Testicular cancer is the most common solid tumor in men between the ages of 20 and 35 years.
- Careful history, physical examination, and serum tumor markers (hCG, AFP, and LDH) are helpful in establishing the correct diagnosis.
- Scrotal ultrasonography is extremely accurate in identifying solid intratesticular lesions, with greater than 95% sensitivity and specificity.
- Each year, approximately 8000 new cases and almost 400 deaths due to testicular cancer are expected.
- The incidence of germ cell tumors (GCTs), the most common solid tumor in men between the ages of 20 and 35 years, is rising both in the United States and Europe.
- Although testicular cancer is highly curable, it requires appropriate management at all stages.
- Both the cure rate and the morbidity are highly sensitive to nuances of management.
- The clinician and, more importantly, the patient pay a high price for inappropriate management.
- Surgery remains an integral part of the management of patients with GCTs, but the advent of effective chemotherapy and improvements in clinical staging, including sophisticated imaging modalities and reliable serum tumor markers, have altered its role over the past 30 years.
- Delays in the timely and accurate diagnosis of testicular cancer continue to be a significant problem.
- A radical orchiectomy with high ligation of the spermatic cord at the level of the internal ring is the first step in the treatment of patients suspected of harboring a testicular neoplasm.
- This procedure provides histopathologic diagnosis and tumor (T) staging categorization, is associated with minimal morbidity and no mortality, and provides local control of the tumor in the vast majority of patients.
- The rare exceptions are usually due to tumor spillage, suboptimal orchiectomy, or transscrotal surgery.
- Staging evaluation must include thorough history and physical examination with particular attention to the contralateral testis.
- Serum tumor markers should be repeated immediately before RPLND and should include hCG, LDH, and AFP. Computed tomography (CT) of the chest, abdomen, and pelvis is the most efficient and cost-effective means of detecting metastatic disease.
- Magnetic resonance imaging (MRI) is usually reserved for the setting of major vascular involvement to assess patency of the inferior vena cava and renal vessels.
- In 1997 the American Joint Committee on Cancer (AJCC) and Union Internationale Contre le Cancer (UICC) adopted a comprehensive staging system that now includes serum tumor markers (TNMS).
- Stage I refers to disease confined to the testis,
- stage II implies retroperitoneal metastases, and
- stage III disease indicates supradiaphragmatic or visceral metastases.
- In the TNMS system vascular or lymphatic invasion in the primary tumor are classified in the T2 category and serum tumor markers are included because of their independent prognostic significance
References
- AJCC cancer staging handbook, Philadelphia, Lippincott-Raven, 1998.Bergstrom R, Adami HO, Mohner M, et al: Increase in testicular cancer incidence in six European countries: a birth cohort phenomenon. J Natl Cancer Inst 1996; 88:727-733.
- Bosl G, Bajorin D, Sheinfeld J, et al: Cancer of the testis. In: DeVita Jr VT, Hellman S, Rosenberg S, ed. Cancer: principles and practice of oncology, 6th ed. Philadelphia: JB Lippincott; 2000:1491-1518.
- Jemal A, Siegel R, Ward E, et al: Cancer statistics, 2007. CA Cancer J Clin 2007; 57(1):43-66.
- McKiernan JM, Goluboff ET, Liberson GL, et al: Rising risk of testicular cancer by birth cohort in the United States from 1973 to 1995. J Urol 1999; 162:361-363.
- Moul JW: Early and accurate diagnosis of testicular cancer. In: Paulson D, ed. Testicular cancer, Philadelphia: JB Lippincott; 1994:58-66.
- Whitmore Jr WF: Surgical treatment of clinical stage I nonseminomatous germ cell tumors of the testis. Cancer Treat Rep 1982; 66:5-10.