The Fellow on Call: The Heme/Onc Podcast

Episode 127: Testicular Cancer Series, Pt 1 – Introduction

Date: January 23, 2025
Hosts: Broenok (A), Vivek (B), Dan (C)

Overview

This episode kicks off a new series on testicular cancer, introducing the fundamental concepts, epidemiology, diagnosis, staging, and management considerations. The discussion provides approachable, high-yield explanations for trainees and practitioners, with an emphasis on core knowledge, practical pearls, and the nuances that routinely appear on board and in-service exams.

Key Discussion Points & Insights

1. Series Launch & Podcast Anniversary

• The hosts celebrate the three-year anniversary of the podcast and set personal New Year's resolutions.
• Commitment to building expertise together:

  “At the end of this series, hopefully all of us and all of our listeners are going to be experts in this topic.” — Broenok (A), [00:59]

2. Why Testicular Cancer Matters

• High Curability:

  "Testicular cancer is such a huge success story in solid tumor oncology with just the high curates that we have." — Vivek (B), [00:31]

• Relevance on Board Exams:

  “I can attest that this is certainly something that felt like it came up far more disproportionately [on boards] than it probably should have.” — Broenok (A), [00:59]

• Focus for the episode: Fundamentals, terminology, and the foundation for diagnosis/staging.

3. Case Presentation: Setting the Stage ([04:05])

• Patient: 28-year-old male with a painful left testicular lump, gynecomastia, hypoechoic mass on ultrasound, normal tumor markers, orchiectomy confirms pure seminoma (2.5 cm, no lymphovascular invasion).

4. Epidemiology & Embryology ([05:13])

• Germ Cell Tumors vs. Testicular Cancer: Testicular cancer is a subtype of germ cell tumors.
• Embryologic Basis: Explains why germ cell tumors can arise in the mediastinum due to migratory paths of primordial germ cells.
• Incidence:

  “Peak incidence of seminoma occurs between the ages of 25 and 29, and non seminoma between 35 and 39.” — Dan (C), [06:22]

• Risk factors: Cryptorchidism and family history (not smoking/obesity).

5. Seminoma vs. Non-Seminoma ([07:08])

• Seminoma: More favorable prognosis, unique treatment paradigm.
• Non-Seminoma: Includes yolk sac tumor, embryonal carcinoma, choriocarcinoma, and teratoma.
• Mix: Mixed germ cell tumors can include both.
• Tumor markers:

  “It is critical to know that seminomas will never secrete AFP… Any AFP elevation... means that the patient has a non seminoma.” — Broenok (A), [09:24]

• Clinical pearls: Tumor markers are central to diagnosis and surveillance in germ cell tumors.

6. Role of Tumor Markers ([09:24–12:02])

• Markers: AFP, beta HCG, LDH; get before and after orchiectomy.
• Interpretation:
  • AFP: Any meaningful elevation (above 20) before/after orchiectomy rules out pure seminoma.
  • Beta HCG: Markedly high (>50,000) raises concern for choriocarcinoma/brain mets.
• Diagnosis Aids: Helpful in cases of unknown primary, especially with mediastinal masses.

7. Staging & Imaging Essentials ([12:02–13:58])

• Inguinal Orchiectomy: Critical to avoid seeding tumor to the scrotum/pelvic nodes.
• Lymphatic Drainage: Retroperitoneal nodes are first echelon (not pelvic).
• Imaging:
  • CT abdomen/pelvis for nodes
  • Chest X-ray or CT for lung and mediastinal involvement

8. Staging Breakdown ([15:03])

• Three Stages:
  • Stage 1: Localized to testes
  • Stage 2: Retroperitoneal lymph node involvement only
  • Stage 3: Non-retroperitoneal nodes or other sites (lungs, liver, brain, etc.)
• Curative Intent: All stages are potentially curable.

