31 - testicular cancer Flashcards
(221 cards)
1
Q
testicular ca RR and undescended testicle
A
6 x rr
2
Q
RR of contralateral testicle ca in undescended testicle
A
1.7 x RR
3
Q
tca and age of orchiopexy
A
increased risk the later in age of orchiopexy
4
Q
greatest risk of testis cancer is?
A
prior history of testis ca
5
Q
relative risk of germ cell testis ca with prior hx germ cell ca
A
25 x RR
6
Q
3 genetic syndromes assd w testicular ca
A
- kleinfelter (47 xy), 2. mullerian duct syndrome, 3. downs
7
Q
2 prenatal RF for testis ca
A
- estrogen exposure, 2. inverse relationship with birth order
8
Q
where does ITGCN arise from in testicle
A
spermatogonia
9
Q
genetic finding that is diagnostic of GCT
A
presence of extra copies of short arm of chr 21
10
Q
do the majority of seminomas secrete hcg?
A
no
11
Q
tumor marker found in seminoma
A
HCG - only 20%
12
Q
what cells secrete HCG
A
synctiotrophoblasts
13
Q
tumor markers in embryonal carcinoma
A
hcg and afp
14
Q
tumor marker in yolk sac
A
AFP
15
Q
pathognomonic finding in yolk sac
A
schiller-duval bodies
16
Q
choriocarcinoma tumor marker
A
HCG
17
Q
feature of choriocarcinoma tumor marker
A
very high HCG level
18
Q
clinical feature of choriocarcinoma
A
small primary, wide spread hematologic mets (brain/ lungs)
19
Q
malignant potential of teratoma in children
A
benign
20
Q
when is teratoma found in adults
A
NSGCT
21
Q
% gct are mixed
A
30-50%
22
Q
malignant potential of epidermoid cyst
A
benign
23
Q
what lines epidermoid cysts
A
squamous epithelium
24
Q
mgmt of suspected epidermoid cyst
A
do open biopsy/ partial orchiectomy. if epidermoid cyst confirmed, then close. if malignant, orchiectomy
25
major difference between seminoma and nonseminoma and treatment
only nonseminoma can have teratoma, which has to be eradicated
26
afp half life
5 days
27
hcg half life
24-36 hrs
28
2 tumors producing AFP
embryonal and yolk sac
29
nl function of HCG
produced by placenta to maintain corpus luteum in pregnancy
30
low testosterone and tumor markers
high LH can cross react with HCG
31
HCG homologous to what other protein
b-subunit of LH
32
how to manage aberrantly elevated LH
give testosterone shot and re-test hcg
33
signifance of nl tumor markers
does not gaurantee eradication of all cancer cells
34
drainage of retroperitoneal lymphatics
mediastinum then chest
35
GCT clinical stage 1
all disease confined to testicle w nl tumor markers after orchiectomy
36
GCT clinical stage 1s
same as CS1 with elevated post orchectomy markers
37
NSGCT CS1s mgmt
chemo
38
clinical stage 2a vs 2b vs 2c for sem and non-sem germ cell tumor
retroperitoneal disease < 2 cm, 2-5 cm, > 5 cm
39
GCT clinical stage 3
supradiaphragmatic (including lungs) or visceral mets
40
tumor primary location and risk stratification in GCT
good and intermediate risk gonadal/retroperitoneal primary, poor risk is mediastinal or non-pulmonary visceral mets
41
AFP and risk stratification in GCT
good risk < 1000, intermediate risk 1000-10,000, poor risk > 10,000
42
HCG and risk stratification in GCT
good risk < 5000, intermediate risk, 5000-50,000, poor risk > 50,000
43
LDH and risk stratification in GCT
good risk > 1.5x nl, intermediate risk 1.5-10x nl, poor risk > 10x nl
44
good risk criteria
1. gonadal/retroperitoneal primary, 2. no non-pulmonary mets, 3. AFP < 1000, HCG < 5000, LDH > 1.5 x nl
45
intermediate risk criteria
1. gonadal/ retroperitoneal primary, 2. no non-pulm visceral mets, 3. AFP 1000-10,000, HCG - 5,000 - 50,000, LDH 1.5 x - 10x nl
46
