Testicular

Question 1

Most common type

Answer 1

Germ cell tumour (95%) - HIGHLY METASTATIC

Also arise in retroperitoneum and mediastinum

Non-seminomatous (60%) - teratoma, yolk sac tumours
Seminous (40%)

Question 2

Lymphatic spread

Answer 2

Para-aortic nodes

Question 3

Blood spread

Answer 3

Lungs, liver, boine and brain

Question 4

RF

Answer 4

15-25yrs
Caucasian 
FH
Cryptochordism 
Testicular atrophy

Question 5

Presentation

Answer 5

Typical - painless testicular swelling

Metastatic

• lung = cough, SOB
• para-arotic = lower back pain

Question 6

Investigations

Answer 6

1. Testicular USS (can differentiate teratoma from seminoma)
2. Tumour markers
   - b-HCG (raised in both types)
   - AFP (only raised in non-seminous)
   - LDH = marker for prognosis
3. Orchidectomy - guides definitive treatment
4. Biopsy of C/L testicle for cryptochordism patients
5. CT - staging

Question 7

Staging

Answer 7

1 = confined to testicle
2 = para-aortic below diaphragm
3 = para-aortic above diaphragm
4 = visceral mets

Question 8

Management

Answer 8

1. Orchidectomy = 1st line (done through iguinal conal to avoid spread through scrotal tissue)
   - do biopsy during op
   - can be done as adjuvant after chemo
2. Chemo - depends on type - v. responsive to chemoRx
   - Non-seminous = Carboplatin
   - Seminous = BEP (bleomycin, etoposide, cisplatin
3. Radiotherapy
   - for para-aortic nodes
   - Adjuvant chemo-RTx for malignant teratoma
   - Palliative - bone, brain and nodes

Question 9

Prognosis (non-seminoma)

Answer 9

Non-seminoma:

• Good (92%) = AFP<1,000ng/ml, bHCG <5000 IU/L, LDH <1.5 normal limit
• Poor (48%) = >10,000ng/ml, bHCG >50,000 IU/L, LDH>10 x upper limit