Exogenous Estrogen Therapy, Testicular Cancer, and the Male to Female Transgender Population

A Case Report

Gursimran Chandhoke; Bobby Shayegan; Sebastien J. Hotte

Disclosures

J Med Case Reports. 2019;12(373) 

In This Article

Discussion

TC is the most common malignancy in men aged 15–40. Over 95% are germ cell tumors, of which the main classification is seminoma and non-seminoma.[1] Non-seminomas include tumors of the yolk sac, embryonal cell, teratoma, and choriocarcinoma, while pure seminomas have no non-seminomatous components present. Biochemically, pure seminomas do not produce AFP but may produce a small amount of β-HCG.

Patients with TC will often present with a mass or lump in the testis. Signs and symptoms suggestive of loco-regional/metastatic disease include swelling of the lower extremities, back pain, dyspnea, or hemoptysis.

In patients where TC is suspected, baseline investigations should include routine bloodwork with AFP, β-HCG, and LDH. Imaging studies should include a scrotal ultrasound and CT of the chest/abdomen/pelvis (in cases of stage I seminoma, a chest X-ray is suitable). Additional investigations such as a bone scan or CT scan of the head are indicated if there are symptoms suggestive of disease in these locations.

On completion of these investigations, patients should be assessed for consideration of orchiectomy.[2] Orchiectomy is a simple, straightforward procedure that is unlikely to cause a significant delay toward the start of chemotherapy. Given that a pathologic assessment of the testicle provides vital prognostic information and guides treatment decisions (for example, seminoma, non-seminoma, and teratoma), orchiectomy should only be delayed in exceptional circumstances (life-threatening disease, significant overall burden of disease).

In patients with localized disease, tumor markers should decline as predicted by their half-lives (AFP < 7 days, ß-HCG < 3 days).

In the metastatic setting, defining the tumor as seminoma versus non-seminoma, the level of tumor markers, and the sites of metastases helps to stratify risk and define the approach to therapy (see Table 1).[3] Based on international randomized clinical trial data, seminomas and good prognosis non-seminomas can be treated with three cycles of BEP chemotherapy whereas intermediate/poor risk non-seminomas are most often treated with four cycles of BEP.

Following the completion of therapy, patients should be followed with regular physical examinations, tumor markers, and imaging investigations (see Table 2).[4]

In metastatic non-seminomas, residual masses (with normal tumor markers) may remain following chemotherapy. While a "residual mass" has not been defined in terms of size, consensus guidelines do recommend surgical resection of amenable masses > 1 cm. In almost 50% of the cases, these resected masses demonstrated post treatment necrosis while 10% demonstrated viable cancer cells. While there is no reliable way to predict the likely pathology of these residual masses, favorable factors include absence of teratoma in the primary tumor, large shrinkage of the mass with chemotherapy, and residual size < 1 cm.[2]

In metastatic seminomas, residual masses are classified as > 3 cm or < 3 cm. For lesions greater than or equal to 3 cm, fluorodeoxyglucose (FDG)-PET should be obtained for further assessment, while for masses < 3 cm, PET scans are optional. If the PET scan is positive, the treatment of choice would be surgical resection. Radiation therapy may also be considered, although the benefit of this would be less clear.[2] In our case, since the lesion was thought to be a seminoma (normal AFP), monitoring with FDG-PET would be in keeping with consensus guidelines.

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