poor risk criteria
any of the following: 1. mediastinal primary, 2. non-pulm visceral mets, 3. AFP > 10,000, HCG > 50,000, LDH > 10x nl
47
5 yr survival for good risk
90%
48
5 yr survival for intermediate risk
80%
49
5 yr survival for poor risk
50%
50
treatment for good risk
BEP x 3
51
when is BEP x 3 not given for good risk - 2
smoking hx and older pts
52
what to give instead of BEP x 3 in good risk
EP x 4
53
2 options for chemo in intermediate risk
BEP x 4 or BEP x 3 + EP x 1
54
poor risk chemo
BEP x 4 only
55
3 reasons for inguinal vs scrotal orchiectomy
1. lower chance of cutting into tumor by accident, 2. removal of lymphatics draining primary, 3. prevent aberrant lymphatic drainage if tumor is spilled
56
partial orchiectomy indications
1. contralateral abscent testis, 2. tumor < 2 cm, 3. polar tumor location
57
when to do adjuvant radiation in partial orchiectomy
if CIS present - done to reduced recurrence if done routinely
58
adjuvant tx post partial orchiectomy
20 gy to eradicate CIS
59
purpose of partial orchiectomy
maintains leydig cell function, not fertility
60
basics of stage 1, 2, 3 in staging system
1 - no evidence of mets, 2 - retroperitoneal mets, 3 - chest mets or disseminated mets
61
physical exam potion of clinical staging - what lymph nodes are palpated
cervical and axillary
62
what kind of visceral metastasis does not = poor prognosis
pulmonary
63
lymphatic drainage based on gonadal vein drainage - Left
left GV drains to L renal vein --> lymphatic drainage to left peri-aortic area
64
lymphatic drainage based on gonadal vein drainage - right
right GV drains to IVC --> lymphatic drainage to inter-aorta-caval region
65
2 main things setting apart seminoma from non seminoma on followup
seminoma does not have teratoma and seminoma is radiosensitive
66
incidence of occult retroperitoneal mets in seminoma
20%
67
2 equivelant mgmt options for CS 1 seminoma
abdominal EBRT for occult mets vs observation
68
% CS 1 patients with sem vs non-sem who will relapse due to micromets during observation
15% for sem vs 30% for non-sem
69
mgmt of seminoma who recur on observation
chemo with BEP x 3 or EP x 4
70
% of seminoma who will need chemo on observation for mets
20%
71
dose of retroperitoneal radiation for CS 1 seminoma
20 gy
72
how long do you watch patients with seminoma on surveillance
5 yrs
73
2 RF for retroperitoneal spread in seminoma
rete testis invasion and tumor > 4 cm
74
dog leg radiation for seminoma
not done
75
newer mgmt option for CS1 seminoma
carboplatin to all patients. still investigational
76
rationale for carboplatin in all CS1 seminoma
1. seminoma sensitive to carboplatin, 2. low morbidity, 3. and easy to administer
77
CS 2 seminoma substratification
> 5 cm (bulky) or < 5 cm (nonbulky)
78
location of mets and CS 2 seminoma
retroperitoneal only
79
non bulky cs2 seminoma treatment
radiation therapy (felt to be less morbid than chemo)
80
cure with radiation alone in nonbulky cs 2 seminoma
90%
81
mgmt of recurrence after radiation in nonbulky cs 2 seminoma
chemo
82
cure of radiation + chemo in nonbulky cs 2 seminoma
95-99%
83
bulky CS 2 sem mgmt
chemo - BEP x 3 (or EP x 4)
84
rationale for chemo in bulky CS 2 sem
high risk of occult micromets outside retroperitoneum with bulky disease. chemo is systemic
85
CS 3 sem mgmt
chemo - bep x 3 (or ep x 4)
86
cure rate with chemo in CS3 sem
95%
87
post chemo mass in seminoma - initial mgmt
observation with imaging as 85% chance of necrosis only
88
postchemo mass in pure sem- imaging?
