The Management of Testis Cancer

Presentation and Diagnosis

Testis cancer presents most commonly as a pain­ less testicular mass but there are a number of other clinical scenarios. Approximately 20% manifest with scrotal pain and 10% will initially experience an acute orchitis.1 The primary imag­ ing modality in the first instance is ultrasound.2 This has a sensitivity approaching 100% in expe­ rienced hands but there are circumstances where it is difficult to differentiate orchitis from tumor and in addition, small intratesticular lesions may produce considerable diagnostic uncer­ tainty.Where precise clinical diagnosis is impos­ sible and a lesion is suspicious, open biopsy or orchidectomy may be needed for definitive veri­ fication. If biopsy is to be undertaken, it is usu­ ally done using the Chevassu technique,bivalving the testis along its long axis on the opposite side to the epididymis. In these circumstances, surgi­ cal exploration should always be through the groin and testis conservation should be attemp­ ted where possible. It is inevitable that following surgery some lesions will ultimately prove to be benign: this should be explained to the patient preoperatively.

Serum Tumor Markers

Blood must be taken for marker evaluation before surgical removal of the testis. The main markers for non­seminoma are a fetoprotein

(AFP), b HCG, and LDH. AFP is elevated in 50–70% of NSGCT, has a half­life of approxi­ mately 5 days, and is produced by yolk sac ele­ ments. It is not elevated in pure seminoma. bHCG is increased in 40–60% of NSGCTs and in up to 30% of pure seminomas. It is produced by trophoblastic elements in the tumor and has a half­life of 1 day. LDH is less specific but is more common in seminoma. Overall, 90% of NSGCTs elaborate at least one tumor marker, while in seminoma, markers are elevated in <40%.1

Primary Surgery

It is vital to undertake imaging of the scrotum with ultra sound prior to exploring any scrotal mass, thereby avoiding an inappropriate surgical approach through the scrotum (scrotal violation). If scrotal violation occurs, additional subsequent treatment may be required, often involving local radiotherapy to the scrotal area. This carries the potential for immediate compromise of fertility and a long­standing risk to the endocrine func­ tion of the contralateral testicle.

The standard primary treatment for a testic­ ular tumor is radical orchidectomy. This invo­ lves a groin approach, opening the inguinal canal surgically and detaching the spermatic cord at the level of the internal inguinal ring before delivering the testis from the scrotum and removing the testis and cord en bloc (Fig. 39.1). If the patient wishes, a testicular prosthesis can be inserted safely at the same

operation, although this should be avoided if the tumor is invading the scrotal wall or if there is preexisting infection.

Testis Preserving Surgery

to surgery and the patient should be counselled about the long­term risks of tumor recurrence, long­term endocrine failure, and the require­ ment for subsequent radiotherapy or comple­ tion orchidectomy if TIN is detected.

This may be undertaken in specific circum­ stances, namely, the presence of synchronous bilateral tumors, development of a metachro­ nous contralateral tumor, or in patients with a single testis. Conservative surgery is usually restricted to tumors of 2 cm or less although it may be possible to undertake local excision of larger tumors provided they are in the polar areas. It should be noted that testicular intraepi­ thelial neoplasia (TIN) is present in up to 80% of patients undergoing testis preservation.3,4 Sperm storage issues should be discussed prior

Contralateral Testicular

Biopsy and TIN

TIN is present in the contralateral testis of up to 5% of men presenting with testicular cancer. When present,it is associated with a high chance of progression to invasive disease. Treatment is usually by low dose irradiation of the affected testis after preliminary storage of semen.

In the case of primary orchidectomy, contro­ versy surrounds the issue of whether synchronous