Tuesday, December 21, 2010

Testicular cancer - not as bad as I thought!

It has been a long time since I heard about testicular cancer(the most recent ..as you all know..was in relation to Tour de France!!). Today a case of metastatic choriocarcinoma was presented ...in a male in his mid twenties. He has been classified as Stage 3C and is undergoing chemotherapy ,after having had b/l orchiectomy. He has metastasis to lungs and bowels. Looking at this...his prognosis appeared grim. Lets see how grim it is??


Testicular cancer can be divided into 3 - (1) germ cell tumors, (2) non–germ cell tumors, and (3) extragonadal tumors. Germ cell tumors, which are the most common, are classified as either seminoma or nonseminoma, based on histology. Lets concentrate on non seminomatous germ cell tumors(NSGCT)...which is what our patient had. NSGCTs refer to the germ cell tumors that contain embryonal stem cells.The 4 histologic classifications of NSGCTs include (1) embryonal carcinoma, (2) teratoma, (3) choriocarcinoma and (4) yolk sac tumor.


Patients come to attention due to a hard feel to the testis or swelling of scrotum or may even present with a swollen metastatic lymph node in the supraclavicular region. 5% have gynaecomastia on presentation.
Once suspected...confirm the presence of a mass in scrotum by ultrasound. Then 3 things need to be done as part of evaluation - (as orchiectomy is the first step in treatment)
1. Tumor markers which include alpha feto protein(AFP - elevated only in NSGCT , and not in seminoma), beta hCG, and LDH( just indicates tumor burden).
2. Staging the disease with imaging.(CT scan is the choice) - its TNM staging...have a look at the AJCC staging system. Our patient had the worst staging...Stage 3C with AFP >50,000 & visceral mass >5cm.
3. Inform patient about sperm banking for future fertility concerns.


Treatment - After orchiectomy(and you have a tissue diagnosis), then next option is chemotherapy based on staging. A common regimen is bleomycin plus etoposide plus cisplatin. Other treatment options are radiotherapy(esp with brain mets), and high dose chemo with bone marrow transplant.
Prognosis -  In general terms ...testicular cancer has the best prognosis of all solid tumors ..EVEN IF THEY HAVE METASTASIZED AT THE TIME OF DIAGNOSIS !!!!! 
Patients are classified into good, intermediate & poor prognosis based on some of the above factors. Generally...none of the patients with seminoma are categorised into poor prognosis( as they usually do well). The classification can be found in National Cancer Institute webiste. Poor prognostic factors in a pt with NSGCT are 
  • Mediastinal primary, or
  • Nonpulmonary visceral metastases, or
  • For markers–any of: AFP more than 10,000 ng/mL, or hCG more than 50,000 IU/mL (10,000 ng/mL), or LDH more than 10 × the upper limit of normal
The 5 year survival of this poor prognosis group(and our patient) is around 70% !! .....and the same for good & intermediate risk groups are 94% & 83% respectively.( National Cancer Institute & Eur J of Cancer 2006). 
This gentleman to the right is a famous survivor of this cancer....as u all know!!! 

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