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.