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Testicular Cancer

Hayden Schafer, MD and Matthew Zeitler, MD
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22:53

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Testicular cancer is most common in young men, and the guidelines for screening are somewhat controversial. Listen in as Dr. Matt Zeitler discusses this with Dr. Hayden Shafer, who shares his own personal experience as well.

Pearls:

  • Screening for testicular cancer either by self exam or having the PCP do it in the office is actually not recommended by most professional organizations because testicular cancer is so rare and accounts for only 0.1% of cancer deaths in men while having 95% survivorship rate at 5-years.

  • Active surveillance is the most common outcome for testicular cancer nowadays once that stage 1 tumor is removed with the orchiectomy.

  • Even after the radical orchiectomy, many patients in the first two years will experience recurrence and need further treatment with either chemotherapy or another surgery called retroperitoneal lymph node dissection.

 

  • Epidemiology:

    • Rare - 1% of all cancers in men

    • Most common solid malignancy between 15-35 in men

    • 95% five year survival rate and accounts for 0.1% of deaths in cancer for men

  • Presentation:

    • Painless swelling or node in the testicle

      • Only 10% have an pain and 30-40% will have more generalized lower abdominal pain

    • 10% of people will present with metastatic disease with symptoms based on location (GI, bone, lung)

    • If the tumor is Leydig or germ cell in origin, the patient may present with gynecomastia because of the elevated HCG or even hyperthyroidism because HCG is weakly thyroid stimulating

  • Diagnosis:

    • Ultrasound of the testicle

    • CMP

    • Tumor markers: LDH, AFP, beta-HCG

    • Definitive diagnosis is orchiectomy

    • CT abdomen/pelvis with contrast for staging using TNMS (tumor, nodes, metastasis, serum markers)

  • Screening:

    • Per most organizations (except American Urological Association): no benefit to doing self-exam or for physician to do on routine exam

      • Even if picked up once symptomatic, it is highly survivable. Early detection does not have significant impact on outcome

  • Treatment:

    • Orchiectomy (diagnosis and treatment)

    • Depending on staging:

      • Adjunctive chemotherapy

      • Radiation

      • Retroperitoneal lymph node dissection

    • Active surveillance is an option after treatment may include:

      • Regular CT scans and chest X-ray

      • Lab monitoring

  • Fertility options:

    • Sperm banking is recommended prior to orchiectomy

      • 48-92% are reported to successfully conceive children

  • Impact on testosterone:

    • Removal of one testicle has no impact on fertility

  • Prognosis:

    • Stage 1 tumors removed by orchiectomy, 75% reoccur in the first 2 years

 

References:

  1. Siegel RL, et al. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7-30. PMID: 31912902.

  2. Bosl GJ, Motzer RJ. Testicular germ-cell cancer [published correction appears in N Engl J Med 1997 Nov 6;337(19):1403]. N Engl J Med. 1997;337(4):242-253. PMID: 9227931.

  3. U.S. Preventive Services Task Force. Final Recommendation Statement: Testicular Cancer: Screening. Rockville (MD): U.S. Preventive Services Task Force. 2011. 

  4. Albers P, et al. Guidelines on Testicular Cancer: 2015 Update. Eur Urol. 2015;68(6):1054-1068. PMID: 26297604

  5. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology. Testicular cancer. December 8, 2016. Link [free registration required]. Accessed December 29, 2016.

  6. Aparicio J, et al. Prognostic factors for relapse in stage I seminoma: a new nomogram derived from three consecutive, risk-adapted studies from the Spanish Germ Cell Cancer Group (SGCCG). Ann Oncol. 2014;25(11):2173–2178.

  7. Aparicio J, et al. Prognostic factors for relapse in stage I seminoma: a new nomogram derived from three consecutive, risk-adapted studies from the Spanish Germ Cell Cancer Group (SGCCG). Ann Oncol. 2014;25(11):2173-2178. PMID: 25210015

  8. Fung C, et al. Long-term morbidity of testicular cancer treatment. Urol Clin North Am. 2015;42(3):393–408. PMID: 26216826

  9. Oldenburg J. Hypogonadism and fertility issues following primary treatment for testicular cancer. Urol Oncol. 2015;33(9):407–412. PMID: 25736189.

  10. Stephenson A, et al. Diagnosis and Treatment of Early Stage Testicular Cancer: AUA Guideline. J Urol. 2019;202(2):272-281. PMID: 31059667

  11. Baird DC, et al. Testicular Cancer: Diagnosis and Treatment. Am Fam Physician. 2018;97(4):261-268. PMID: 29671528.

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