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Testicular cancer and its surgical management Mr Charles Carey Surgical Oncology Teaching Series Learning objectives • Understand how to assess cases with possible testicular cancer • Evaluate how these processes may be applied to real-world cases • Appreciate the different types of testicular cancer • Focus in on the management of germ cell testicular tumours • Understand the surgical management of early stage testicular cancer • Gain an insight into the post-op management of early stage testicular cancer Introduction • Testicular cancer is an uncommon cancer that tends to occur in younger men • Despite often being aggressive, it generally has good survival outcomes • Management may involve surgery, radiotherapy and/or chemotherapy • Multiple forms of testicular cancer exist • Ultrasound and tumour markers are very useful tools in tumour assessment Epidemiology • Testicular cancer is relatively rare – represents <1% of total UK cancer cases • It is the 17th most common cancer in the UK among men • Around 2,400 men are diagnosed with testicular cancer each year • Testicular cancer is generally a condition of younger men • Arises most commonly in men aged 15 – 49 o The peak age arises between age 30 – 34 • The incidence of testicular cancer has been rising since 1990 • 1 – 2% of cases are bilateral Risk factors • The risk of testicular cancer is small even with the presence of risk factors • There are no clear causes of testicular cancer • Known risk factors include: o Cryptorchidism o Family history o Previous testicular cancer o HIV o Previous testicular cancer o Congenital hypospadia o In the UK caucasian men have been shown to be at higher risk Presenting features • Typically presents as: o Young man o PainLESS in 90% of cases o Pain in 10% of cases o Unilateral scrotal mass – firm, irregular, non-tender, no erythema o May have a reactive hydrocoele o May occur in an undescended testis o Some cases may lead to gynaecomastia o Metastatic features – weight loss, dyspnoea, haemoptysis, back pain Differential diagnoses • Hydrocoele • Varicocoele • Hernia • Epididymal cyst • Sperm granuloma • Abscess • Sebaceous cystWhat investigations would you organise? WREQUIRED IN TESTICULAR WHWOULD YOU CONSIDERTS CANCER? Investigations • Ideal management would include a same day ultrasound scan o If not possible then a scan ASAP (within 2 weeks minimum) • If a cancer is suspected – tumour markers o AFP o Beta-HCP o LDH • Staging CT-TAP o Assesses for LN and distant metastases Metastatic spread • The testes' lymphatic drainage is initially to the para-aortic LNs • The para-aortic nodes are retroperitoneal and are parallel to the aorta • The lungs are usually the first site of visceral metastatic spread Types of testicular cancer Testicular cancer Germ cell tumours (>95%) Non-germ cell tumours (<5%) Sarcomas Seminoma Non-seminoma Leydig cell Sertoli cell Lymphoma Anaplastic Classical Spermatocytic Yolk sac Teratoma Choriocarcinoma What is a germ cell? • Germ cells go on to produce spermatozoa and ova • They may also be seen at extra-gonadal sites o Some residual germ cells may remain in ectopic sites after embryogenesis o These are very rare o Example sites – mediastinal, retroperitoneal, pineal region, saccrococcygeal region • Germ cell tumours may be malignant or benign • Teratomas are tumours with tissues that are not normally present at that site • Teratomas are derived from all 3 germ cell layers Types of testicular cancer • Seminoma and NSGCTs occur at around the same rate • Seminomas are most common between ages 35 – 45 o Classical seminomas – 85% o Anaplastic – 10% o Spermatocytic – 5% • NSGCTs are most common between ages 20 – 35 o Most common forms are teratoma and embryonal cell carcinoma • Non-germ cell testicular tumours are incredibly rare Tumour markers • 51% of testicular cancers have raised tumour markers • 90% of NSGCTs secrete AFP and beta-HCG • Choriocarcinomas always secrete beta-HCG. • 5 – 10% of seminomas secrete beta-HCG and LDH – do NOT secrete AFP • Tumour marker half lives o AFP = 5 days o LDG = 3 days o Beta-HCG = 36 hours Tumour markers • May be used to aid cancer diagnosis but are not themselves diagnostic • These markers are not specific o LDH is a generic marker of tumour growth and burden o AFP can be raised in HCC o Beta-HCG is raised in pregnancy and is used in pregnancy tests • May be useful in monitoring response to treatment and for recurrence • Not all tumours secrete tumour markers Prognostic factors Good prognosisgroup Intermediate prognosis group • Features – must have all of the below • Features – any of the following o Testicular or retroperitoneal primary o Testicular or retroperitoneal primary o No non-lung distant metastases o No non-lung distant metastases o AFP <1,000 ng/mL o AFP = 1,000 – 10,000ng/mL o Beta-HCG <5,000IU/L o Beta-HCG 5,000 – 50,000IU/L o LDH<1.5xULN o LDH1.5 – 10xULN • NSGCT • NSGCT o 5-year progression free survival – 90% o 5-year progression free survival – 78% o 5-year overall survival – 96% o 5-year overall survival – 89% • SGCT • SGCT o 5-year progression free survival – 89% o 5-year progression free survival – 79% o 5-year overall survival – 95% o 5-year overall survival – 88% Prognostic factors Poor prognosis group • Features – any of the following o Mediastinal primary o Non-lung distant metastases • No SGCT are classed as having a poor prognosis o AFP >10,000 ng/mL o Beta-HCG >50,000IU/L o LDH >10xULN • NSGCT o 5-year progression free survival – 54% o 5-year overall survival – 67% Staging • PTis – intratubular germ cell neoplasia o This is a carcinoma in situ • pT1 – 3 staging alone does not change surgical management • pT4 staging involves invasion into the scrotum • N1 – 3 staging depends on the size and not number of LN mets • M1a – non-regional nodes or lung mets • M1b – non-nodal or lung distant metastases Sperm banking • Men who have notcompleted their family should be offered spermbanking • Orchidectomy results in reduced butnot complete infertility • Patients who need chemo may suffer infertility o Difficult to know if chemo is needed without histological analysis • Banking involves taking 3 semen samples • The samples are frozen and stored for up to 10 years • Patients must be screened for BBVs – may still provide samples Anatomy • The testes originate on the posterior abdominal wall • They descend via the inguinal canal into the scrotum during development • They are guided into the canal via the gubernaculum • The are suspended from the abdomen via the spermatic cord • The SC carries the testes' neurovascular, lymph supply + vas deferens • The testes are encased by multiple scrotal fascial layers • They are separated by the scrotal septumAnatomyAnatomy Anatomy • The testes have an elliptical shape and a vertical lie • The left testis often lies lower than the right • Surrounded by a fibrous capsule that separates sections into locules o The tunica albuginea • The testes contain seminephirous tubules and intestitial tissue o Sertoli cell – epithelial cells that aid spermatozoa development o Leydig cells – interstitial cells that produce testosterone Management • The risks of radical orchidectomy should be explained during the consent process o Infection o Tumour recurrence o Palpable sutures o Bleeding o Damage to local structures o Chronic scrotal pain o Swelling and bruising of the scrotum – 100% o Scrotal haematoma o Subfertility o Dissatisfaction with the cosmetic result – 20% o Need for additional treatment o Need for additional procedures o Anaesthetic risks o Failure to remove the whole tumour Management • Assess patients' fitness for surgery • Surgically fit patients w/ local disease should be offered a radical orchidectomy • On the day of surgery: o Identify the patient o Introduce yourself to the patient o Ensure they are aware of why they are having surgery o Take the patient's consent o Mark the side of the operation o Deliver a concise but thorough theatre brief o Write a clear op note after surgery Management • Radical orchidectomy is performed via the inguinal approach • This approach ensures inguinal LNs are removed • Usually performed under GA • Ensure the patient is prepped and draped • Anoblique incision is made between the ASIS and pubic tubercle • The incision is made parallel to the inguinal ligament • The incision is made along a langer line Management • The size of the incision depends on the size of the testis/tumour • Dissect until the external oblique aponeurosis, incise this layer and extend the incision medially and laterally • An inguinal exploration is performed – identify the ilioinguinal nerve +/- preserve • Identify and dissect the spermatic cord • The testis and cord are moved from the scrotum into the canal • The testis is exteriorised inside the tunica vaginalis • The spermatic cord is ligated at the level of the internal ring Contralateral testicular biopsy • 5 – 9% of testicular cancer patients have a contralateral carcinoma in situ • The EAU recommends a biopsy for men <40 o Contralateral testis volume <12mL o History of cryptorchidism o Subfertility • Biopsies are taken from the superior and inferior poles Testicular prosthesis • Patients may be offered a testicular prosthesis • Prostheses have been shown to not delay chemo • They can help patients come to terms with their surgery and cosmetically • They may present their own issues: o Infection o Associated pain o Cosmetic dissatisfaction o Mismatch over size Post-op management • Patients normally have a post-op staging CT if this has not been performed pre-op • The removed testis will be sent for histological analysis o Key for prognostication and deciding future management • Patients should have their tumour markers repeated in 1 week • The patient's case will be rediscussed in MDT • All patients should undergo tumour surveillance • May be referred for chemo/radiotherapy • Patients with retroperitoneal lymph nodes may undergo lymph node dissection Histological risk factors • Staging and grading are key to deciding if chemo/radiotherapy is needed • pT1 + no vascular invasion o Surveillance o If not willing to have surveillance bleomycin, etoposide and cisplatin (BEP) adjuvant chemo • PT2 – pT4 – invert the above options Patients with advanced disease • Patients with metastatic disease require management with chemotherapy • BEP is the standard chemo combination used in these cases • Orchidectomy for these patients will not sure the remaining metastatic tumour • Some may receive radical lymph node dissection Summary • Testicular cancer is a rare condition that usually affects younger men • Early stage disease prognosis is usually excellent following orchidectomy • There are many forms of testicular tumour • Many testicular tumours can be very aggressive • Understanding the diagnostic process is key to avoid treatment delay • Radical inguinal orchidectomy is the standard treatment method • Appreciate the post-operative care these and other cancer patients require o Attending MDT and follow up clinics is very helpful for this References • Cancer research UK • Content gained in part from the BAUS core urology course • EAU guidelines • Kenhub