How to approach patient with suspected testicular mass

26 year old referred with right sided testicular mass how to assess.


History

Duration of symptoms
Painful or painless mass
Change in size of mass
Any previous history of surgery on the genitalia
Sexual history: recent sexual contact or penile discharge
Associate urinary symptoms
Trauma

Previous relevant history and risk factors

• History of cryptorchidism (on either side) 

Increases the risk of testicular cancer in the undescended testicle by 4-13 times.

• Family history of testicular cancer 

Especially in fathers and brothers increases the risk by 6 and 8 times.

• Racial origin

Three times more common in Caucasians and in Northern Europe, with the highest incidence in Scandinavia. (11/100000) In UK (7/100000)

• Maternal oestrogen exposure 

Fetal exposure to diethylstillboestrol increases the rik by 2.8-5.3 %

• History of subfertility 

Increases the risk by 1.6 times.

• Contralateral history of testicular tumour 

5-10% risk of cancer in the remaining testicle

• HIV 

increased risk of seminoma


Physical examination

Palpation of supraclavicular nodes
Chest examination
Abdominal examination to palpate for retroperitoneal nodal mass
Check for inguinal scars from childhood orchidopexy
Examin testicle for the mass, size, painful painless, examine contralateral testicle.


Investigations if suspicious

Urgent ultrasound scan (has almost 100% sensitivity for testicular tumor detection)
Walk the patient to the radiology department

If USS confirm tumour any other investigations

Tumour markers
AFP (half life 5 days)
bHCG (half life 36 hours)
LDH (half life 3 days)

Chest xray

Note: Presence of widespread testicular metastases on chest X-ray is an oncological emergency, and the patient must be referred urgently to an oncologist. Immediate chemotherapy may be necessary prior to radical inguinal orchidectomy in these cases).

Do all patients have raised tumour markers?

51% of all testicular tumours will have raised tumour markers.

Seminomas
5-10% of pure seminomas will have a raised bhCG
Pure seminomas do not secrete AFP
10% have raised LDH levels

NSGCT
50-70% of NSGCT have raised AFP
40% of NSGCT have raised BhCG

Other
100% of choriocarcinomas have raised BhCG
40-60% of embryonal carcinoma have raised BhCG


What is the role of tumour markers?

Diagnostic
Prognostic

Post orchidectomy measurement is useful in assessing the likelihood of retroperitoneal and metastatic disease.

What is the significance of measuring LDH?

Determins tumour burden
Surrogate marker for tumour volume and cell necrosis
Helpful for seminomas as a measure of tumour response

What else can raise tumour markers?

BhCG can be raised in the following cancers

Liver
Pancreatic
Stomach
Lung
Breast
Kidney
Bladder
and in
Marijuana smokers
Hypogonadotrophic patients raised LH may cross-react with some radioimmunoassay techniques for BhCG

AFP can be raised in the following cancers
Liver
Pancreas
Stomach
Lung
and in Benign liver dysfunction

Post operative imaging?

If GCT is confirmed
Staging CT Abdo and pelvis is performed

NSGCT
Chest CT is undertaken

Chest CT is not mandatory of sage I seminoma according to EAU guidelines

Roles of MRI and PET

MRI to assess retroperitoneal nodes in patients with contrast allergy
PET to assess residual retroperiotneal mass after chemotherapy can be safely watched or whether it requires active treatment.

Management of this patient

Urgent radical inguinal orchidectomy (generally within 1 week)
Assess whether contralateral testic biopsy is required

How would you perform a radical inguinal orchidectomy?

An inguinal incision.
Prior to manipulation of the testis the cord is isolated and clamped to allow control of the draining lymphatics to minimize tumour spill towars the retroperitoneal nodes.

The tumour-bearing testicle and cord are mobilised to the deep inguinal ring.

The cord is transected and secured with one heavy tie (0 or 1 vicryl) and an additional transfixation suture. Some authors suggest that a prolene suture should be used at the cut end of the cord to act as a marker for possible future nodal dissection.

Complications

Bleeding
infection
loss of sensation on the inner thigh and ipsilateral scrotal wall 
chronic groin pain (damage to ilioinguinal nerve)

Anything else you offer patient prior to orchidectomy

Sperm backing
Insertion of testicular prosthesis
EAU recommends Cryopreservation of sperm prior to orchidectomy

Banking is advisable if

History of sub-fertility
Small contralateral testicle
Fertility is an issue for the patient

Prosthesis
Should be offered at the same sitting
Caution in patients likely to need early post-operative chemotherapy (Pulmonary metastases, markedly raised markers) because prosthesis related infection (0.6-2%) may delay this.

How patients bank sperm?

Attend a designated fertility clinic
Provide three semen samples with a 2-3 day period of abstinence.
Brief assessment of sperm quality is undertaken microscopically
Sample is then frozen in liquid nitrogen at −196C.

