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Seminoma
Germ Cell Carcinoma-in-situ
Orchidectomy
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Epidemiology
- most common tumour between age 25-35
- 1 new case / 20,000 / year
Pathology
- variety of pathologic subtypes, including
- seminoma,
- embryonal,
- yolk sac,
- teratoma, and
- choriocarcinoma
GCTs have the following subtypes and frequencies: seminoma (40%), embryonal (25%), teratocarcinoma (25%), teratoma (5%), and choriocarcinoma (pure) (1%).
- usually seminomas
- present 30-50 years
- cut surface creamy-white, homogeneous
- germ cell tumour
- sub-types
- classical
- spermatocytic
- anaplastic
- syncitiotrophoblast
- teratomas
- present 20-30 years
- wide range of differentiation
- more aggressive than seminomas
- secrete beta-HCG
- sub-types
- differentiated
- intermediate
- undifferentiated
- trophoblastic
- embryonal tumours
Clinical features
- testicular lump
- usually painless
- secondary hydrocoele
Spread
- para-aortic nodes at L1, L2
- lung secondaries common in teratomas
Investigation
- USS
- CXR
- beta-HCG, alpha-fetoprotein, lactic dehydrogenase
- surgical exploration +/- biopsy
- CT scanning
Staging
- Stage 1
- tumour confined to testis
- Stage II
- retroperitoneal lymph node involvement
- Stage III
- Metastasis above diaphragm confined to lymph nodes
- Stage IV
- extralymphatic metastases
Treatment
- seminoma
- stage I - orchidectomy + prophylactic radiotherapy
- stage IIa/b- + radical radiotherapy
- stage IIc+ - +chemotherapy
- non-seminoma
- Stage I - orchidectomy and careful surveillance
- stage II + chemotherapy - cis-platinum, vinblastine/etoposide,
bleomycin
- Orchidectomy
- On the right, the cancer landing zone is between the aorta and the inferior vena cava; on the left, it is on top of and lateral to the aorta.
Scrotal skin lymphatics are different from testicular lymphatics and drain into the inguinal nodes. Perform all orchiectomies for solid masses through an inguinal route to avoid tumor spill into the inguinal drainage basin. If a patient undergoes scrotal exploration, subsequent therapy may necessitate hemiscrotectomy and radiation treatment of the inguinal nodes.
In patients with prior herniorrhaphy, orchiopexy, or other alteration in lymphatic drainage, extend their radiation field to include the contralateral inguinal region with contralateral testis shielding.
Fertility
- many patients sub-fertile at presentation
- unpredictable effects of chemotherapy
- semen collection has poor success rate
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