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Management

Revised 08 May 2013 

All testicular tumours at any stage must be treated for cure. Testicular tumours are rare, but it is the most common solid tumour in men between 15-34 years of age. The majority of tumours are of germ cell origin and approximately equally divided between seminoma and non-seminoma. It is very unusual to see a malignant non-seminoma in a patient over 40 years of age. Whilst only 10% of seminoma cases have overt dissemination at diagnosis, some 30% of patients with embryonal carcinoma have spread when seen initially. Other pathologies include stromal tumours, and lymphoma is the commonest cause of a malignant testicular mass in the elderly. 

Pathology review is strongly recommended.

A large body of evidence from clinical trials exists for initial management that allows physicians and patients to choose between different first-line treatments which offer the best curative option with the least amount of toxicity. However, due to the multitude of available treatment options, decision making regarding the optimal management of a patient has become more complicated and complex. This applies in particular to patients with early stage disease who are often cured with minimal interventions and who are at risk of being overtreated. Likewise, patients with advanced, relapsed or refractory disease are difficult to treat.

Germ cell cancer is a rare and highly curable disease that needs expert treatment. Clear evidence has evolved that in particular patients with advanced germ cell cancer benefit from the expertise of their managing physician with significantly improved survival and less toxicity. There is a correlation between the experience of the physician and the number of patients treated per year. A large patient volume resulting in competence and experience even with rare clinical scenarios is crucial, and it is strongly recommended by all existing guidelines to refer patients, in particular patien​ts with metastatic or even relapsed disease to experienced tertiary centers with special experience in the field of germ cell cancer. 

Discussion of patients at the weekly multidisciplinary GU Tumour Case Conference is also highly recommended.

Rare histologic subtypes such as malignant lymphoma of the testicle, and primary sarcomas of the testicle are dealt with in the lymphoma and sarcoma sections of the cancer management manual.

Reference:

  1. Collette L, Sylvester RJ, Stenning SP, Fossa SD, Mead GM, de Wit R, de Mulder PHM, Neymark N, Lallemand E, Kaye SB. Impact of the treating institution on survival of patients with „poor-prognosis" metastatic nonseminoma. European Organization for Research and Treatment of Cancer Genito-Urinary Tract Cancer Collaborative Group and the Medical Research Council Testicular Cancer Working Party. J Natl Cancer Inst 1999;91: 839-846.

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