Introduction

These are germ cell tumours. There are two main types (these account for 80% of all tumours)

  • Seminoma (dysgerminoma in women). These arise from the seminiferous tubules. They are a low-grade tumour and metastasis can occur via lymphatics and to the lungs.
  • Teratoma. A teratoma has a mixture of both mature and immature cells. initially they arise from germ cells, and often contain muscle, bone, fat and a variety of all sorts of other tissue. They are classified according to the degree of differentiation. As always, well differentiated tumours have the best prognosis.
Occasionally both types of tumour occur together.
Rarely, germ cell tumours can occur at extragonadal sites. They generally occur along the midline in the mediastinum, pituitary and retroperitoneum. These tumours should be treated in the same way.
Often they secrete tumour markers which provide a good way to diagnose the condition.

Epidemiology

  • These account for 1-2% of all tumours
  • The incidence is very low, with prevalence being about 5 per 100 000
  • They are the most common cancer in men ages 15-35
  • Ovarian cell cancers are far less common than testicular cancers
  • Teratomas tend to occur in younger populations than seminomas

Presentation

  • Often they will be discovered incidentally as a firm lump on the testes. It may or may not be painful.
  • There may be some evidence of spread to para-aortic lymph node with associated back pain.
  • Some patients complain of a testicular ache.
  • In women the presentation may be of vague pelvic symptoms, but it will present itself at a much younger age than we would expect a common epithelial ovarian cancer.

Investigation

  • All suspicious testicular lumps should be examined by ultrasound.
  • There should be tests for serum tumour markers:
    • α-fetoprotein (AFP)
    • β-human chorionic gonadotrophin(HCG)
    • Lactate dehydrogenase (LDH)
  • The above markers tend to be increased more with more severe disease.
  • CT / MRI to check for distant metastasis (particularly in the lungs, liver, and retronperitoneally)

Treatment

Seminoma

These are far less common then teratomas. They are both radio and chemo sensitive. These can be diagnosed by:
  • Raised LDH
  • Possible mildly raised HCG
  • Never a raised AFP
Even with stage I disease, there is a 30% chance of recurrence. Adjuvant therapy decreases this to less than 5%. Chemotherapy is not associated with long-term side effects (Such as secondary malignancy) that you find in those that have been treated with radiotherapy.
Combination chemotherapy will cure 90% of those with metastatic disease.
5-year survival is 90-95%

Teratoma

This is mostly treated with inguinal orchiectomy. This is a posh way of saying castration! One of the testicles will be removed via the inguinal route to minimise the risk of highly malignant cells spilling in the scrotum. The testicle and spermatic chord are removed to as far up as the inguinal ring.
Relapse is twice as likely as in Seminoma, however, the cure rate can be increased to 95% with use of an adjuvant chemotherapy.
Metastatic spread commonly involves the lungs and lymph nodes.
80% of tumours will express AFP or HCG.
About 20% of men will be infertile at the time of diagnosis, but almost 100% of the rest will retain fertility and be able to father children.
5-year survival is 60-95% depending on tumour stage and metastatic spread at the time of diagnosis.

Screening

Self-examination of the testicles should be encouraged. All men from teenagers to those over 50 should examine their testicles on a monthly basis. Any abnormality should be examined by testicular ultrasound.
Of the urological tumours this is the most quickly progressing.

Differentiating Teratoma and Seminoma

Feature
Teratoma
Seminoma
Age of onset
20-30
30-40
αFP
Produced
Not produced
Β-HCG
Produced
Produced
Clinical picture
Painless, palpable, hard irregular swelling
Painless, palpable, hard, irregular swelling

 

Testicular Pain

This is torsion until proven otherwise!
Torted testes is more likely in a young patient.
Epididymitits or epididy orchitis is more likely in an older (>35) patient.
As a casualty officer, always get the opinion of a urologist in the case of testicular pain!
Prostatitis can have an effect. A swollen prostate will close off the ejaculatory duct, which can then result in inflammation of vas deferens and epididymus.
Could also be caused by mumps, aneurysm or stone.

Testicular torsion

The spermatic cord twists, and moves the testes up and makes it lie on its side, and high up. Will also be red and swollen. Epidiymitis will have a very similar appearance.
To tell the difference try a USS. However, this is often inconclusive. It does show the blood supply.
You have 4 hours to treat it surgically! (if it is torsion).

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