DEPARTMENT OF SURGERY

SURGERY 2 (MED 5024)

CASE WRITE UP / EVIDENCE BASED MEDICINE

TESTICULAR CANCER

NAME: MOHAMMAD FAIZ TAQIYUDDIN B MOHD NOR

MATRIC NO.: MBBS 1411-5964
GROUP: 3 (C)
SUPERVISOR: ASC. PROF. DR. AHMED ALI. A. ALMUTAWKEL
 A. Case Summary

Mohd Farihi b Hassan, a 25 years old Malay gentleman from Kelantan with underlying
hypertension presented with left testicular swelling and pain for the past 2 months. The pain
gradual in onset, radiate to lower abdomen, intermittent pain with pain score 3 over 10, dull
ache in nature and aggravated by movement. No recent trauma to his scrotal region. Bowel
output and urine discharge are normal. Systemic review shows normal finding. His
hypertension diagnosed on 2015 and currently controlled with medication. Other past medical
history, family history and social history are unremarkable.

On physical examination, general condition of this patient is normal with stable vital sign.
Abdomen is soft and non tender. Cough impulse is negative. Focus examination on genitalia,
penile is normal with no abnormal discharge. The left testicular mass measured 10x10cm
with some fluid and hard in consistency. He had a negative transillumination test. The
overlying scrotal skin was vascular but had no indurations or erythematous areas and looked
markedly distended.

All results of investigation are within normal parameter except for his tumor marker which
elevated with result: AFP = 7029, HCG = 40, LDH-1 = 437.

For management, he electively admitted for high ligation orchidectomy of left testis and
tissue send for biopsy for further management.

B. DISCUSSION

1. What is the best approach for patients follow up post high ligation
orchidectomy?

In the treatment of early stage disease, active surveillance is now a cornerstone of

treatment. It is more than just follow-up, but a strategy to avoid overtreatment and to use
chemotherapy only for those patients who do really need it. The excessive risk of radiation
may lead to tumor recurrence, while long-term side effects of chemotherapy and radiotherapy
may lead to various illnesses such as hypogonadism, metabolic syndrome, cardiovascular
disease and secondary malignancies1.

According to the American Cancer Society, they have devised different strategies for each
follow up groups, according to their stage of cancer created by International Germ Cell
Cancer Collaborative Group (IGCCCG)2:

Seminomatous germ cell tumours (Seminoma):

Stage 0 & I

Active surveillance - often the preferred option for up to 10 years with treatments like
radiation or chemo only if cancer spread is found.
 Adjuvant radiotherapy - Radiation aimed at para-aortic lymph nodes. Because seminoma
cells are very sensitive to radiation, low doses can be used, usually about 10 to 15 treatments
(given over 2 to 3 weeks).

Adjuvant chemotherapy: an option that works as well as radiation is to give 1 or 2 cycles of

chemotherapy (chemo) with the drug carboplatin after surgery.

Stage IIA/B, treated with radiotherapy. Usually stage II seminomas are given
higher doses of radiation than stage I seminomas. The other option is chemo,
with either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP
(bleomycin, etoposide, and cisplatin).

Stage IIB/C: chemo is the preferred treatment. Either 4 cycles of EP or 3

cycles of BEP may be used. Radiation may be an option instead of chemo for
patients who dont have lymph nodes enlarged from cancer spread. Radiation
therapy is generally not used for stage IIC seminoma.

Stage III: Give chemo with 4 cycles of EP or 3 or 4 cycles of BEP.

For the rare case of seminoma patients with residual postchemotherapy disease >3 cm and a
positive PET-CT (performed at an adequate chemotherapy-PET interval of at least two
months) or patients with metastatic seminoma in the intermediate prognosis group, individual
follow- up is recommended, preferably at centres with special expertise in the field.

*Of note, most patients, about 85%, with seminoma present with stage I disease, which is
defined as local disease with no lymph node or distant metastases3.

Non-seminomatous germ cell tumours (Non-seminoma):

Stage I
- For stage IA (T1): Active surveillance with or without Retroperitoneal lymph node
dissection (RPLND)
- For stage IB (T2, T3, or T4): RPLND and chemotherapy with the BEP regimen for 2
cycles with active surveillance.

*Stage IS non-seminoma: If the tumor marker levels are still high even after the
testicle/tumor is removed but no tumor is seen on a CT scan, chemo is recommended, with
either 3 cycles of BEP or 4 cycles of EP.

Stage II: treatment depends on the remaining levels of tumor markers in the
blood and the extent of spread to retroperitoneal lymph nodes. There are 2
main options:
- RPLND for stage IIA. If the lymph nodes removed contain cancer, further treatment
with chemo may be needed.
 - Chemotherapy: For many stage II cancers, the preferred treatment is chemo instead of
RPLND. Either 4 cycles of EP or 3 cycles of BEP may be used. After chemo, a CT
scan is repeated to see if the lymph nodes are still enlarged. If they are, they are
usually removed by RPLND.

Stage III: 4 cycles of EP or BEP for 3 to 4 cycles. 4 cycles of BEP are needed
for patients with poor prognosis non-seminomas (usually because they have
spread to distant areas other than the lungs or because of very high tumor
marker levels). If the patient has medical reasons that make treatment with
bleomycin unsafe, then he may be treated with VIP (vinblastine, ifosfamide,
and cisplatin).

