Podcast Summary: Rod Squad - Ep. 48 "Testes Cancer Initial Treatment and Staging"

Host: Parker Adams
Date: August 18, 2020

Overview

In this episode, Parker Adams provides a comprehensive, clear, and student-friendly overview of the initial evaluation, treatment, and staging of testicular cancer, drawing from the AUA core curriculum and classic urology texts. He covers epidemiology, risk factors, clinical presentation, diagnostic workup, the rationale behind initial treatment decisions, and an in-depth guide to staging.

Key Discussion Points and Insights

1. Epidemiology and Types of Testicular Cancer

• Incidence:

  • Testicular cancer is the most common tumor in men aged 20 to 40.
    Quote:
    "Testis cancer is the most common tumor in young men from the age of about 20 to 40 years old." (00:16)
  • Most prevalent in Hispanic or non-Hispanic white men, least common in African Americans.

• Histology Breakdown:

  • Germ cell tumors: 95% (seminomas and non-seminomas).
    • Non-seminomas include embryonal carcinoma, yolk sac tumor, choriocarcinoma, teratoma, or mixed types.
  • Sex cord/stromal tumors: 5% (e.g., Leydig, Sertoli cell tumors).

2. Presentation and Risk Factors

• Most Common Presentation:

  • Localized seminoma (50% of cases).
  • 2.5% of unilateral cases will eventually develop cancer in the opposite testis (median 6 years later).
    Quote:
    "2.5% of these patients...are gonna end up with a cancer in the other testicle." (01:39)

• Key Risk Factors:

  1. Cryptorchidism:
     • Relative risk 4–6; corrected before puberty reduces risk to 2–3.
  2. Intratubular germ cell neoplasia (precursor lesion).
  3. Family or personal history of testicular cancer.

3. Clinical Evaluation

• Symptoms:

  • Usually presents as a painless testicular mass, but can include symptoms of metastasis (e.g., abdominal mass, supraclavicular lymphadenopathy, lung symptoms such as shortness of breath or hemoptysis).
    • Non-classic symptoms point to potential metastasis.
      Quote:
      "It can cause lung symptoms...shortness of breath or hemoptysis from going to your lungs." (03:19)

• Initial Diagnostic Steps:

  • Scrotal ultrasound is the test of choice.

    • Heterogeneous mass suggests non-seminoma; homogeneous mass suggests seminoma.
    • "If it's heterogeneous, then it signifies a non seminoma, whereas if it's homogeneous, it would signify more of a seminoma." (04:00)

  • No role for CT, MRI, or advanced imaging at initial presentation.

  • Serum tumor markers are mandatory before surgery (orchiectomy):

    • AFP (alpha-fetoprotein)
    • β-hCG (beta human chorionic gonadotropin)
    • LDH (lactate dehydrogenase)

4. Tumor Markers: Characteristics and Clinical Relevance

• AFP:

  • Half-life: 5–7 days.
  • Elevated in yolk sac tumors and embryonal carcinoma.
  • Can be falsely elevated (e.g., liver pathology, other malignancies).
  • Decision Threshold:
    "We don't treat testis cancer based solely on an AFP level that's less than 20." (08:09)

• β-hCG:

  • Half-life: 24–36 hours.
  • Elevated in 20–60% of non-seminomas, 15% of seminomas, all choriocarcinomas.
  • Non-cancer causes: smoking marijuana, other cancers, liver disease.

• LDH:

  • Half-life: 24 hours.
  • Indicates tumor burden, not specific to tumor type.
  • Quote:
    "It can help us guide and learn more about the amount of burden that this patient has." (10:28)

5. Initial Treatment Approach

• Radical Inguinal Orchiectomy is standard.

