Editing Germ Cell Tumours (section)

=== Orchiectomy ===

* '''See [[Orchiectomy]] Chapter Notes'''

==== Radical inguinal orchiectomy ====

* '''<span style="color:#ff0000">Testicular prosthesis should be discussed prior to orchiectomy.</span>'''
* '''<span style="color:#ff0000">Approach: inguinal</span>'''
** '''<span style="color:#ff0000">Trans-scrotal orchiectomy: contraindicated due to risks of scrotal violation (see above)</span>'''
*** '''Patients who have undergone scrotal orchiectomy for malignant neoplasm should be counseled regarding the increased risk of local recurrence and may rarely be considered for adjunctive therapy (excision of scrotal scar or radiotherapy) for local control'''
**** In patients that have received systemic therapy following scrotal orchiectomy, local relapse is rare and adjuvant therapy is not needed
* '''<span style="color:#ff0000">Patients suspected of having a testicular neoplasm should undergo a radical inguinal orchiectomy with removal of the tumor-bearing testicle and spermatic cord to the level of the internal inguinal ring.</span>'''
** '''In very rare cases where there is a possibility of a benign tumour, excisional biopsy with a frozen section should be performed prior to definitive orchiectomy to allow for the possibility of organ-sparing partial orchiectomy.'''

* '''<span style="color:#ff0000">Timing</span>'''
** '''<span style="color:#ff0000">In general, orchiectomy should be performed prior to any further treatment.</span>'''
*** '''<span style="color:#ff0000">Exception: in patients with life-threatening metastatic disease and an unequivocally elevated AFP and/or HCG, orchiectomy should not delay the start of chemotherapy and can be postponed until later in the treatment course</span>'''

==== Testis-sparing surgery (TSS)[https://www.auanet.org/guidelines/testicular-cancer-guideline] ====

* '''<span style="color:#ff0000">Not recommended in patients with a testicular lesion suspicious for malignant neoplasm and a normal contralateral testis; radical inguinal orchiectomy is recommended</span>'''
* '''<span style="color:#ff0000">Indications (3)</span>'''
*# '''<span style="color:#ff0000">Patients wishing to preserve gonadal function</span>'''
*# '''<span style="color:#ff0000">Mass <2cm</span>'''
*# '''<span style="color:#ff0000">And one of the following:</span>'''
*## '''<span style="color:#ff0000">Equivocal ultrasound/physical exam findings and negative tumor markers (hCG and AFP)</span>'''
*## '''<span style="color:#ff0000">Congenital, acquired or functionally solitary testis</span>'''
*## '''<span style="color:#ff0000">Bilateral synchronous tumors</span>'''
* '''Patients considering TSS should be counseled regarding (5):'''
*# '''Higher risk of local recurrence'''
*# '''Need for monitoring with physical examination and ultrasound'''
*# '''Role of adjuvant radiotherapy to the testicle to reduce local recurrence'''
*# '''Impact of radiotherapy on sperm and testosterone production'''
*# '''Risk of testicular atrophy and need for testosterone replacement therapy, and/or subfertility/infertility'''
* '''When TSS is performed, in addition to the suspicious mass, multiple biopsies of the ipsilateral testicle normal parenchyma should be obtained for evaluation by an experienced genitourinary pathologist to rule out GCNIS.'''
** 50-80% undergoing TSS have concomitant GCNIS in the ipsilateral testis
** '''GCNIS'''
*** '''Rationale for treatment is based on the high risk of developing invasive GCT.'''
*** Can be diagnosed by testicular biopsy performed for the investigation of infertility, contralateral testis biopsy in patients with GCT, or within the affected testis in a patient undergoing TSS
*** '''Management options'''
***# '''Orchiectomy'''
***# '''Low-dose (18-20 Gy) radiotherapy'''
***# '''Close observation'''
** '''If GSCNIS on testis biopsy or malignant neoplasm after TSS are found:'''
*** '''If patient prioritizes preservation of fertility and testicular androgen production, surveillance is recommended'''
**** '''For patients with abnormal semen parameters but sufficient for assisted reproductive techniques, close surveillance with periodic ultrasound evaluation of the testis is a reasonable strategy with deferred therapy until successful pregnancy and/or development of GCT.'''
*** '''If patient prioritizes reduction of cancer risk, testicular radiation (18-20 Gy) or orchiectomy is recommended'''
**** '''Radiation'''
***** '''Advantage'''
****** '''Reduced risk of hypogonadism compared to orchiectomy'''
******* '''Leydig cells are radioresistant compared with germinal epithelium.'''
******* Leydig cell function may decline over time, and 40% of men who receive radiation therapy require supplemental testosterone
***** '''Disadvantage'''
****** '''Increased risk of infertility compared to orchiectomy'''
******* '''For patients with a normal contralateral testis who desire future paternity, radical orchiectomy is preferred because scatter to the contralateral testis from radiotherapy may impair spermatogenesis.'''
******* Radiation at these doses causes permanent sterility of the treated testis, but can be delayed in patients who wish to father children.
**** '''Radical orchiectomy'''
***** '''Advantage'''
****** '''Most definitive treatment, although low-dose radiotherapy (≥20 Gy) is associated with similar rates of local control with the prospect of preserving testicular endocrine function'''
** '''If GCNIS is not found on biopsy:'''
*** '''It is highly likely that GCNIS is present outside of the sampled tissue, and the patient should be followed with serial self-testicular exam, ultrasound, and tumor markers as appropriate.'''
* '''Any local recurrence within the ipsilateral testis occurring with or without adjuvant therapy should be managed with completion radical orchiectomy'''

==== Contralateral testis biopsy ====

* An open inguinal biopsy of the contralateral testis may be considered in patients with risk factors for testicular cancer or patients with suspicious lesions on preoperative ultrasound scan

==== Delayed orchiectomy ====

* In a small subset of patients with widespread and/or symptomatic GCT, the diagnosis is made based on biopsy of a metastatic lesion or empirically based on clinical and serologic features. In these unique settings, initiation of systemic chemotherapy supersedes diagnostic orchiectomy. '''Because of high discordance of pathologic response rates within the testicle, a delayed orchiectomy is recommended for all patients with NSGCT after induction chemotherapy, even in the setting of a complete response in the retroperitoneum'''
* The role of delayed orchiectomy is more controversial in patients with presumed primary retroperitoneal/extragonadal GCT.
** Radical orchiectomy has been advocated when the metastatic pattern of retroperitoneal disease lateralizes to the expected distribution of a testicular primary.