9. Role & Timing of Tumor Marker Nadir ([17:18])

• Why wait:

  “…it’s critically important that we don’t rush the start of treatment and to let the values nadir because this can greatly affect the amount of chemotherapy that we give...” — Vivek (B), [18:31]

• Half-lives:
  • Beta HCG: ~1 day
  • AFP: ~1 week
• Timing: Nadir typically at 5–8 weeks post-surgery; start chemotherapy if the markers begin to rise.

10. Special Cases: Stage 1S Disease ([19:26–20:28])

• Definition: Rising tumor markers post-orchiectomy with no radiographic disease.
• Implication: Treated as disseminated disease; requires chemotherapy, similar to higher-stage patients.

11. Prognostic Risk Stratification ([21:41])

• For Non-Seminoma:

  • Favorable, intermediate, or poor risk based on nadir tumor markers (AFP, HCG, LDH) at start of chemotherapy.
  • Mnemonic: 1, 5, 1.5 (AFP >1,000; beta HCG >5,000; LDH >1.5x ULN for intermediate risk)
  • Poor risk: Marked elevations; treatment is same as intermediate.

• For Seminoma:

  • Only favorable and intermediate, based on metastatic sites rather than markers.

• Treatment Impact:

  • Higher risk: More intensive regimens (BEP x4 or VIP x4).
  • Lower risk: Standard regimens (BEP x3 or EP x4).

12. When to Image the Brain ([24:43])

• Indications:
  • Neurologic symptoms
  • AFP >10,000 or beta HCG >5,000
  • Extensive pulmonary/non-pulmonary visceral mets
  • Predominant choriocarcinoma

13. Pathology Pearls: Embryonal Histology & Teratoma ([26:09])

• Embryonal predominance, lymphovascular invasion, scrotal invasion: Key risk factors for relapse in stage 1; may shift management away from surveillance.
• Teratoma: Not chemo- or radio-sensitive; requires surgical excision of residual disease.

  “We call that growing teratoma syndrome. And those patients need to go straight to surgery.” — Vivek (B), [27:20]

Notable Quotes & Memorable Moments

• On testicular cancer success:

  "Testicular cancer is such a huge success story in solid tumor oncology..." — Vivek (B), [00:31]

• On AFP and seminoma:

  "It's critical to know that seminomas will never secrete AFP. Any AFP elevation…means that the patient has a non seminoma." — Broenok (A), [09:24]

• On importance of nadir:

  "It’s critically important that we don’t rush the start of treatment and to let the values nadir because this can greatly affect the amount of chemotherapy that we give..." — Vivek (B), [18:31]

• On the mnemonic for risk categories:

  “I always remember this with a mnemonic 1, 5 and 1.5…” — Vivek (B), [22:53]

• On teratoma management:

  "Any residual masses...need to undergo resection. The other thing that we can see is as we're giving chemotherapy...we call that growing teratoma syndrome. And those patients need to go straight to surgery." — Vivek (B), [27:20]

Timestamps for Important Segments

| Segment | Timestamp | |-----------------------------------------------------|-----------| | Launch, resolutions, podcast birthday | 00:00–04:05 | | Case presentation | 04:05 | | Epidemiology & embryology | 05:13 | | Seminoma vs. non-seminoma + markers | 07:08–10:30 | | Marker-based diagnosis and practical pearls | 09:24–12:02 | | Lymphatic drainage and surgical approach | 12:02 | | Staging imaging summary | 13:58 | | Staging system outlined | 15:03 | | Marker nadir and timing | 17:18 | | Stage 1S disease | 19:26–20:28 | | Prognostic risk groups and treatment implications | 21:41–24:43 | | Brain imaging—when to obtain | 24:43–26:09 | | Pathology pearls—embryonal histology, teratoma | 26:09–27:55 | | Closing thoughts | 28:26–28:35 |

Final Thoughts & Looking Ahead

• The hosts emphasize that mastering these core concepts lays the foundation for all further nuance in testicular cancer care and exam preparedness.
• Next episodes will dive deeper into active surveillance, management regimens, and further nuances in pathology and risk stratification.

Closing:

“So, until next time, everybody. We'll see you all later.” — Broenok (A), [28:30]