296 CHAPTER 6 Urological neoplasia

Testicular cancer: clinical presentation

Symptoms

Most patients present with a scrotal lump, usually painless or slightly aching. Delay in presentation is not uncommon, particularly in those with metastatic disease. This may be due to patient factors (fear, self-neglect, ignorance, denial) or earlier misdiagnosis.

Occasionally (5%), acute scrotal pain may occur, due to intratumoral hemorrhage, causing diagnostic confusion.

The lump may have been noted by the patient, sometimes after minor trauma, or by his partner. In 10%, symptoms suggestive of advanced disease include weight loss, lumps in the neck, cough, and bone pain.

Signs

Examination of the genitalia should be carried out in a warm room with the patient relaxed. Observation may reveal asymmetry or slight scrotal skin discoloration. Using careful bimanual palpation, the normal side is first examined, followed by the abnormal side. This will reveal a hard, non-tender, irregular, non-transilluminable mass in the testis or replacing the testis.

Care should be taken to assess the epididymis, spermatic cord, and overlying scrotal wall, which may be normal or involved in 10–15% of cases. Rarely, a reactive hydrocele may be present if the tunica albuginea has been breached.

General examination may reveal cachexia, supraclavicular lymphadenopathy, left-sided neck mass, chest signs, hepatomegaly, lower limb edema, or abdominal mass—all suggestive of metastatic disease.

Gynecomastia is seen in <5% of patients with TC and is due to endocrine manifestations of some tumors.

Differential diagnosis

The majority of scrotal masses are benign; however, no risks should be taken. Every patient who is concerned should be seen, examined, and if any doubt persists, investigated further.

There is often a delay in diagnosis of testicular cancer either because of denial by the patient or delayed diagnosis by the physician, who may ascribe the mass to an infectious cause and initially treat with antibiotics.

Box 6.6 provides a comprehensive listing of scrotal and testicular masses in adults and children.

Investigations

Scrotal ultrasound

This is an extension of the physical examination and will confirm that the palpable lesion is within the testis, distorting its normally regular outline and internal echo pattern. Any hypoechoic area within the tunica albuginea should be regarded with suspicion. It may distinguish a primary from a secondary hydrocele.

298 CHAPTER 6 Urological neoplasia

Ultrasound may also be used to identify impalpable lesions as small as 1–2 mm—an occult primary tumor in a patient presenting with systemic symptoms and signs or an incidental finding.

Image contralateral testis as 2% of patients will have bilateral testicular cancers.

Abdominal and chest CT scans are usually obtained for staging purposes if the diagnosis of TC is confirmed, usually following radical orchiectomy.

Serum tumor markers are measured prior to any treatment of a confirmed testicular mass (p. 298).

Treatment

All patients with a testicular mass should be evaluated for testicular cancer. Studies have shown that 18–33% of patients with testicular cancer were initially treated for epididymitis, resulting in a delay in diagnosis.

Radical orchiectomy

Radical orchiectomy should be performed for diagnosis and treatment of the primary tumor. This involves excision of the testis, epididymis, and cord, with their coverings, through a groin incision. The cord is clamped, transfixed, and divided near the internal inguinal ring before the testis is manipulated into the wound, preventing inadvertent metastasis.

A silicone prosthesis may be inserted at the time of the procedure or at a later date. This treatment is curative in up to 80% of patients. Sperm cryopreservation should be offered to patients without a normal contralateral testis.

Contralateral testis biopsy should be considered in patients at high risk for IGCN (see pp. 294, 308).

TESTICULAR CANCER: SERUM MARKERS 299

Testicular cancer: serum markers

Germ cell tumors may express and secrete into the bloodstream relatively specific and readily measurable proteins. These tumor markers (with the exception of PLAP) are useful in diagnosis, staging, prognostication (see

p.303), and monitoring of response to treatment (see p. 304).

Currently, testicular cancer is the only malignancy to incorporate serum

markers into the staging system.

Oncofetal proteins

A-Fetoprotein (AFP)

AFP is expressed by trophoblastic elements within 50–70% of teratomas and yolk sac tumors. With respect to seminoma, the presence of elevated serum AFP strongly suggests a non-seminomatous element.

Serum half-life is 3–5 days; normal is <10 ng/mL. It can be elevated.

Human chorionic gonadotrophin, B subunit (B-hCG)

B-hCG is expressed syncytiotrophoblastic elements of choriocarcinomas (100%), teratomas (40%), and seminomas (10%). Serum half-life is 24–36 hours. Assays measure the Bsubunit with the normal <5 mIU/mL.

When used together, 90% of patients with advanced disease have elevation of one or both markers; it is less among patients with low-stage tumors.

Cellular enzymes

Lactate dehydrogenase (LDH)

LDH is a ubiquitous enzyme, elevated in serum for various causes and is therefore less specific. It is elevated in 10–20% of seminomas, correlating with tumor burden, and is most useful in monitoring treatment response in advanced seminoma.

Other markers with limited current clinical use include PLAP, CD30, and GGTP.

Clinical use

These markers are measured at presentation, 1–2 weeks after radical orchiectomy, and during follow-up to assess response to treatment and residual disease.

Normal markers prior to orchiectomy do not exclude metastatic disease. Normalization of markers post-orchiectomy cannot be equated with absence of disease, and persistent elevations of markers postorchiectomy may occur with liver dysfunction and hypogonadotrophism, but usually indicate metastatic disease.