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Testicular cancer: current views. Dr. M. Mangala MD (Kin); FRCS (Ireland); MMed (Wits); FCS (SA) Urology 38 th BMA CONGRESS. Background. 1% and 1.5% male neoplasms 5% all urological tumors Prevalence 2-3/100000 In the 15-34 y.o 62/100000 5% cases bilateral

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testicular cancer current views

Testicular cancer: current views

Dr. M. Mangala

MD (Kin); FRCS (Ireland); MMed (Wits); FCS (SA) Urology

38th BMA CONGRESS

background
Background
  • 1% and 1.5% male neoplasms
  • 5% all urological tumors
  • Prevalence 2-3/100000
    • In the 15-34 y.o 62/100000
  • 5% cases bilateral
  • Duplication of the short arm of X12
    • Isochromosome 12p or I(12p)
diagnosis
Diagnosis
  • Scrotal US
    • Sensitivity 100%
  • MRI
    • Sensitivity 100% and Specificity 95-100%
    • High cost: not justified
diagnosis1
Diagnosis
  • Serum tumour markers
    • AFP produced by yolk sac: T1/2 5-7 days
    • hCG expression of trophoblasts: T1/2 2-3 days
      • B subunit specific
    • LDH marker of tissue destruction (bulk)
  • Inguinal exploration and orchidectomy
    • Radical orchidectomy
diagnosis2
Diagnosis
  • False AFP elevation
    • Cancers: Hepatobiliary, pancreatic, gastric, lung
    • Benign: Liver conditions
  • False elevation hCG
    • Cancers: Lung, hepatobiliary, gastric, pancreatic, multiple myeloma
on orchidectomy
On orchidectomy
  • Organ-sparing surgery
    • In suspicion of a benign-lesion
    • In synchronous, bilateral testicular tumours
    • In metachronous, contralateral tumours
    • In a tumour in a solitary testis

The tumour should be less than 30% of the testicular volume.

staging and clinical classification
Staging and clinical classification
  • To determine the presence of metastatic or occult disease
    • Tumour markers
    • Nodal pathway screened
    • Visceral metastasis excluded
      • Abdominal, supra-clavicular nodes, liver
      • Status of mediastinal and lung metastasis
      • Status of brain and bone if suspicion
staging and clinical classification1
Staging and clinical classification
  • Abdominal, pulmonary, extra-pulmonary, mediastinal node assessed by CT
  • Supraclavicular nodes. PE and CT
  • Retroperitoneal nodes CT
  • MRI as CT but cost limit its use.
  • FDG-PET: F/U of Residual mass seminoma post CRx
    • WW or active treatment?
classification
Classification
  • TNM
    • pTX: Primary tumour can’t be assessed
    • pT0 : No evidence of primary tumour
    • pTis: Intratubular germ cell neoplasia
    • pT1: Tumour limited to testis and epidydimis

without vascular/lymphatic invasion

_ pT2: same with invasion

classification1
Classification
  • TNM
    • pT3: Invasion of the spermatic cord
    • pT4: Tumour invades scrotum with or without vascular/lymphatic invasion
  • Serum markers
    • Sx, S0, S1, S2, S3 according to level of LDH, hCG, AFP.
classification2
Classification
  • Stage I: Confined to the testis
    • Stage IA: pT1, N0, M0, S0
    • Stage IB: pT2, N0, M0, S0
    • Stage IS: pT/Tx, N0, M0, S1-3
  • Stage II: Retroperitoneal involvement
    • IIA nodes < 2cm, IIB nodes > 2cm
  • Stage III: Nodes visceral or supradiaphragmatic
treatment seminoma
Treatment: Seminoma
  • Low-stage: I,IIA
    • Surgery, DXT to retroperitoneum
  • High-stage: IIB, III (Bulky and elevated AFP)
    • Primary CRx (Sensitivity to platinum)
    • Residual mass Mx controversial
treatment nsgct
Treatment: NSGCT
  • Low-stage
    • RPLND
    • Surveillance
      • Tumour within tunica albuginea
      • Normal tumour markers after orchidectomy
      • No vascular invasion
      • No sign of disease on imaging
      • Reliable patient
treatment nsgct1
Treatment: NSGCT
  • Surveillance
    • Monthly visit 1/12 for 2 years
    • Bimonthly third year
    • Tumour markers each visit
    • CXR, CT Scan q 3/12
treatment nsgct2
Treatment: NSGCT
  • High-stage
    • Primary CRx
      • Tumour marker stable
        • If residual mass excision
      • Tumour marker raised
        • Salvage CRx
follow up
Follow-up
  • Labour intensive
  • Don’t forget to palpate
    • Remaining testis
    • Abdomen
    • Lymph node area
ad