Testicular Cancer
Scenario: A 40-year-old male presents to the surgical out-patient clinic with a 6-8 week history of a painless lump in his left scrotum. He however complains of a dull ache in the scrotum and a feeling of heavy sensation in his lower abdomen. 1. What would be your differential diagnoses? (2 marks) Testicular tumour. Hydrocele. Varicocele. Epididymitis. Inguinoscrotal hernia. Testicular torsion. Haematoma. Metastasis from other cancers (e.g., lung cancer, melanoma, prostate cancer). Tuberculosis and other testicular infections.
Scenario continued: On examination, you can get above the lump, the testis is not felt separately and it does not transilluminate. 2. What is the most likely diagnosis?(1 mark) Testicular tumour. 3. What are the risk factors for testicular tumours?(2 marks) Age (about 50% occurs between the ages of 20-40). Cryptorchidism (undescended testis). Positive family history. Contralateral testicular cancer. Carcinoma in situ. Race and Ethnicity (higher risk in Caucasians by about 4-5 times). HIV/AIDS. 4. Describe the lymphatic drainage of the testis and scrotum.(1 mark) Lymphatic drainage from testes follows the testicular arteries back to the paraaortic lymph nodes. Lymphatic drainage from scrotum drains to the inguinal lymph nodes.
5. How would you classify testicular tumours?(3 marks) They can be broadly classified into Germ cell tumours (about 95%) and Non-germ cell tumours (about 5-6%). Germ cell tumours are of two main types: (i) Seminomas and (ii) Non- Seminomas. Nearly 40-45% of all testicular tumours are seminomas (most common) Non-Seminomas include choriocarcinoma, embryonal cell tumour, teratoma, yolk sac tumour and mixed germ cell tumour. Non-germ cell tumours are Leydig cell tumour, sertoli cell tumour, gonadoblastoma and mixed sex cord stromal tumour. Lymphomas can also arise in the testis.
6. What is the difference in the age of presentation of common testicular tumours? (2 marks) Non-seminomas such as the teratoma affects the younger age group (15-30 years old) Seminomas affect a slightly older age group (30-45 years old) 7. Which testicular tumour is more common in elderly individuals? (1 mark) Lymphoma
8. What is the histological appearance of a seminoma?(2 marks) Large tumour cells with vesicular nuclei and pale watery cytoplasm. Lymphocytic infiltration. Granulomas. Sheet-like or lobular pattern of cells with a fibrous stromal network. Seminomas contain glycogen and are therefore positive for periodic acid-schiff (PAS) staining. 9. What investigations would you perform in a patient with a suspected testicular tumour?(2 marks) Routine bloods FBC; urea and electrolytes; LFTs Tumour markers- αfp, βhcg, LDH, alkaline phosphatase USS of the testis CXR CT scan of the abdomen and pelvis NB: Placental ALP and β-hcg levels may be raised in seminomas. Serum alfa fetoprotein(afp) is not raised in pure seminomas. LDH is the only marker that is elevated in seminomas. The degree of elevation in serum LDH has prognostic vanue in advanced seminomas.
10. What tumour markers are used in testicular cancers?(2 marks) Alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (betahcg), and lactase dehydrogenase (LDH) Non-seminomas: AFP and beta-hcg (40% to 60% of patients). LDH elevated but may be non-specific Seminomas: beta-hcg (in about 15% with Stage I pure seminoma and 50% of metastatic seminoma). LDH (mainly used for prognosis/identify metastasis)
11. What is the role of CT scan in testicular tumours?(1 mark) CT scan is useful to evaluate for evidence of metastases (e.g., lymph nodes, liver, lung, bones and brain) and to stage the tumour. Stage I: Cancer limited to testis Stage II: Metastasize to retroperitoneal lymph nodes Stage III: Distant organs 12. What are the treatment options for testicular tumours?(3 marks) Surgery (radical inguinal orchidectomy) is the first-line of treatment. Radiotherapy: Seminomas are radio-sensitive. Chemotherapy: Teratomas are usually radio-resistant and adjuvant chemotherapy may be required. Rarely used - Retroperitoneal lymph node dissection: Following radiographic evaluation of the retroperitoneum and radical inguinal orchiectomy, this procedure should be considered to identify nodal micrometastases and provide accurate pathologic staging of the retroperitoneal disease.