Patient should be made aware of the following
1- quality of sperm is not guaranteed when thawed.
2- Illness prior to banking sperm may affect the quality of the sperm
3- Banking can still be done in the first week or so following initiation of chemotherapy.
4- Some evidence that quality of sperm in men with GCT is poor compared with matched healthy males, assisted techniques might be required.
5- Maximum storage period is 10 years
6- All men should be screened for HIV and for hepatitis B and C. Men with HIV can bank sperm in separate storage vessels.
7- The cost for the first year is met by the NHS, thereafter the patient pays 200£ per year of storage.
8- Patient might need to travel some distance to bank sperm.

Complications of testicular prosthesis

Extrusion from scrotum (3-8%)
Scrotal contraction and migration (3-5%)
Chronic pain (1-3%)
Haematoma (0.3-3%)
Infection (0.6-2%)

Who should have contralaterla testicular biopsy?.

To identify ITGCN (5-9%) risk in patients with testicular cancer.

Men under the age of 40
Testis volume < 12 ml
History of undescended testis and subfertility.

What pathological info you need?

1- Histological type of tumour (germ-cell tumour, sex cord tumours)
2- Size
3- Multiplicity
4- Rete testis involvement
5- Pathological stage
6- Presence of ITGCN
7- Presence of microvascular invasion
8- in case of seminoma any non-seminomatour elements.

Prognostic factors for relapse

Seminoma
Size > 4 cm
Rete testis invasion
(If both present relapse rate is 32%, If one present 16% and if none present 12%)

NSGCT
Presence of vascular and lymphatic invasion
Percentage of embryonal carcinoma (>50%)
Proliferation rate (>70%)

if specimen shows seminoma what would you do now?

1- Complete staging by performing chest abdo/pelvic CT with contrast.
2- Repeat tumour markers post-op to document kinetics.

inguinal canal and orchidectomy

Inguinal Canal

Anatomical Landmarks 

Inguinal Orchidectomy Illustration

A para-inguinal incision is made 2 cm above the inguinal fold from the pubic tubercle toward the superior anterior iliac spine. A 5–6 cm incision is usually enough.

The spermatic cord is isolated at the external inguinal ring.

The index fingers of both hands are introduced along the spermatic cord down to the testicle to detach the scrotal skin from the distal spermatic cord and the proximal testicle in an avascular plane.

The testis, covered by its tunics, is brought outside the scrotum by a combined pushing of the testis from below and drawing of the spermatic cord upward.

The vaginoscrotal ligament, or gubernaculum testis, is divided and ligated. The testis is free and can be inspected and palpated carefully outside the inguinal incision.

If the diagnosis of testicular cancer is uncertain, the operative field is protected with surgical sponges, the spermatic cord is clamped and a biopsy is taken for intraoperative frozen-section histological analysis.

The procedure is performed under general, psinal or local anesthesia on an outpatient basis. 

The patient is placed in the supine position with the scrotum prepped in the sterile field. 

a 5 to 7 cm oblique incision is made in the inguinal area along langerhans skin lines approximately 2 cm above the pubic tubercle. 

This incision can be extended onto the upper scrotum to facilitate removal of large tumours. 

Camper’s and Scarpa’s fascia are incised to the level of the external oblique aponeurosis. 

External oblique aponeurosis is incised in the direction of its fibers to the level of the internal ring. 

The ilioinguinal nerve is identified, dissected free of the cord, and preserved. 

The spermatic cord is isolated and either occluded with a non-crushing clamp or a 0.5-inch Penrose tourniquet at the level of the internal ring. 

The tests and its investing tunics are delivered into a carefully draped off fiield as gubernacular attachments are divided. 

If a diagnositc biopsy or subtotal orchiectomy is planned, meticulous draping off is necessary befroe opening the tunica vaginalis and incising testicular parenchyma. 

Radical orchiectomy is completed by mobilising the cord 1 to 2 cm inside the internal ring and individually ligating the vas deferens and the cord vessels between separate clamps 

The cord vessels are secured with silk ligatures, which can then be used to identify the stump if a retroperitoneal lymph node dissection is performed. 

the wound and scrotum are thoroughly irrigated, and homeostasis is secured. 

A testicular prosthesis can be placed at this time. 

The external oblique aponeurosis is clsoed with a running 2-0 Prolene suture. 

Scarpa’s fascia is closed with absorbable sutures and the skin with either skin staples or a subcuticular sutures. Compressive fluff dressings iwth a scrotal support minimize postoperative edema. 

Diagnostic evaluation

Diagnostic evaluation: 

The diagnosis of testicular cancer is based on: 

• Clinical examination of the testis 
• General examination to rule out enlarged nodes or abdominal masses.
• Ultrasound (US) of both testes should be performed whenever a testicular tumour is suspected. 
• An additional US of the retroperitoneum is recommended to screen for extensive retroperitoneal metastasis. Ultrasound of both testes should also be performed in patients with a retroperitoneal mass and/ or elevated tumour serum markers without a palpable scrotal mass.
• Serum tumour markers, both before, and 5-7 days after orchiectomy (AFP and hCG) and LDH. The latter is mandatory in advanced tumours.
• Inguinal exploration and orchiectomy with en bloc removal of testis, tunica albuginea, and spermatic cord. 
• If the diagnosis is not clear, a testicular biopsy (tumour enucleation) is to be taken for histopathological frozen section.
• Organ-sparing surgery can be attempted in special cases (bilateral tumour or solitary testes). 
• Routine contralateral biopsy for diagnosis of carcinoma in situ should be discussed with the patient and is recommended in “high risk” patients 
• Testicular volume < 12 mL, 
• A history of cryptorchidism and 
• Age < 40 years.

