History
Presenting Complaint
Most non-seminomatous germ cell tumours (NSGCTs) will present with a painless testicular lump, in a similar way to seminoma.
- Pure choriocarcinoma may often present with symptoms related to metastatic disease, including haemoptysis (lung metastasis), headaches/confusion (brain metastasis) or back pain (bony metastasis)
Occasionally patients may complain of scrotal pain or discomfort.
Past Medical History
Important questions include:
- Past history of crypto-orchidism (undescended testis)
- Past history of inguinal surgery (due to alterations in lymphatic flow)
- Presence of chromosomal abnormalities (Down's, Kleinfelter's)
Medications/Allergies
No special questioning required
Family History
About 1-2 percent of germ cell tumours have a genetic component and this is important to inquire into.
Social History
The patient's current family situation is critically important. The desire for future children should be explored. If it has not already occurred, patients should be encouraged to explore sperm banking.
The patient's ability to attend treatment regularly should also be inquired into.
Examination
A focussed physical examination should be performed based on patient symptoms.
At the very least, examination of the scrotum, inguinal regions and abdomen should be performed. Chest examination may detect abnormal signs due to metastatic lung deposits.
Investigations
Bloods
Three tumour markers are performed to evaluate testicular tumours:
- AFP is elevated in a number of testicular germ cell tumours, and suggests the presence of embryonal carcinoma or yolk sac carcinoma.
- β-hCG is produced by syncytiotrophoblastic cells, which can be found in a small number of otherwise 'pure' germ cell tumours (including seminoma). They are always found in choriocarcinoma and this must be excluded if the β-hCG is elevated
- LDH is not a specific test but, if elevated, can be used to estimate tumour burden and response to disease
Imaging
CT of the chest, abdomen and pelvis is essential for staging purposes. If a patient has cerebral symptoms or choriocarcinoma then a CT brain is also warranted.
Staging
Australian guidelines on staging can be found here.
TNM Staging
The TNM system is used to stage testicular malignancy. Importantly, there are only three levels of overall stage (I, II, III) and serum markers are also considered in the staging system (S stage).
T Stage
T0 - No evidence of primary tumour
Tis - Intratubular Germ Cell Neoplasia
T1 - Tumour limited to testis/epididymis; no invasion into tunica vaginalis; no lymphovascular invasion
T2 - As for T1 but with lymphovascular invasion or involvement of tunica vaginalis
T3 - Invasion of spermatic cord
T4 - Invasion of scrotum
N Stage
N0 - No regional node involvement
N1 - Lymph node metastases, less than 2 cm AND no more than 5 nodes involved
N2 - Lymph node metastases, 2 - 5 cm, OR more than 5 nodes involved
N3 - Lymph node metastases > 5 cm
M Stage
M0 - No distant metastasis
M1a - Non-regional lymph node or lung metastases
M1b - Other metastases
S Stage
| Stage | β-hCG | AFP | LDH |
|---|---|---|---|
| S0 | Not elevated | Not elevated | Not elevated |
| S1 | < 5,000 | < 1,000 | < 1.5 × normal |
| S2 | 5,000 - 10,000 | 1,000 - 10,000 | 1.5 - 10 × normal |
| S3 | > 10,000 | > 10,000 | > 10 × normal |
Final Stage
| Stage | T stage | N stage | M stage | S stage |
|---|---|---|---|---|
| 0 | Tis | N0 | M0 | S0 |
| IA | T1 | N0 | M0 | S0 |
| IB | T2-4 | N0 | M0 | S0 |
| IS | Any | N0 | M0 | S1-3 |
| IIA | Any | N1 | M0 | S0-1 |
| IIB | Any | N2 | M0 | S0-1 |
| IIC | Any | N3 | M0 | S0-1 |
| IIIA | Any | Any | M1a | S0-1 |
| IIIB | Any | Any | M1a | S2 |
| IIIC | Any | Any | M1a | S3 |
| IIIC | Any | Any | M1b | Any |
IGCCCG Staging
The International Germ Cell Cancer Collaborative Group (IGCCCG) have determined an additional staging method for germ cell tumours, dividing prognosis into 'good', 'intermediate' and 'poor' depending on staging investigations. It is often recommended that the IGCCCG system be used for determining therapy for metastatic disease.
| Stage | Seminoma | NSGCT | TNM Equivalent |
|---|---|---|---|
| Good | Any primary site AND normal tumour markers AND no non-pulmonary metastases |
Testis/Retroperitoneal Primary AND no non-pulmonary metastases AND low tumour markers |
I - IIIA |
| Intermediate | Elevated β-hCG | Testis/Retroperitoneal Primary AND no non-pulmonary metastases AND medium tumour markers |
IIIB |
| Poor | Not applicable | Mediastinal Primary OR non-pulmonary metastases OR high tumour markers |
IIIC |
The latest release of the TNM staging criteria incorporates the IGCCCG recommendations by splitting Stage III into three sub-stages depending on tumour markers (S stage).