do pet scan
89
pet scan agent for sem
FDG
90
role of PET scan in sem
can distinguish necrosis from active cancer (teratoma is not present in sem)
91
do we still resect post-chemo masses > 3 cm in pure sem
only if pet is positive
92
mgmt of + pet in sem
post chemo RPLND or high dose chemo
93
pet and NSGCT
not useful
94
why is pet useless in NSGCT
cant distinguish teratoma from necrosis. no teratoma in seminoma
95
postchemo mass in NSGCT - % necrosis
45%
96
postchemo mass in NSGCT - % teratoma
45%
97
postchemo mass in NSGCT - % active ca
10%
98
NSGCT CS1s mgmt
chemo
99
why chemo in CS1s NSGCT
ct scan negative and likly have disease beyond retroperitoneum
100
NSGCT - % with active cancer in cs1
30%
101
% relapse after RPLND in NSGCT
30%
102
NSGCT surveilance - % relapse
30%
103
3 benefits to RPLND in stage 1
1. stage retroperitoneum, 2. 50-75% pts cured, 3. less chemo
104
2 probs with RPLND in stage 1
1. 70% overtreated, 2. extra-retroperitoneal mets not treated and will need chemo
105
CS 1 s mgmt
systemic chemo
106
CS 1 s- why chemo
have systemic disease from persistently elevted markers and neg imaging
107
what sexual action is affected with non-nerve sparing rplnd
ejaculation only. orgasm and sensation are nl
108
ejaculation rate for full bilateral templace
0
109
ejaculation rate for modified nerve sparing
99%
110
left standard template
left peri-aortic region and left gonadal vein
111
right standard template
right peri-caval, interaortocaval and right gonadal
112
left modified template - medial border
interaortocaval LN above IMA
113
right modified template - medial border
left (contralateral) peri-aortic LN (above IMA)
114
why are modified templates based on IMA
below IMA can effect the nerves
115
chemo for NSGCT CS 1 at relapse
bep x 3 or ep x 4
116
% fertility after chemo
25-50%
117
cardiovascular side effect with chemo
7x OR + HTN
118
neuro side effect with chemo
numbness, tingling, reynauds
119
surveilance - pure seminoma recurrence mgmt vs nsgct recurrence mgmt
pure sem - chemo or rad and thats it, nsgct 30% who recur and get chemo will still need surgery
120
advantage of surveilance in CS 1 NSGCT
only those with spread will need treatment
121
disadvantage to surveilance in NSGCT
1/3 given chemo will need surgery when they recur
122
main reason to avoid chemo in nsgct
fertility, other reasons (nausea, immune status) less significant. also now evidece of late toxicity
123
CS 1 nonseminoma - primary chemo option
BEP x 2
124
pro/cons to chemo in CS1
good cure rate, however overtreatment in 70%
125
CS1 - % with micromets at rplnd who will relapse postop
30%
126
adjuvant chemo in rplnd in CS 1?
BEP x 2
127
problem with adjuvant chemo after primary rplnd in CS 1
only 30% will have micromets, 70% overtreated
128
CS 2 or 3 - initial mgmt in NSGCT
70% cured with chemo
129
% with residual mass in CS 2/3 nsgct
30%
130
mgmt of residual mass in post chemo stage 2/3 NSGCT
rplns because 55% have cancer or teratoma
131
retroperitoneal mass cutoff for RPLND vs primary chemo
> 5-6 cm treated with chemo because of high (50%)likelyhood of extra-retroperitoneal disease
132
< 5-6 cm retroperitoneal mass and surgery cure rate in CS 2
50-70% cured with surgery and can be primary treatment
133
each initial tx (chemo or rplnd) requires the other about x %
30%
134
postchemo rplnd template
always full bilateral template
135
postchemo rplnd for nonseminoma - mgmt if cancer is found
give 2 rounds adjuvant chemo
136
when does late relapse usually happen
2 yrs after initial sccessful mgmt
137
how does late relapse usu present
elevated afp
138
tx of late relapse
always surgery unless unresectable or multifocal disease
139
what is despiration surgery
rplnd with elevated markers post chemo
140
seminoma CS1s mgmt
radiation (20 gy to periaortic and ipsilateral iliac) or single agent carboplatin
141
what differentiates stage 1a from 1b in TNM for Sem and Non-Sem
1B is confined to testicle with LVI or tunica vaginalis involvement
142
mgmt of nsgct stage 2a with S1 vs S0
S1 gets chemo (BEP x 3 or EP x 4), S0 has option for RPLND, chemo (BEP x 3 or EP x 4), or surveillance if highly motivated
143
Most common presentation of testes ca.
