Testicular cancer

Aimee Lettis from GP Update on how the management of testicular cancer has come a long way in the last 50 years.

Testicular cancer survival has been one of the real success stories in cancer treatment in recent years, with cure rates of 95% in patients diagnosed with testicular cancer and 80% in those with metastatic disease. Compare this to 50 years ago when 90% of patients presenting with metastatic testicular cancer could expect to die within a year and it becomes clear how far things have progressed. Its profile has also been raised by celebrity sufferers such as Lance Armstrong and popular campaigns such as #Feelingnuts!

A recent clinical review provides a useful summary of recent advances (NEJM 2014;371:2005).

Risk factors

Like most cancers, a combination of genetic and environmental factors is important. Current thinking suggests the initial trigger which gives germ cells malignant potential may occur in utero but is not active until the hormonal changes that occur in puberty.

Risk factor Relative risk increase
Family history Affected brother 8-10
Affected father 4-6
Cryptorchism Treated pre-puberty (<13y) 2.2
Treated post-puberty (≥13y) 5.4
Down's syndrome ?
Klinefelter’s syndrome (XXY) 8-10

Presentation

Commonly presents with a testicular lump, with most patients diagnosed with early stage 1 disease.
Rarer presentations include back pain (due to retroperitoneal lymph nodes) and cough, headache or pain due to metastatic disease.

Diagnosis and staging

  • Scrotal ultrasonography is the gold standard investigation (a hypoechoic mass is diagnostic).
  • Needle biopsy should not be performed because of the lymphatic invasion risk.
  • Inguinal orchidectomy is diagnostic and the treatment of choice.
  • Further treatment depends on the outcome of immunohistological examination.
  • CT chest/abdomen is essential for staging.
  • Measurement of β-hCG, alpha-fetoprotein (AFP) and LDH gives an indicator of disease bulk and activity and are used to monitor treatment response.
  • Stage I = localised disease
  • Stage II = lymph node involvement
  • Stage III = distant metastases

Management

The table details treatments recommended in addition to orchidectomy.

Stage/tumour type Treatment
Stage I seminoma Active surveillance only (relapse rate 20%) +/- choice of 20Gy lymph node radiotherapy or carboplatin chemotherapy (relapse rate 4%). Overall cure rate nearly 100% regardless of which initial strategy chosen.
Stage II seminoma 30-35Gy radiation to lymph nodes +/- multiagent chemotherapy. Cure rate 98%.
Stage I Non-seminoma germ cell Active surveillance +/- choice of lymph node dissection +/- multiagent chemotherapy. Cure rates 99%.
Stage II Non-seminoma germ cell Lymph node dissection +/- multiagent chemotherapy. Cure rates 95-99%.
Stage III disease (both types) Multiagent chemotherapy (3 or 4 cycles). High dose chemotherapy and stem cell transplant.

Survivorship

The impressive survival means increasing attention is being focused on the long term effects of treatment. Many of these effects can be generalised to all cancer survivors who have received chemoradiotherapy. These include:

  • Increased risk of second cancers (particularly thyroid, bladder, kidney, soft tissue, stomach and pancreas).
  • Infertility.
  • Metabolic syndrome.
  • Neurotoxic, nephrotoxic and pulmonary toxic side effects.
  • Raynaud’s phenomenon.
  • Hypogonadism.
  • Psychosocial issues.
This article first appeared in the February edition of The Sessional GP magazine.

 

Aimee Lettis

Aimee Lettis from the GP Update team gives us short, sharp nuggets of clinical information for sessional GPs. The GP Update team run one-day courses, bringing GPs up to date with all the latest evidence and guidelines.

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