical Presentations
Embryonal carcinoma, choriocarcinoma & yolk sac tumors spread via lymphatics & hematogenously
Pulmonary mets are common
Less common are bone, brain & liver
Teratoma does not spread hematogenously, but grows by local extension
Can be carried to distant sites by other components of cancer (e.g.. Embryonal)
Can transform into other cancers (sarcomas, neural tumors, carcinomas)

13. Treatment Surgery…Radical Orchiectomy
Surveillance. Frequently with CTs & markers
Radiation Rx possibly for Seminoma
Chemotherapy for higher than stage 1 seminoma and non-seminoma
Cis platinum, Bleomycin & Etoposide