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Testicular cancer: Difference between revisions
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(Created page with "'''Testicular cancer''' is most frequent in young males. It is the most common tumor in men in the 15 – 35 age group. There are three age peaks where testicular cancer is most common: * 15 – 35 years (the most common age group) * 0 – 10 years * > 60 years 96% of all testicular tumors are malignant. Most present with metastases already present, but despite this the prognosis is excellent. Even advanced and metastatic testicular cancers are often curable. Most (95%)...") |
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'''Testicular cancer''' is most frequent in young males. It is the most common tumor in men in the 15 – 35 age group. There are three age peaks where testicular cancer is most common: | <section begin="pathology" />'''Testicular cancer''' is most frequent in young males. It is the most common tumor in men in the 15 – 35 age group. There are three age peaks where testicular cancer is most common: | ||
* 15 – 35 years (the most common age group) | * 15 – 35 years (the most common age group) | ||
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Germ cell tumors develop from totipotent germ cells. During embryonal development these totipotent cells can travel down normal differentiation pathways and become spermatocytes. However, if they instead travel down abnormal developmental pathways, they can become seminomas or embryonal carcinomas. Embryonal carcinoma cells can then take one or more of these courses: They can undergo (intra)embryonic differentiation and form a (postpubertal) teratoma (which is comprised of embryonic tissues). They can undergo extraembryonic differentiation and form (postpubertal) yolk sac tumors or choriocarcinomas (which are extraembryonic tissues). Lastly the totipotent germ cells can remain undifferentiated and remain embryonal carcinoma. This is better illustrated on the figure below: | Germ cell tumors develop from totipotent germ cells. During embryonal development these totipotent cells can travel down normal differentiation pathways and become spermatocytes. However, if they instead travel down abnormal developmental pathways, they can become seminomas or embryonal carcinomas. Embryonal carcinoma cells can then take one or more of these courses: They can undergo (intra)embryonic differentiation and form a (postpubertal) teratoma (which is comprised of embryonic tissues). They can undergo extraembryonic differentiation and form (postpubertal) yolk sac tumors or choriocarcinomas (which are extraembryonic tissues). Lastly the totipotent germ cells can remain undifferentiated and remain embryonal carcinoma. This is better illustrated on the figure below: | ||
[[File:Classification of testicular germ cell tumours.png|center|thumb|Classification of testicular germ cell tumours. From https://www.nature.com/articles/s41572-018-0029-0. I don’t think this is very important to know but it might impress the examiners.]] | [[File:Classification of testicular germ cell tumours.png|center|thumb|Classification of testicular germ cell tumours. From https://www.nature.com/articles/s41572-018-0029-0. I don’t think this is very important to know but it might impress the examiners.]] | ||
Germ cell tumors account for 95% of all testicular tumors. It’s very common (in 60% of cases) for germ cell tumors to contain more than one histological subtype. These are called ''mixed germ cell tumors''. The remaining 40% of cases are ''pure germ cell tumors'' and contain only one histological subtype. | Germ cell tumors account for 95% of all testicular tumors. It’s very common (in 60% of cases) for germ cell tumors to contain more than one histological subtype. These are called ''mixed germ cell tumors''. The remaining 40% of cases are ''pure germ cell tumors'' and contain only one histological subtype. | ||
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The first diagnostic step for a testicular mass is ultrasound and physical examination. If these raise suspicion for malignancy, we proceed to orchidectomy. | The first diagnostic step for a testicular mass is ultrasound and physical examination. If these raise suspicion for malignancy, we proceed to orchidectomy. | ||
Testicular masses are never biopsied, unlike most suspected tumors elsewhere in the body. Instead, sperm is cryopreserved, and the testis is removed by orchiectomy. Because the vast majority of testicular tumors are malignant there is a high chance the testis would have been removed anyway. Also, biopsying a malignant testicular tumor could allow tumor cells to seed in the scrotum. | Testicular masses are never biopsied, unlike most suspected tumors elsewhere in the body. Instead, sperm is cryopreserved, and the testis is removed by orchiectomy. Because the vast majority of testicular tumors are malignant there is a high chance the testis would have been removed anyway. Also, biopsying a malignant testicular tumor could allow tumor cells to seed in the scrotum.<section end="pathology" /> | ||
