Testis


 * **Epidemiolgy:** || The most common malignancy in men between 20 - 34 years old. 1 Higher rates are reported among United Kingdom, Denmark, and Caucasians in the United States. ||
 * **Etiology:** || It may be related to gonadal dysgenesis. There is a higher incidence in men with cryptorchidism, which is the condition for undescended testis. 1 ||
 * **Signs & Symptoms:** || * Painless swelling in the scrotum, occasionally pain and tenderness 1
 * Dull ache
 * Heaviness or pulling sensation in the scrotum
 * Aching in lower abdominal area

Advanced disease symptoms Laboratory studies Surgery Diagnostic Radiology Special studies 1) Germ cell tumors (GCTs) – this tumors compose approximately 95% of all testicular tumors. GCTs are further broken down into seminomas, which compose approximately 40% of GCTs, and nonseminomas, which make up 60% of all GCTs. Nonseminomas are further broken down into four categories that include embryonal (15% to 20%), teratoma (20% to 25%), yolk sac (10%), and choriocarcinoma (1%). 2) Nongerm cell tumors (NGCTs) – this tumors make up only 4% to 5% of all testicular tumors. 3 || || In stage I and stage II nonseminomas, almost all patients will survive with modern treatment techniques. Nonseminoma patients with mediastinal primary tumors have a far worse prognosis than those with testicular or retroperitoneal primary tumors. ||
 * Neck mass
 * Respiratory symptoms
 * Low back pain ||
 * **Diagnostic Procedures:** || General 2
 * History (document cryptorchidism and previous inguinal or scrotal surgery)
 * Physical exam
 * CBC
 * Biochemistry profile
 * Serum assays
 * Radical inguinal orchiectomy
 * Chest x-ray
 * CT chest for nonseminoma
 * CT abdomen and pelvis
 * Ultrasound of contralateral testis (baseline)
 * Semen analysis ||
 * **Histology:** || Testicular neoplasms are classified into two major histologic groups:
 * **Lymph node drainage:** || Para aortic lymph nodes and retroperitoneal lymph nodes are the most common nodes involved in testicular cancer. Seminomas usually spread via regional lymph nodes to supraclavicular, mediastinal, and retroperitoneal nodes. Nonseminomas metastasize by both lymphatic and hematogeneous routes, especially to the liver and lungs. 3 ||
 * **Metastatic spread:** || Tumors originating in the testis typically spread through the lymphatic channels. While nonseminomas are more common to have metastatic spread than seminomas, metastasis is possible in both. The most common site to find metastatic disease is in the retroperitoneal space, but visceral metastasis is also very common. Some of the distant metastatic organs include the lungs, liver, bones, brain, kidney, spleen, and adrenal glands. 2 ||
 * **Grading:** || Testicular cancer is typically not graded, but staging is the primary assessment by the pathologist. The staging system listed below is the TNM system created by the American Joint Committee on Cancer (AJCC). ||
 * **Staging:** || AJCC Staging System for Testicular Cancer 4
 * **Radiation side effects:** || Side effects of radiation therapy include 1 :
 * Nausea
 * Diarrhea
 * Decreased sperm count
 * Dyspepsia
 * Peptic ulceration ||
 * **Prognosis:** || Stage I seminomas have a 5-year relapse free rate of 82%.2 Tumor size greater than 4cm and invasion of the rete testis were shown to be associated with higher rates of recurrence. Stage II disease is dependent on the bulk of retroperitoneal disease. Stage II and IV disease has a wores prognosis than the earlier stage seminomas.
 * **Treatments:** || Seminoma
 * Stage I is treated with radical orchiectomy and postoperative irradiation of the paraaortic and ipsilateral pelvic nodes to a dose of 2500cGy. 1
 * Stage IIA disease the dose and the paraaortic and ipsilateral portals are similar but must include adequate margin for the enlarged lymph nodes.
 * Stage IIB needs the paraaortic and ipsilateral lymph nodes irradiated with a modification to the field to cover the larger mass. Dose to nodal volume is 2500cGy with a 1000cGy boost to the gross tumor.
 * Stage IIC, which is retroperitoneal disease, must be individualized.
 * Stage IID rarely occurs typically these patients are treated with cisplatin containing combination chemotherapy.

Nonseminoma


 * Initially nonseminomas are treated by radical inguinal orchiectomy; chemotherapy follows with the use of cisplatin based agents. 1
 * Advanced disease is treatment mainstay is chemotherapy. ||
 * **TD 5/5:** || Listed are doses that can cause complications or injury with 5% of patients within 5 years. 1

Testis: 1Gy: Sterilization Bladder: 65 Gray (Gy): Bladder contracture or volume loss Femoral head: 52Gy: Necrosis Colon: 45Gy: Obstruction, perforation, ulceration, fistula Rectum: 60Gy: Ulcer, stricture Intestine: 45Gy: Ulcer, perforation, hemorrage || Reprinted from International Journal Of Radiation Oncology, Biology, Physics, 2013. 5 The above image shows multileaf collimator blocks based on bony anatomy. The field is treating paraaortic and ipsilateral iliac lymph nodes.
 * **Additional images** || [[image:uwlmedicaldosimetry2013/Fig5a.gif]]

Reprinted from International Journal Of Radiation Oncology, Biology, Physics, 2013. 5 The above image shows multileaf collimator blocks based on nodal anatomy. The field is treating paraaortic and ipsilateral iliac lymph nodes. Centers with expertise in vascular and nodal anatomy may consider use of anteroposterior-posteroanterior ﬁelds based on three-dimensional conformal radiotherapy instead.

Reprinted from International Journal Of Radiation Oncology, Biology, Physics, 2013. 5 The above image shows a multileaf collimator block in a boost plan. For Stage IIA and IIB patients, an anteroposterior-posteroanterior boost is then delivered to the adenopathy with a 2-cm margin to the block edge. ||
 * **References:** || # Washington CM, Leaver D. // Principles and Practice of Radiation Therapy // . 3rd ed. St. Louis, MO: Mosby Elsevier; 2010.
 * 1) Chao K, Perez C, Brady L. //Radiation Oncology Management Decisions//. 3rd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2011.
 * 2) Medscape. Overview of testicular cancer. http://www.medscape.com/viewarticle/473629_7. Accessed on June 14, 2013
 * 3) Feldman DR. The approach to the patient with synchronus bilateral germ cell tumors: a lesson in oncologic prioritization. CancerNetwork Website. http://www.cancernetwork.com/testicular-cancer/content/article/10165/1616320. Published July 21, 2010. Accessed June 18, 2013.
 * 4) Wilder RB, Buyyounouski MK, Estathiou JA, Beard CJ. Radiotherapy treatment planning for testicular seminoma. //Int J Radiat Oncol Biol Phys//. 2012;83(4):445-452. doi:10.1016/j.ijrobp.2012.01.044. ||

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