47.1: Testicular Cancer – Flashcards
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What is the pertinent epidemiology for testicular cancer?
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Most common solid tumor in men age 20-34
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What are the majority of testis cancers attributed to?
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Germ Cell Tumors - 90-95% Seminoma and Nonseminoma
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Where do the rest of testis cancers come from?
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Supporting cells Leydig cell Sertoli cell Gonadoblastoma
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What is the main risk factor for testicular cancer?
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Cryptorchidism
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What is the increased risk for those with cryptorchidism of testicular cancer?
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3-14x the incidence (absolute risk 2.8%)
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What percent of testicular tumors develop in patients with a history of cryptorchidism? What percent of these are in the contralateral testis?
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7-10% 5-10%
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In someone with cryptorchidism, what increases the relative risk of malignancy?
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The higher the testicular was previously located (intraabdominal vs inguinal)
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How can we decrease the risk of testicular cancer in someone with cryptorchidism?
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Placing the testis in the scrotum (orchidoplexy) as soon as possible - decreases the risk of testicular cancer
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What are the five basic histologic cell types for germ cell tumors?
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Seminoma Teratoma Embroyonal Choriocarcinoma Yolk sac
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Which histologic cell types are considered NSGCT?
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Teratoma Embryonal Choriocarcinoma Yolk Sac
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What types of seminoma are there? What are their prevalence?
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Typical/classic (85%) Anaplastic (5-10%) Spermatocytic (2-12%)
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Describe the typical/classic seminoma
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Radiation sensitive Syncytiotrophoblastic Slower growth rate Occasionally can have met of NSGCT
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What hormones might seminoma secrete? What doesn't it secrete?
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Might: bHCG (10-15%) NEVER: AFP
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Describe anaplastic seminoma
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Greater met potential Present in 30% of those who die from seminoma Higher bHCG production
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Describe spermatocytic seminoma
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Older patients (half >50) Favorable prognosis Usually alone
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What is an important characteristic of NSGCT tumors?
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Fast growth rate - double every 10-30 days based on CXR
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Describe a teratoma
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More than 1 germ cell layer - cartilage, bone, intestinal, pancreatic, liver, muscle, neural, connective tissue
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What other NSGCT is teratoma linked with? How?
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Embryonal Met is often embryonal (80%) (vs teratoma or chorio) Embryonal can mature to teratoma
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What is important in the treatment of teratoma?
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NOT chemosensitive Retroperitoneal teratoma is poor prognosis
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Describe an embryonal tumor
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Tendency to invade tunica and cord structures
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Embroyonal is in what percent of NSGCT?
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40-60%
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When >40% of a tumor is embroyonal, what does that mean?
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Risk factor for nodal disease More aggressive
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Describe choriocarcinoma
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May hemorrhage
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In what way is choriocarcinoma different?
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May present with small testicular mass and distant mets Exception to normal stepwise spread - mets can spread hematogenously
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Describe a yolk sac tumor
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Most common testis tumor of *children*
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Describe the patterns of local spread
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Uncommon to have extension to scrotal wall or up spermatic cord - tunica albuginea is a barrier to local growth
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How do we respect the pattern of local spread when surgically removing a testis?
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Iatrogenic scrotal violation can result in inguinal metastasis, thus the incision for a radical orchiectomy is inguinal
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Describe the pattern of regional spread
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To nodes - retroperitoneal nodes
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How does the right testis differ from the left in regional spread?
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Right testis --> to interaortocaval area Left testis --> para-aortic area Right to left crossover mets are common, but not left to right (retroperitoneum)
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Describe the pattern of metastatic spread for choriocarcionoma
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Unusual - more hematogenous vs lymphatic Can have early mets
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Where does choriocarcinoma like to spread to?
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Lungs
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Describe the pattern of metastatic spread for advanced disease
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Can have visceral mets to the lung, liver, brain, bone, and supraclavicular nodes
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What is the simplified staging paradigm for testicular cancer?
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Stage I: confined to testis Stage II: retroperitoneal lymph nodes Stage III: mets/visceral disease
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Testicular tumors are one of the few tumors where...
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Lymphovascular invasion impacts the T stage T1 --> T2
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What is the most common symptom of testicular cancer?
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Painless enlargement of the testis 98-99% unilateral
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What are more uncommon symptoms of testicular cancer?
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Acute pain/swelling seen in 10% only 10% asymptomatic and detected after trauma or on routine physical exam
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What is the typical delay in presentation of testicular cancer and why?
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3-6 months - both patient and provider May be misdiagnosed initially
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What is the most common misdiagnosis of testicular cancer?
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Epididymitis
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What are self-exams so important for testicular cancer?
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10% are asymptomatic
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What percent of testicular cancer patients have metastatic symptoms?
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10%
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What are metastatic symptoms of testicular cancer?
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Abdominal pain, Back pain Cough, hemoptysis, dyspnea Anorexia, N/V Bone pain, neck mass Neurologic, lower extremity edema Gynecomastia
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When would you consider testicular cancer (besides a mass and symptoms listed previously)?