localized seminoma
144
Most common age range at presentation
20-35 y.o.
145
Risk factors for testes cancer
Cryptorchidism
Family or personal hx of testes cancer
Intra-tubular germ cell neoplasia
146
Must perform orchiopexy before ____ to decrease testicular cancer rates
puberty
147
Seminomas often have ____ that produce bHCG
synctiotrophoblasts
148
Choriocarcinoma
VERY HIGH ____
Spreads via ____
Hemorrhagic ____ mets
v high bHCG
Hematogenous spread
hemorrhagic brain mets
149
____ tumors are chemo/rads resistant
Teratoma
150
____ tumors are most commonly in pre-pubertal children
Yolk Sac
151
Imaging study for testicular mass
scrotal u/s
152
Tumor markers should be followed up ____ s/p orchiectomy
4-5 weeks
153
Staging imaging
CT abd/pelvis
CXR (low risk) vs CT chest
154
Tumor confined to testes + epididymis w/o LVI
p___
pT1
155
Tumor confined to testes + epididymis w LVI OR tunica vaginalis invasion
p___
pT2
156
Tumor invading spermatic cord
p___
pT3
157
Tumor invading scrotum
p___
pT4
158
Nodal disease
*only applies to RP nodes*
N1 - ___ cm
N1 - <2cm
N2 - 2-5 cm
N3 - >5 cm
159
Seminoma with <3cm Tumor confined to testes + epididymis w/o LVI
p___
T1a
160
Seminoma with >3cm Tumor confined to testes + epididymis w/o LVI
p___
T1b
161
Seminoma confined to testes is always clinical stage ____
T1
T1a - pT1
T1b - pT2-4
162
Seminoma with RP nodal mets & S0-1 is clinical stage ___
T2
T2a - cN1
T2b - cN2
T2c - cN3
163
Seminoma with distant mets is clinical stage ___
T3
T3a - S1
T3b - S2
T3c - S3
164
Half life of AFP
5-7 days
165
AFP is NEVER elevated in ____
seminoma
166
Half life of bHCG
24-36h
167
Half life of LDH
24 hrs
168
Yolk sac has elevated ___ tumor marker
AFP
169
Seminoma - localized or with pulmonary mets
____ risk disease
Good
170
Seminoma with non-pulmonary mets
____ risk disease
Intermediate
171
Non-seminoma with S1 tumor markers
____ risk disease
Good
172
Non-seminoma with S2 tumor markers
____ risk disease
Intermediate
173
Non-seminoma with S3 tumor markers OR mediastinal primary OR non-pulmonary mets
____ risk disease
Poor
174
Right testes tumors spread to ____ LNs
inter-aortocaval
175
Left testes tumors spread to ____ LNs
Para-aortic
176
ITCGN ___% develop testes cancer
50
177
ITCGN Treatment
Surveillance
Orchiectomy (100% cure)
XRT (100% cure)
Chemo (66% cure)
178
Relapse rates for seminoma
Surveillance only - ___%
1 round of Carboplatin - ___%
Surveil - 14%
Chemo - 4%
179
Median time to relapse for seminoma s/p orchiectomy
1.5 years
180
Strongest risk factors for non-seminoma relapse
LVI
| Embryonal tumors
181
Relapse rates for seminoma (without risk factors)
Surveillance only - ___%
BEP x1 - ___%
15%
1%
182
Relapse rates for seminoma (with risk factors)
Surveillance only - ___%
BEP x1 - ___%
40%
3%
183
Treatment if node + at time of primary RPLND
N1 - ____
N2 - ____
N3 - ____
N1 - surveillance
N2 - EPx2 or BEPx2
N3 - BEPx3 or EPx4
184
To preserve antegrade ejaculation after RPLND, spare ___ nerves
L1-L3 post-ganglionic sympathetic nerves
**behind the IVC**
185
Bleomycin adverse effects
pulmonary toxicity
186
Which stages of non-seminoma do you offer primary RPLND?