In cases where very high levels of the tumor marker HCG is found in a man, distant spread of
cancer is seen on scans, and there is a high suspicion that he may have a testicular
choriocarcinoma, chemo may be started without a biopsy or initial removal of a testicle.

2. Does testicular cancer can affect fertility and sexual function of the patient?

Most testicular cancer patient are being diagnosed at the range of age between 15 to 25
years old, which often have not yet attempted to father children. As cured testicular patients
have a long life expectancy, minimizing effects on long-term health and quality of life are
important goals.

In one study done in health facilities in the French Midi-Pyrenees region, they found out
that 91.2% of patients that had been diagnosed with testicular cancer able to get their partner
pregnant before undergo treatment, compared with 67.1% of patients after treatment, with
radiotherapy had a much more deleterious effect on fertility compared with chemotherapy
alone4.

However, another research clearly shown that testicular patient was oligozoospermic way
before radical orchiectomy had been done, and most of subject with oligozoospermic had an
increased risk of cancer compared with fertile control subjects based on concentration of
semen and on sperm count5. The development of testicular cancers is associated with other
testicular abnormalities such as testicular maldescent, testicular atrophy and subfertility.
Preorchidectomy sperm counts and LH levels are lower and FSH levels higher than age-
matched normal controls and patients presenting with lymphoma in a Danish study6. Infertile
men with abnormal semen analyses have a 20-fold greater incidence of testicular cancer
compared to the general population7.

In patients presenting with testicular cancer, hormone secretion and sperm production may
be preserved by performing a partial orchiectomy, which has become an established method
for selected patients. In particular, a conservative approach should be undertaken when the
testicular mass is small. The German Testicular Cancer Study Group reported a 98.6%
disease-free survival rate at 7-year follow-up after conservative surgery for tumors <2 cm in
73 patients. However, the benefits must be weighed against the risk of tumor recurrence in
these patients. It may advisable to offer sperm banking prior to surgery, even to patients who
 may consider a partial orchiectomy at the outset. Successful cases of sperm retrieval from the
cancerous testicle in men with azoospermia at the time of radical orchiectomy have been
reported, as well as sperm extraction from the epididymis and vas deferens of the
orchiectomy specimen8.

Initial management in most patients is with orchidectomy, so it could be anticipated there

would be evidence of gonadal dysfunction in a significant proportion of patients. Therefore in
active surveillance of the patient, screening for hormonal problems should be considered as a
routine part of patient management. Patient with orchiectomy should be informed regarding
availability of testicular prostheses as it had been reported to improved their body image.
Prostheses were well accepted and no systemic disease was reported with sexual life and
performances were apparently not compromised by having prostheses9.

C. REFERENCES

I. Cathomas, R., Helbling, D., Stenner, F., Rothermundt, C., Rentsch, C., Shahin, O.,
Seifert, H.H., Zaugg, K., Lorch, A., Mayer, F. and Beyer, J., 2010. Interdisciplinary
evidence-based recommendations for the follow-up of testicular cancer patients: a
joint effort. Swiss Med Wkly, 140(25-26), pp.356-69.
II. Eleni Berger, Amy Sherrod & Elizabeth Mendes, Treatment Options for Testicular
Cancer, by Type and Stage. American Cancer Society. Available at:
https://www.cancer.org/cancer/testicular-cancer/treating/by-stage.html#references
[Accessed September 7, 2017].
III. Warde, P. and Jewett, M.A., 1998. Surveillance for stage I testicular seminoma: is it a
good option?. Urologic Clinics of North America, 25(3), pp.425-433.
IV. Huddart, R.A., Norman, A., Moynihan, C., Horwich, A., Parker, C., Nicholls, E. and
Dearnaley, D.P., 2005. Fertility, gonadal and sexual function in survivors of testicular
cancer. British Journal of Cancer, 93(2), p.200.
V. Hanson, H.A., Anderson, R.E., Aston, K.I., Carrell, D.T., Smith, K.R. and Hotaling,
J.M., 2016. Subfertility increases risk of testicular cancer: evidence from population-
based semen samples. Fertility and sterility, 105(2), pp.322-328.
VI. Huyghe, E., Matsuda, T., Daudin, M., Chevreau, C., Bachaud, J.M., Plante, P., Bujan,
L. and Thonneau, P., 2004. Fertility after testicular cancer treatments. Cancer, 100(4),
pp.732-737.
VII. Raman, J.D., Nobert, C.F. and Goldstein, M., 2005. Increased incidence of testicular
cancer in men presenting with infertility and abnormal semen analysis. The Journal of
urology, 174(5), pp.1819-1822.
VIII. Rodriguez-Wallberg, K.A. and Oktay, K., 2014. Fertility preservation during cancer
treatment: clinical guidelines. Cancer management and research, 6, p.105.
IX. Chapple, A. and McPherson, A., 2004. The decision to have a prosthesis: a qualitative
study of men with testicular cancer. PsychoOncology, 13(9), pp.654-664.