| Testicular
Cancer |
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Anatomy
The testis consists of predominantly seminiferous tubules, which produce sperm, and these drain to the epididymis. Its blood supply is from the spermatic artery and its venous drainage is to the pampiniform plexus of gonadal veins. Its lymphatic drainage is to the retroperitoneal lymph nodes.
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Normal testicular anatomy
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Incidence
Testis cancer is most commonly seen in men between
the ages of 15 to 35 years. Fortunately, testis
cancer is an eminently curable disease, provided
patients are compliant with treatment and follow
up. Testis cancer is a perfect example of how
the interplay of different treatment modalities
have resulted in excellent outcomes.
Symptoms and
Signs
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Testicular cancer usually effects one testicle only, however, in a small percentage of patients testis cancer can occur in both testicles either at the same time or at some time in the future.
Most patients who present with testicular cancer will have noticed a swelling in one testicle. The swelling is usually painless but in about 10% of patients, pain in the testicle is the initial presenting symptom.
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Patient with a painless testicular mass |
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Rarely patients may present with symptoms related to the spread of the cancer to other areas of the body, such as, swollen lymph nodes in the neck, shortness of breath, or abdominal or low back pain.
Cryptorchidism or undescended testicle is thought to be a risk factor for the development of testis cancer.
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Testicular tumour in an undescended (inguinal) testicle |
Diagnosis
Any patient who suffers from persistent pain in the testicle or notices a lump in the body
of the testicle should see their general practitioner for review. A scrotal ultrasound is a painless examination and the most reliable way of detecting testicular tumours.
Multiple sonolucent areas seen
in a testi with cancer
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Testicular self examination on a monthly basis is a sensible recommendation allowing early detection of testicular abnormalities.
Two thirds of testicular tumours produce proteins that can be measured in the blood called tumour markers. Alpha feto protein (AFP) and beta human chorionic ganatoprophin (HCG) are the most common markers produced.
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If testicular cancer is suspected, the testicle will need to be removed through a small incision in the groin. Provided the remaining testicle is normal this operation will have no impact on a patients libido or erectile function. Unfortunately infertility is not uncommon in patients suffering from testicular cancer. Patients should have sperm collected and frozen prior to treatment. Fortunately in the vast majority of patients, simply removing the testicle will result in cure of their disease. The majority of testicular tumours arise from germ cells within the testicle. |
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Pathology
There are essentially 2 different types of testicular cancers, seminoma
and non seminoma. Within the non seminomatous group there are 4 sub types namely embryonal carcinoma, choriocarcinoma, yolk sack tumour and teratoma. Commonly testicular tumours will consist of multiple different germ cell types (eg: embryonal carcinoma, yolk sack tumour and teratoma, i.e. a mixed germ cell tumour).
The spread of testicular cancer is relatively predictable based upon the lymphatic drainage of the testicle. The most common sites of spread are
to the lymph nodes within the abdomen, the lungs and the lymph nodes
in the chest. Rarely testicular cancer can spread to the brain or bones.
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Operative specimen.
The uniform appearance typical of pure seminoma.
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Staging
The TNM classification system is used to stage testicular tumours. This system uses the microscopic examination of the testicular tumour, the size and number of abdominal lymph nodes involved with tumour and the presence of spread elsewhere to stage testicular cancer. |
TNM classification system for testis cancer
Summary of AJCC / UICC Staging |
pT1 |
Testis and epidiymis, no LVI |
pT2 |
LVI or invasion tunica vaginalis |
pT3 |
Spermatic cord |
pT4 |
Scrotum |
N1 |
< 2 cm |
N2 |
2 to 5 cm |
N3 |
> 5 cm |
M1a |
Regional or pulmonary metastases |
M1b |
Non-pulmonary visceral metastases |
S1-S3 |
Good, intermediate or poor marker levels |
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Once the diagnosis of testicular cancer is made,
patients require measurement of their testicular
tumour markers and CT scans of their chest,
abdomen and pelvis to adequately stage their
disease.
Staging is important as it dictates treatment options.
Treatment of
testis cancer
As already indicated the vast majority of patients
with testicular cancer are cured simply by removing
the testicle, however diligent follow up is
required in order to detect a recurrence of
disease at the earliest possible time. Treatment
options are dependent on both the type of testicular
cancer (seminoma or non seminoma) and the stage
of the disease. In patients with seminoma treatment
options include surveillance radiotherapy and/or
chemotherapy.
For patients with non seminomatous testicular cancer, treatment options include surveillance, surgical removal of the abdominal lymph nodes and/or chemotherapy. Surgical removal of the abdominal lymph nodes (RPLND – retroperitoneal lymph node dissection), often resulted in the inability to ejaculate because the post-ganglionic sympathetic nerves were damaged. Today, in experienced hands, these nerves can be preserved and ejaculation
maintained in the majority of patients. |
Preservation of the post-ganglionic sympathetic nerves of L1-4 after RPLND |
To ensure the best possible outcome, patients
with testicular cancer need to be managed in
centres that offer multi disciplinary treatment
clinics and in units that treat large volumes
of patients with the disease.
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