Stage IIA/B
* do not perform with elevated tumor markers*
* potential reduces chemo burden*
187
Which stages of seminoma can you offer RT?
Stage IIA/B - nodal positive disease, 2-5 cm
188
Must wait at least ____ s/p chemo to perform PET CT
6 weeks
189
Seminoma s/p chemo
Next step if no mass or <3cm mass - ____
Surveillance
190
Seminoma s/p chemo
Next step if >3cm mass - ____
PET CT
- Negative - surveillance
- Positive - resection
191
Seminoma s/p chemo
Next step if tumor growth or tumor marker elevation - ____
2nd line chemo
| TIP/VeIP
192
Non-seminoma s/p chemo
Next step if no mass or <1cm mass with normal tumor markers - ____
Surveillance or RPLND
193
Non-seminoma s/p chemo
Next step if >1cm mass with normal tumor markers - ____
post-chemo RPLND
194
Non-seminoma s/p chemo
Next step if persistent elevated tumor markers - ____
2nd line chemo
| TIP/VeIP
195
Long term risks of chemo for testes ca patients
Cardiovascular disease
2ndary cancers
196
Management of post-chemo distant mets
resect if possible
197
Offer all patient ____ prior to treatment to maintain fertility
sperm banking
198
Treatment after trans-scrotal orchiectomy
Observe vs excise scar vs RT
199
pTX
Primary tumour can not be assessed
200
pT0
No evidence of primary tumour
201
pTIS
Intratubular germ cell neoplasia (carcinoma in situ)
202
pT1
Tumour limited to testis and epididymis without vascular/lymphatic invasion. Tumour may invade tunica albuginea but not tunica vaginalis
203
pT2
Tumour limited to testis and epididymis with vascular/lymphatic invasion, or tumour extending through tunica albuginea with involvement of tunica vaginalis
204
pT3
Tumour invades spermatic cord with or without vascular/lymphatic invasion
205
pT4
Tumour invades scrotum with or without vascular/lymphatic invasion
206
NX
Regional lymph nodes cannot be assessed
207
N0
No regional lymph node metastasis
208
N1
Metastasis with a lymp node mass 2 cm or less in greatest dimension or multiple lymph nodes, none more than 2 cm in greatest dimension
209
N2
Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension; or more than 5 nodes positive, none more than 5 cm; or evidence of extranodal extension of tumour
210
N3
Metastasis with a lymph node mass more than 5 cm in greatest dimension
211
MX
Distant metastasis cannot be assessed
212
M0
No distant metastasis
213
M1
Distant metastasis
214
M1a
Non-regional lymph node(s) or lung metastasis
215
M1b
Distant metastasis other than non-regional lymph nodes and lung metastasis
216
SX
Serum marker studies not available or not performed
217
S0
Serum marker study levels within normal limits
218
S1
```
LDH <1,5xN
and
hCG < 5 000
and
AFP < 1 000
```
219
S2
```
LDH 1,5-10xN
or
hCG 5 000-50 000
or
AFP 1 000-10 000
```
220
S3
```
LDH >10xN
or
hCG >50 000
or
AFP >10 000
```
221
following adult male germ cell tumor (GCT) subtypes arise from germ cell neoplasia in situ (GCNIS)
a. embryonal tumor. b. choriocarcinoma. c. classic seminoma. e. teratoma.
