Testicular cancer- clinical features, staging and surgical management

Abstract

The majority of men with testicular germ cell tumours present with a painless testicular mass typically between 20 and 40 years of age. Staging includes measurement of serum tumour markers AFP, ß-hCG and LDH and imaging by computed tomography of the chest, abdomen and pelvis. Primary management consists of extirpation of the tumour-bearing testis and its cord (radical orchiectomy) through the inguinal approach. In doubtful cases intraoperative frozen section analysis may be considered. An organ sparing approach can be carefully considered in men with synchronous or metachronous bilateral TGCT or a tumour in solitary testicle, but this awaits wider acceptance. A contralateral testicular biopsy to rule out testicular intraepthelial neoplasia is recommended in high-risk patients (testicular volume <12 ml, age <30 years, history of cryptorchidism). In clinical stage I nonseminomatous TGCT, a risk adapted approach is recommended with active surveillance, primary chemotherapy with 2 cycles or nerve sparing retroperitoneal lymph node dissection (RPLND). Low volume metastatic disease (clinical stages IIA-B) associated with elevated tumour markers are best managed by primary systemic chemotherapy whereas patients with negative markers might be approached by active surveillance or by nerve sparing RPLND. Postchemotherapy RPLND remains an integral part of the multimodality treatment of advanced testicular cancer. Small indeterminate lesions less than 1 cm in diameter might be managed by active surveillance in men with good prognosis. In all other cases, all residual retroperitoneal lesions should be completely resected.