TESTICULAR CANCER

INCIDENCE AND EPIDEMIOLOGY

Annual incidence is about 9560 cases with 410 deaths. Peak age incidence is 20–40. Occurs 4–5 times more frequently in white than black men. Cryptorchid testes are at increased risk. Early orchiopexy may protect against testis cancer. Risk is also increased in testicular feminization syndromes, and Klinefelter syndrome is associated with mediastinal germ cell tumor.

ETIOLOGY

The cause is unknown. Disease is associated with a characteristic cytogenetic defect, isochromosome 12p.

PATHOLOGY

Two main subtypes are noted: seminoma and nonseminoma. Each accounts for ∼50% of cases. Seminoma has a more indolent natural history and is highly sensitive to radiation therapy. Four subtypes of nonseminoma are defined as embryonal carcinoma, teratoma, choriocarcinoma, and endodermal sinus (yolk sac) tumor.

CLINICAL PRESENTATION

Painless testicular mass is the classic initial sign. In the presence of pain, differential diagnosis includes epididymitis or orchitis; a brief trial of antibiotics may be undertaken. Staging evaluation includes measurement of serum tumor markers α fetoprotein (AFP) and β-human chorionic gonadotropin (hCG), CXR, and CT scan of abdomen and pelvis. Lymph nodes are staged at resection of the primary tumor through an inguinal approach. Stage I disease is limited to the testis, epididymis, or spermatic cord; stage II involves retroperitoneal nodes; and stage III is disease outside the retroperitoneum. Among seminoma pts, 70% are stage I, 20% are stage II, and 10% are stage III. Among nonseminoma germ cell tumor pts, 33% are found in each stage. hCG may be elevated in either seminoma or nonseminoma, but AFP is elevated only in nonseminoma. Ninety-five percent of pts are cured if treated appropriately. Primary nonseminoma in the mediastinum is associated with acute leukemia or other hematologic disorders and has a poorer prognosis than testicular primaries (∼33%).

Treatment: Testicular Cancer

For stages I and II seminoma, inguinal orchiectomy followed by retroperitoneal radiation therapy to 2500–3000 cGy is effective (Figure 73-1). For stages I and II nonseminoma germ cell tumors, inguinal orchiectomy followed by retroperitoneal lymph node dissection is effective. For pts of either histology with bulky nodes or stage III disease, chemotherapy is given. Cisplatin (20 mg/m2 days 1–5), etoposide (100 mg/m2 days 1–5), and bleomycin (30 U days 2, 9, 16) given every 21 days for four cycles is the standard therapy. If tumor markers return to zero, residual masses are resected. Most are necrotic debris or teratomas. Salvage therapy rescues about 25% of those not cured with primary therapy.

FIGURE 73-1
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Stage-based treatment of testicular germ cell tumor.

Outline

TESTICULAR CANCERis the Harrison's Manual of Medicine Word of the day!