Testis


 * **Epidemiolgy:** || Epidemiology: Testicular is seen in more often in white males compared to black males. A white male is 4 to 5 times more likely to develop testicular cancer. Testicular cancer peaks at an age range of 20-40. Approximately 8090 patients are diagnosed with testicular cancer on a yearly basis, 380 of these cases are fatal. A patient with cryptorchid testes are considered to be at an elevated risk. To decrease the likelihood of developing testis cancer a patient may have an early orchiopexy. The chance that a patient may develop testis cancer is increased in patients with testicular feminization syndrome and Klinefelter syndrome. [1] ||
 * **Etiology:** || Testicular cancer is associated with a cytogenetic defect, isochromosome 12p; however the cause for testicular cancer is currently unknown. [1] ||
 * **Signs & Symptoms:** || Some patients have no sign or symptom of testicular cancer however, more than 95% present with a painless lump or mass in the testicle. [1] As much as 25% may present with metastatic disease symptoms before diagnosis.

Common symptoms of testicular include the following. These symptoms can be symptoms of other conditions as well. Earlier stage signs and symptoms include:


 * Lump or mass in one or both testicles
 * Swelling in one or both testicles
 * Pain in testes
 * Scrotal pain or feeling of heaviness
 * Dull pain in low back, abdomen and/or groin
 * Breast tenderness or growth
 * Decreased libido
 * Abnormal early age of hair growth on face and body

Signs and symptoms of advanced stage testicular cancer include:


 * Dull pain in back and abdomen
 * Headache
 * Confusion
 * Dementia
 * Shortness of breath
 * Coughing
 * Chest pain
 * Unexplained sweating
 * Lack of energy
 * Fever
 * Hemoptysis
 * Malaise [1] ||
 * **Diagnostic Procedures:** || Complete history with physical exam. Blood work including complete blood chemistry and serum assays. Testicular ultrasound of contralateral testis. [1] ||
 * **Histology:** || Germ cell tumors make up 95% of cases.

Two categories used for treatment: pure seminomas and non-seminomatous germ cell tumors. The second group is associated with a higher occurrence of nodal and distant metastasis and is more radioresistant.

Spermatocytic tumors are rare, typically occurring in older patients, and have a better prognosis than seminomas.[1] ||
 * **Lymph node drainage:** || Lymph drainage is from the hilum of the testis to the internal inguinal ring and retroperitoneal nodes. From the retroperitoneal nodes, drainage is to the mediastinal nodes, supraclavicular fossa and possibly the axillary nodes. On the left side, the retroperitoneal nodes are at the level of the renal vessels. On the right side, the nodes lie anterior to the aorta and anterior, lateral and medial to the inferior vena cava. On the left side, the nodes lie anterior and lateral to the aorta. Ipsilateral and contralateral nodes are involved in 15-20% of stage I tumors. Lymphatic crossover from right to left is constant, but crossover from left to right is rare.



[1,3] ||
 * **Metastatic spread:** || The tumors of the testis typically spread through lymphatic channels. The retroperitoneum is the most common site in metastatic disease. Also, visceral metastases have seen in advanced disease. The distance metastasis sites include the lungs, liver, brain, bone, kidney, adrenal gland, and spleen. [1] ||
 * **Grading:** || Testicular cancer is not generally given a microscopic grade. It is staged by a pathologist according to the TNM staging system published in the American Joint Committee on Cancer (AJCC) staging manual. [4] ||
 * **Staging:** || Currently, the American Joint Committee of Cancer (AJCC) TNM staging system is the standard system used for testicular cancer. The extent of primary tumor is assigned after radical orchiectomy. [4]

TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Intratubular germ cell neoplasia T1: Tumor limited to the testis and epididymis T2: Tumor limited to the testis and epididymis with vascular/lymphatic invasion T3: Tumor invades the spermatic cord with or without vascular/lymphatic invasion T4: Tumor invades the scrotum with or without vascular/lymphatic invasion
 * Primary tumor (T) **

NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis with a lymph node mass < 2 cm N2: Metastasis with a lymph node mass >2 cm  N3: Metastasis with a lymph node mass >5 cm
 * Regional lymph nodes (N) **

M0: No distant metastasis M1: Distant metastasis M1a: Non-regional nodal or pulmonary metastasis M1b: Distant metastasis ||
 * Distant metastasis (M) **
 * **Radiation side effects:** || Early acute side effects from the radiation include nausea, vomiting, and diarrhea. Also, temporary suppression of blood counts has been seen. The late side effects include infertility, cardio toxicity, gastrointestinal toxicity, second neoplasms, and immunosuppression. Among gastrointestinal toxicity, gastric ulceration, dyspepsia, and heart burn has been seen in patients who received higher doses of radiation. [4] ||
 * **Prognosis** || * Testicular cancer has one of the highest cure rates of all cancers. Prognosis depends on cancer stage, type of cancer, size of tumor, number and size of retroperitoneal lymph nodes.
 * The survival rate for men with early stage seminoma is greater than 95%. The disease free survival rate for Stage II and III cancers is slightly lower, depending on the size of the tumor.
 * Men with stage II or III testicular cancer can be classified as having a good, intermediate, or poor prognosis based upon the stage of disease and particular type of testicular tumor. Men with stage I testicular cancer have an excellent prognosis. [1]

**Good prognosis** — Men with seminoma have a good prognosis if the tumor has not metastasized to organs other than the lungs.

Patients with nonseminomatous germ cell tumor (NSGCTs) have a good prognosis if the tumor is located only in the testicle or area outside or behind the abdominal wall, if the tumor has not metastasized to organs other than the lungs, and if their tumor markers in the blood are only slightly elevated.

**Intermediate prognosis** — Patients with seminoma have an intermediate prognosis if the tumor has metastasized to organs other than the lungs.

Patients with NSGCTs have an intermediate prognosis if the tumor is found in only one testicle or in the area outside or behind the abdominal wall, if the tumor has not spread to organs other than the lungs, and if tumor markers in the blood are not significantly elevated.

**Poor prognosis** — Men with NSGCTs are classified as having a poor prognosis if the tumor develops in the center of the chest between the lungs, if it has spread to organs other than the lungs, or if any of the tumor markers are significantly elevated.

Even for patients with a poor prognosis, approximately one-half are cured with aggressive treatment. [2] ||
 * **Treatments:** || Stage I Seminoma
 * Postoperative irradiation of the paraaortic and ipsilateral pelvic nodes.

Stage II Seminoma
 * IIA or IIB Irradiation of the paraaortic and ipsilateral pelvic nodes
 * IIC Treated with infradiaphragmatic irradiation only or treated with cisplatin containing combination chemotherapy.
 * IID Treated with primar cisplatin containing combination chemotherapy

Stage III or IV Seminoma
 * Treated with four courses of cisplatin containing combination chemotherapy.

Nonseminoma Bladder 6500 Cauda equina 6000 Colon 4500 Femoral Head 5200 Rectum 6000 Spinal Cord 4700 || [2] Testicular Cancer – Beyond the Basics. UpToDate. http://www.uptodate.com/contents/patient-information-testicular-cancer-beyond-the-basics. Accessed June 11, 2012. [3] [] Revision received July 1, 2010. Accessed June 14, 2012. [4] Hoppe TR, Phillips LT, Roach M. //Leibel and Phillips Textbook of Radiation Oncology//. 3rd Edition. Philadelphia: Saunders, Elsevier. 2010. || Figure 1. Seminoma [4]
 * Radical iguinal orchiectomy followed by cisplatin based chemotherapy and urologic surgical intervention. [1] ||
 * **TD 5/5:** || **Organ Whole (cGy)** [1]
 * **References:** || [1] Chao C. //Radiation Oncology Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2002.

Figure 2. Example of a seminoma radiation treatment field. [4]

Figure 3. 3D-CRT radiation therapy. [4] Back to Week 4