Pathological examination of the testis

Following orchiectomy, the pathological examination of the testis should include a number of investigations. 

• Macroscopic features: side, testis size, maximum tumour size and macroscopic features of epididymis, spermatic cord and tunica vaginalis.
• Sampling:1cm2section for every centimetre of maximum tumour diameter, including normal macroscopic parenchyma (if present), albuginea and epididymis with selection of suspected areas. At least one proximal and one distal section of the spermatic cord plus any suspected area.
• Microscopic features and diagnosis: 
• Histological type (specify individual components and estimate amount as a percentage)
• Presence or absence of peri-tumoural venous and/or lymphatic invasion
• Presence or absence of albuginea, tunica vaginalis, rete testis, epididymis or spermatic cord invasion,and; 
• Presence or absence of intratubular germinal neoplasia (TIN) in non-tumoural parenchyma intratubular germ cell neoplasia
• pT category according to the TNM 2009. 
• Immunohistochemical studies:in seminoma and mixed germ cell tumour, AFP and hCG.

Diagnosis and treatment of testicular intraepithelial neoplasia (TIN) 

• Biopsy should be offered to patients at high risk for contra- lateral TIN (testicular volume < 12 mL, history of cryptor- chidism or poor spermatogenesis). 
• If performed, a double biopsy is preferred. 
• In the case of TIN, local radiotherapy is indicated following counselling on impaired testosterone production and infertility.

Risk factors for occult metastatic disease in stageI testicular cancer

TNM Classification of testicular cancer 

Pathological lymph nodes and distant metastasis

Prognostic based staging system for metastatic germ cell cancer 

From EAU website 

Staging of testicular cancer 

From EAU website 

Treatment of seminoma StageI 

Treatment of NSGCT Stage I 

Simplified Algorithm

Risk adapted treatments for CS1 NSGCT based on vascular invasion CS1A (pT1, no vascular invasion: low risk 

Risk adapted treatments for CS1 NSGCT based on vascular invasion CS1B (pT2-pT4): high risk

Treatment options in patients with seminoma clinical stage IIA and B

Treatment options in patients with non-seminoma clinical stage IIA 

Guidelines for the treatment of metastatic germ cell tumours

Follow up: 

Treatment summary

Seminoma 

Stage I

Surveillance or

Chemotherapy

Stage II, III

IIA (Any PT/Tx, N1, Mo, S0-1)

N1 single or multiple lymph node mass <equal 2cm

S1: LDH <1.5XN BhCG<5000 AFP<1000

Either Radiotherapy or

Chemotherapy 3x BEP or 4X EP (If contraindications to Bleomycin)

IIB (Any pT/Tx, N2, Mo, S 0-1)

N2 single or multiple lymph node mass 2-5 cm

S1: LDH <1.5XN BhCG<5000 AFP<1000

Either Chemotherapy

3XBEP or 4XEP (If contraindications to Bleomycin, age>40, smokers)

or

Radiotherapy

IIC and higher (Any pT/TX, N3, M0, S0-1)

N3 Lymph node mass > 5 cm in greatest dimension.

Primary chemotherapy according to the same principles used for NSGCT

NSGCT Stage I

(PT1-4/ N0,M0, S0)

Low risk (pT1, No vascular invasion)

Surveillance is standard option

Chemo if conditions against surveillance (not willing)

RPLND if conditions against both surveillance and chemo

High risk (pT2-pT4 vascular invasion present)

Chemo is standard option 1x BEP

NS RPLND if conditions against chemo or

Surveillance also if conditions against chemo

If replase

3-4 x BEP followed by resection in case of residual tumour

NSGCT Stage II,

Stage IIA (Any PT/Tx, N1, Mo, S0-1) S1

Chemotherapy

PEB X3

If residual tumour

Resection

Stage IIA (Any PT/Tx, N1, Mo, S0-1) S0

Either NS-RPLND

If Pathological stage I

Follow up

If Pathological stage IIA/B

            Either follow up or

            2 cycles BEP

Or Follow-up after 6 weeks

            If Progressive disease

                        S1

                                    3 X BEP +/- resection of residual tumour

                        S0

                                    NS-RPLND or

                                    Chemotherapy

            If No change

                        NS-RPLND

            If regression

                        Further follow up

Stage IIC and higher

Good prognosis

Chemotherapy

3X BEP

Intermediate prognosis

4xBEP

Poor prognosis

1x BEP then Tumour markers after 3 weeks

            Unfavourable decline

                        Chemotherapy should be intensified

            Favourable decline

                        BEP x 4

Residual mass after chemo

Surgical resection if visible and markers normal or normallising.