CT of the thorax, abdomen, and pelvis should be made to look for spread, either before or after orchidectomy, but preferably before. This is necessary for staging. MRi of the brain is indicated if brain metastases are suspected. | CT of the thorax, abdomen, and pelvis should be made to look for spread, either before or after orchidectomy, but preferably before. This is necessary for staging. MRi of the brain is indicated if brain metastases are suspected. | ||
<section begin="pathology" /> | |||
=== Tumour markers === | === Tumour markers === | ||
AFP, hCG, and LDH are important tumor markers in testicular tumors. Different histological subtypes have different patterns of expression of these tumor markers. Seminomas often do not have elevated tumour markers. | AFP, hCG, and LDH are important tumor markers in testicular tumors. Different histological subtypes have different patterns of expression of these tumor markers. Seminomas often do not have elevated tumour markers. | ||
<section end="pathology" /> | |||
=== Hormone analysis === | === Hormone analysis === | ||
Before orchidectomy, we also measure hormone levels. | Before orchidectomy, we also measure hormone levels. | ||
<section begin="pathology" /> | |||
=== Stages === | === Stages === | ||
Limited disease refers to cancer which is limited to the testicles. Locally advanced disease is when there is involvement of the retroperitoneal lymph nodes, usually the para-aortic lymph nodes. Metastatic disease is when there is evidence of metastasis. | Limited disease refers to cancer which is limited to the testicles. Locally advanced disease is when there is involvement of the retroperitoneal lymph nodes, usually the para-aortic lymph nodes. Metastatic disease is when there is evidence of metastasis. | ||
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== Management == | == Management == | ||
All patients with suspected testicular cancer on ultrasound and physical examination should undergo surgical exploration. If surgery and intraoperative frozen histology sections cannot rule out malignancy, orchidectomy is performed. This allows for histological examination and complete staging and risk stratification. However, at no point should the urologic surgeon incise the tumour itself, for risk of seeding. A testicular prosthesis can be placed at the same time. If there is sign of retroperitoneal lymph node involvement, retroperitoneal lymph node dissection (RPLND) is indicated. | All patients with suspected testicular cancer on ultrasound and physical examination should undergo surgical exploration. If surgery and intraoperative frozen histology sections cannot rule out malignancy, orchidectomy is performed. This allows for histological examination and complete staging and risk stratification. However, at no point should the urologic surgeon incise the tumour itself, for risk of seeding. A testicular prosthesis can be placed at the same time. If there is sign of retroperitoneal lymph node involvement, retroperitoneal lymph node dissection (RPLND) is indicated. | ||
<section end="pathology" /> | |||
Localised disease with no high-risk features can usually be followed with active surveillance, but if there is intermediate or high-risk, adjuvant chemotherapy is recommended. In locally advanced disease, adjuvant radiotherapy or chemotherapy is indicated. For metastatic disease, adjuvant chemotherapy is indicated. | Localised disease with no high-risk features can usually be followed with active surveillance, but if there is intermediate or high-risk, adjuvant chemotherapy is recommended. In locally advanced disease, adjuvant radiotherapy or chemotherapy is indicated. For metastatic disease, adjuvant chemotherapy is indicated. | ||
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=== Radiotherapy === | === Radiotherapy === | ||
Seminomas are very radiosensitive, whereas non-seminomas are only moderately radiosensitive. For this reason, radiotherapy is mostly only used for seminomas. Radiotherapy is less and less used nowadays in favour of chemotherapy. | Seminomas are very radiosensitive, whereas non-seminomas are only moderately radiosensitive. For this reason, radiotherapy is mostly only used for seminomas. Radiotherapy is less and less used nowadays in favour of chemotherapy. | ||
[[Category: | [[Category:Urology]] | ||
[[Category:Oncology]] | |||