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Cause of abdominal pain in a young man (vs. appendicitis) On the differential for any retroperitonal mass (vs lymphoma)
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What is the differential diagnosis for scrotal swelling?
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Testicular torsion Epididymitis/epididymal-orchitis Hydrocele (transilluminates) Spermatocele (epididymal cyst) Hematocele (trauma) Varicocele (extratesticular)
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What is the typical finding on physical exam for testicular cancer?
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Testicular mass: firm and nontender ROCK HARD
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What other physical exam findings might you have with testicular cancer?
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Hydrocele (ultrasound) Abdominal exam (retroperitoneal lymph nodes rarely palpable) Look for 'distant' adenopathy - supraclavicular, axillary, inguinal Gynecomastia (5%)
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Why might a patient with testicular cancer have gynecomastia?
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hCG
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What tumor markers can you look for in a testicular cancer workup?
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AFP hCG LDH
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In what types of testicular cancer would you see AFP? Not see it?
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NOT in seminoma Produced by yolk sac tumors and embryonal tumors
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What should you do if you have elevated AFP in a seminoma?
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Have pathology recheck the specimen Treat as NSGCT
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In what types of testicular cancer would you see hCG production?
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Choriocarcinoma 15% of seminomas
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What can LDH tell you?
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Reflects tumor burden
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What other test might you get when working up testicular cancer?
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CBC - anemia Creatinine - renal failure (CT) LFTs
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Describe the imaging you would do with a suspected testicular cancer and why
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Scrotal ultrasound - confirms that the mass is testicular and solid, especially in presence of a hydrocele ALWAYS before surgery
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What other imaging studies can you do after an orchectomy? Why?
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CT of abdomen and pelvis - retroperitoneal lymphadnopathy/distant mets Chest xray - pulmonary mets
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When would you usually consider sperm banking and why?
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Radiation or chemotherapy - these can mess with fertility One testis - same risk for infertility as if you have two
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What is the first treatment for all testicular cancers?
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Radial *inguinal* orchiectomy +/- testicular prothesis
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What would you never do when you have a testicular mass? Why?
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Testicular mass biopsy Any solid intratesticular mass is considered neoplastic until proven otherwise
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What is the mortality for testicular cancer?
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<5%
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What other treatment options are there for testicular cancer?
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Surveillance Chemotherapy Radiation therapy Surgery (RPLND)
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What are the mainstays of chemotherapy for testicular cancer and what are their side effects?
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Bleomycin --> pulmonary firosis Etopside --> myelosuppression, alopecia Cisplatin --> renal insufficiency, N/V Ifosfamide --> hemorrhagic cystitis
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When would you use radiation therapy?
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Think seminoma
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When treating stage I seminoma with radiation therapy, what are your parameters?
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Standard fields include ipsilateral pelvis and para-aortic regions 26 Gy
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What are toxicities possible with radiation therapy?
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Infertility Rarely PUD or mild pancreatitis
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What is the most serious long-term side effect of chemotherapy?
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Development of secondary malignancies
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In testicular cancer survivors treated with chemo or radiation therapy, what was their observed:expected malignancy rate?
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1.43 - 43% higher rate of secondary cancer
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What is RPLND and what is it used for?
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Retroperitoneal Lymph Node Dissection Diagnostic and therapeutic
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What is the morbidity of RPLND? What kinds of morbidity?
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5-25% Atelectasis, pneumonitis, ileus, lymphocele, pancreatitis Ejaculation, infertility
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Are erections an issue for men undergoing RPLND? What is?
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No - those nerves are near the prostate Sympathetic nerves are near there - lead to ejaculation problems
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What is the treatment for seminoma?
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Stage related Exquisitely radiosensitive No surgery - too sticky Chemo as a salvage therapy
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In seminoma treatment, why do you use radiation over chemo?
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Both work about the same, but radiation is less toxic
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How do you treat high stage seminoma?
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Cisplatin-based chemotherapy Surgical excision postchemo is difficult and rarely needed
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What is the result of treatment of high stage seminoma?
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90% complete response, 90% of residual masses are fibrosis
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How do you treat low stage NSGCT?
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75% stage I cured by orchiectomy alone RPLND vs surveillance vs chemo - surgery can be considered prophylactically *NO RADIATION*
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After treatment of NSGCT, what is critical?
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Compliance critical for patients on surveillance plan Persistently elevated tumor markers --> chemo
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How do you treat high stage NSGCT?
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Chemotherapy Post chemo masses - RPLND *Teratoma not responsive to chemo* Salvage chemo after if tumor markers not normalized
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What is the cure rate for high grade NSGCT?
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70%
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In what age group is testicular cancer mainly seen?
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Young men
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What is key with testicular cancer?
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Early diagnosis
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Why are cure rates so high with testicular cancer?
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Many cases are localized at diagnosis Those with regional and metastatic disease are often responsive to multimodal therapy
