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FRCR2 > Testicular > Flashcards

Testicular Flashcards

1
Q

How are testicular tumours classified

A

Germ cell (50% seminoma and 50% non-seminomatous)
Sex cord stromal cancers

95% of testicular tumours are germ cells (seminoma vs non-seminoma GCT)
5% are sex cord stromal cancers (Lydia & Sertoli)

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2
Q

What types of non-seminomatous germ cell tumour are there
And where do they arise from

A

Yolk sac, teratoma, chorocarcinoma
Sertoli/Leydig cell
Embryonal

95% are testicular
5% are extra-gonadal (typically midline - retroperitoneum, mediastinum, cerebrum)

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3
Q

What is the risk of future contralateral testicular cancer, if previous testicular cancer

A

5% increased risk of contralateral disease

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4
Q

What risk factors are there for testicular cancer

A

Previous testicular cancer - 5% increased risk
FHx - brother = x10, father = x4
Subnormal testicular development - maldescent, Down’s, Klinefelters
Unilateral maldescent = 5-10x increased risk; bilateral maldescent = 1 in 44)
Intra-tubular germ cell neoplasia (Like CIS: 50% risk at 5yrs)
Testicular atrophy or small volume (<12mls)

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5
Q

What is the typical age range for development of testicular cancer

A

25-35yrs
>60yrs - more likely to be lymphoma

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6
Q

What tumour marker is raised in seminoma

A

bHCG (in 10-20%)

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7
Q

What tumour marker is not elevated in seminoma

A

AFP

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8
Q

What tumour markers are raised in non-seminomatous germ cell tumours

A

bHCG (in 35%) & AFP

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9
Q

What is raised in choriocarcinoma

A

bHCG - very high

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10
Q

Where is the lymphatic spread for testicular tumours

A

R - interaortocaval nodes
L - para-aortic nodes

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11
Q

How should a new testicular tumour be investigated

A

Examination of testes and breast tissue
Bloods - bHCG, AFP, LDH
USS testes
CTCAP, MRI brain
Biopsy (orchidectomy) - note mediastinal primary alone is a poor prognostic marker
consider biopsy of contralateral testis if risk factors (volume <15ml) to exclude ITGCN

Treatment related
Fertility - sperm banking
EDTA (renal function), lung function (bleomycin), audiometry (cisplatin)

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12
Q

What is the first step in management of a testicular cancer, assuming no visceral mets

A

Orchiectomy and recheck serum markers

Residual retroperitoneal lesions >1cm should be resected by post-chemo RPLND to establish if necrotic or viable tumour is present, and to remove any mature teratoma

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13
Q

How does the presence of visceral mets / decompensation at presentation influence initial management of a testicular cancer

A

Start with chemo and delay orchiectomy

Residual retroperitoneal lesions >1cm should be resected by post-chemo RPLND to establish if necrotic or viable tumour is present, and to remove any mature teratoma

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14
Q

What is the management of ITGCN if found at biopsy of the contralateral testis (present in 5%)
What proportion progress to malignancy
What are the risks
what is the follow up

A

RT: 20Gy in 10#
50-100% will progress

Risks: Infertility and need for testosterone replacement

Follow up - annual ultrasound

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15
Q

What is the management of a stage 1 seminoma

How are the risks stratified for stage 1

A

80% are found at stage one (T1-2 N0 - involvement of tunica albuginea or vaginalis, +/- lymph vascular invasion, no nodes or distant mets)

Orchidectomy has 95% cure rate, so priority is to minimise toxicity

Risk is stratified by size (> 4cm or not) and presence of invasion into the Rete testis

Post orchidectomy, tumour size <4cm and no rete testis involvement: surveillance only
Tumour markers 3/12 for first year
Year 1 -> 3-6 monthly CT, then annual scanning

If >4cm or rete testis involvement - requires adjuvant treatment

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16
Q

What is the adjuvant treatment for a high risk stage 1 seminoma (or pt unwilling to undergo surveillance)

A

Single cycle carboplatin at AUC7
reduces risk of relapse to approx 1%, which tends to be para-aortic

Radiotherapy if carboplatin not suitable:
20Gy/10#
Either para-aortic strip (T11- L5 inclusive, laterally to transverse processes of vertebrae (4-4.5cm)
Include left renal hilum in L testicular tumour

Or dog-leg field (T11 - mid-obturator foramen) if previous inguinal surgery, orchidopexy, herniorrhaphy, RP trauma

17
Q

What adjuvant treatment is needed for a spermatocytic seminoma

A

None - low risk

18
Q

What is the treatment for a relapsed stage one seminoma

A

If prev surveillance - give one cycle carboplatin + PA RT, or 4 cycles BEP

If prev carboplatin & good prognosis: 3x BEP
If prev carboplatin and int prognosis: 4x BEP / VIP

19
Q

How is a stage 2A seminoma defined

What is the treatment

A

stage 2 = node positive
2A = T1-4 N1 - <5 positive nodes & all ≤2cm

Treatment options:
Orchiectomy and either adjuvant chemo or RT
3x BEP or 4x EP
OR dog leg RT - 30Gy/15# (para-aortic and ipsilateral iliac LNs) +/- single cycle carboplatin

20
Q

How is a stage 2B seminoma defined

What is the treatment

A

stage 2 = node positive
2B = T1-4 N2 - >5 positive nodes or 2-5cm or ECE

Treatment options:
BEP x3 or EP x4
OR dogleg RT 36Gy/18# OR 30Gy/15# with single cycle carboplatin ahead of RT

21
Q

How is a stage 2C seminoma defined

What is the treatment

A

stage 2 = node positive
2C = T1-4 N3 - >5 positive nodes & any 5cm

Treatment options:
BEP x3 or EP x4
RT not recommended

22
Q

When is scrotal irradiation indicated

A

Extensive tumour in spermatic cord or had scrotal violation during surgery

23
Q

What is the management of a stage 3 seminoma
How is it stratified

A

Split according to prognosis (good and intermediate, no poor prognosis group for seminoma)

If good prognosis: 3x BEP or 4xEP

If intermediate prognosis: 4x BEP, or 4x VIP

24
Q

What is the management of a stage 1 NSGCT
How is it stratified

A

Orchiectomy

LVI- - surveillance (or 1x BEP if not suitable)
LVI+ - 1x BEP

25
Q

What is the management of a stage 2 NSGCT

A

Node positive
Split by marker positive or negative

If S0 (marker negative) - Orchiectomy followed by surveillance

If S1 (marker positive) - 3x BEP if good prognosis, and 4x BEP if int/poor prognosis

26
Q

What is the management of a stage 3 NSGCT

A

Good prognosis - 3x BEP

Int/poor prognosis - 4x BEP

27
Q

When is radiotherapy indicated for testicular tumours

A

Seminoma:
Adjuvant for high risk stage 1 & carboplatin not suitable - 20Gy/10# - para-aortic strip or dog-leg field
Option for a relapsed stage 1 seminoma
Stage 2A-B seminoma if not receiving BEP - dog leg RT - 30Gy/15# (para-aortic and ipsilateral iliac LNs) +/- single cycle carboplatin

NSGCT - not indicated

28
Q

What investigation is not useful after relapse of a NSGCT

A

PET CT

FRCR2 (28 decks)

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