  • Partial orchiectomy in select cases (small tumors, bilateral tumors, or benign suspicion).
  • Always consider sperm banking for those with no normal contralateral testicle or subfertility.
    • "That's someone you want to consider sperm banking." (12:18)

• After Orchiectomy:

  • Wait for pathology report.
  • Proceed to staging with imaging, including:
    • CT of chest, abdomen, pelvis (oral/IV contrast).
    • Consider chest X-ray if no markers and no abdominal mets, but practicality debated.
    • Brain imaging if clinically indicated (neurologic symptoms).
    • No PET scans for initial staging.

6. Detailed Staging Breakdown

Staging Components:

• Adds S (serum marker) to traditional TNM.
• T: Tumor (local invasion)
• N: Regional nodes (size)
• M: Metastasis (pulmonary, non-pulmonary)
• S: Serum markers (AFP, β-hCG, LDH levels)

Tumor (T) Staging:

• PTIS: In situ; has not broken basement membrane.
• T1: Confined to testis, no lymphovascular invasion.
  • T1a: <3cm
  • T1b: ≥3cm
• T2: Lymphovascular, hilar soft tissue, or epididymis involvement.
• T3: Spermatic cord involvement.
• T4: Scrotal invasion.

Nodes (N):

• N1: <2cm
• N2: 2–5cm
• N3: >5cm

Metastasis (M):

• M1a: Non–retroperitoneal nodal or pulmonary mets.
• M1b: Non-pulmonary visceral mets.

Serum Markers (S):

• LDH:
  • S1: <1.5× normal
  • S2: 1.5–10× normal
  • S3: >10× normal
• β-hCG:
  • S1: <5,000
  • S2: 5,000–50,000
  • S3: >50,000
• AFP:
  • S1: <1,000
  • S2: 1,000–10,000
  • S3: >10,000

Memorable Moment:
"I know this is brutal, but the serum markers is the last category of your staging. ...I'll read it off to you just because I want to be complete, but I know it's probably going to go in one ear and out the other." (23:10)

Staging Groups (Broad Brushstrokes):

• Stage I: Node-negative, metastasis-negative, usually normal markers.
• Stage II: Node-positive (size based), metastasis-negative, serum markers start to play a role.
• Stage III: Any tumor, node, or metastasis category, but presence of distant or visceral mets (especially non-pulmonary), markers play a greater role.

Notable Quotes & Memorable Moments

• On Marker Interpretation:
  "So you measure them high, you take out the cancer. You see if they drop to normal. And if they don't, then that would signify that there might be something else in that person's body..." (05:07)

• On Partial Orchiectomy:
  "He only has two testicles. So if he has a tumor on both testicles, then you want to at least consider just cutting out the tumor so he at least has, like, a half of two testicles left, which, like, kind of is one testicle, you know..." (11:19)

• On Staging Nuances:
  "Everything after this...I talk about when it involves this structure that could be involved, whether with or without lymphovascular involvement, and it’ll bump you to that level." (18:26)

Timestamps for Key Segments

• 00:01–01:29: Introduction, epidemiology, tumor types
• 01:29–02:53: Common presentations, risk factors
• 02:53–04:55: Clinical presentation, initial diagnostic steps
• 04:55–10:59: Tumor markers: clinical use and limitations
• 11:09–14:17: Initial treatment: orchiectomy, sperm banking, partial orchiectomy
• 14:17–15:38: Post-orchiectomy staging: imaging and practical considerations
• 15:38–24:34: Staging system: T, N, M, S breakdown with clinical correlations
• 24:34–26:40: How staging translates to stages I, II, III and their clinical consequences

Conclusion

Parker Adams delivers a thorough, exam-relevant, and clinically applicable review on the initial management and staging of testicular cancer, emphasizing what’s most important for medical students and residents. His energetic and relatable teaching style breaks down complex staging frameworks into manageable and memorable parts, peppered with practical pearls and personal reflections for aspiring urologists.

Further Reading:

• AUA Core Curriculum
• Smith & Tanagho’s General Urology
• Weider’s Pocket Guide to Urology

Contact & Resources:

• Email: rodsquadpodmail.com
• Website: rodsquadpod.com
• Twitter: @RodsquadPod