Testicular Cancer
Testicular cancer is a relatively uncommon malignancy. There’s only about 7,000 cases per year in the United States, but it affects men at a young age. The peak incidence of testicular cancer is in the age group of 15-35. It’s highly curable. Nowadays about 90% of patients will be cured, crossing all stages. It’s a model malignancy because multi-modality therapy is used, as we’ll talk about. The cure rates for testicular cancer have improved dramatically over the past 30 years, increasing from 60-65% in the 60’s up to about 90% in the 1990’s. This is attributable to a few factors, probably the most important of which is the development of effective cisplatin-based chemotherapy for this disease. But improved awareness, better staging, and the institution of appropriate multi-modality therapy has also contributed to the improvement in outcomes.
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The etiology of testicular cancer is not known but there are several risk factors that are important. The most important of which is cryptorchidism. Cryptorchidism is seen in about 10% of patients with testicular cancer. When you see cryptorchidism there is anywhere from a five to fifty-fold increased risk of developing testicular cancer in that person’s lifetime. Interestingly, about 25% of the malignancies that occur in the context of cryptorchidism occur in the contralateral testicle. There are some interesting associations with testicular cancer. First of all, rarely do we see families with multiple members having testicular cancer. Testicular cancer can occur bilaterally in about 2-3% of patients, more commonly with seminoma than with non-seminoma. There is a distinct marker in the tumor associated with testicular cancer. It’s an isochromosome or a reduplication of the short arm of chromosome 12, 12P so there are three copies of P. This is seen in about 90% of testicular tumors. An interesting feature of testicular cancer is the relative absence of P53 mutations which may speak to the high chemo-sensitivity of this particular tumor. There is an association of testicular cancer, particularly mediastinal primaries, with Klinefelter’s syndrome as well as hematologic malignancies, in particular AML.
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A typical presentation of testicular cancer is painless enlargement of the testes, although pain may occur when there is bleeding within the testicle or rapid growth within the testicle. A testicular ultrasound is the most important test to do. It will distinguish an intratesticular mass from an extra-testicular mass 98% of the time. If in intratesticular mass is seen, it’s testicular cancer until proven otherwise. Once the diagnosis is established pathologically it’s important to sub-group these tumors. About two-thirds of these tumors are mixed tumors and the most common component of these mixed tumors is embryonal carcinoma. About one-third of these tumors are pure of one type or another, and the most common subtype that is pure is seminoma, which is treated as you’ll see distinctly from non-seminomas.
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