Testicular Flashcards by jaymin patel

Most common risk factor for testicular cancer?

cryptorchidism

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What is recommended prophylaxis for cryptorchidism?

orchiectomy, esp when intra-abdominal

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Relative risk of testicular cancer in 1st degree relatives

increases 6-10 fold

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What is intratubular germ cell neoplasia?

carcinoma in situ, risk of progression is 50% at 5 years if untreated

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Less common risk factors for testicular cancer?

Hypospadias
HIV (seminomas)
Testicular microlithiasis
Klinefelter &amp; Down syndromes
exposure to exogenous estrogens in utero
peutz-Jegher syndrome and Carney complex (Sertoli cell)

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Common presentation for testicular cancer?

painless mass, heavy sensation in lower abd or perianal region

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What are the types of testicular tumors?

Germ cell (95%)
sex cord tumors
lymphoma, leukemia and plasmacytoma

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What are two types of germ cell tumors?

Seminoma and nonseminomas

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What is the most prevalent and specific cytogenetic abnormality in testicular cancer?

gain of 12p sequences; commonly i12p

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What are key histologic and serum characteristics of the different germ cell tumor subtypes?

Seminoma (pure) - AFP normal; bHCG: normal to mildly elevated; i12p (50%) “min b oma)
Spermatocystic seminoma: i12p (0%)
NSGCTs: i12p (80%)
-Embryonal: AFP & bHCG normal to mildly elevated “um bro could be both”
-Choriocarcinoma: AFP normal, bHCG > 1000 IU/L “human ““chorionic”” gonadotropin “
-Yolk sac: AFP > 100; bHCG normal “fetal yolk”
-Teratoma

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What are key serum tumor markers (STMs) and how are they broken up into mild, mod & high risk? What is their half-life

AFP (4-5 days) [ 10,000] “A is a 10 f partner”

b-HCG (18-36 hours) [ 50,000 “beta is two human butt cheegs”

LDH () [10x ULN) “L is 1.5 pieces of wood”

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Staging summary for testicular cancer?

Stage I: tumor only
Stage II: regional node involvement & mild STMs
Stage III: metastatic or high STMs
- IIIA: nonregional lymph nodes, pulm mets and/or mild STMs
- IIIB: nonregional lymph nodes, pulm mets and/or mod STMs
- IIIC: non pulm mets or marked STMs

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What are prognostic catergories for Seminoma?

No Poor

Good: non pulmonary visceral mets; I-IIIB
Int: non pulmonary visceral mets: IIIC

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What are prognositic catergories for NSGCT?

Good: I-IIIA
Int: IIIB
Poor: IIIC

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What is likelihood of cure in Stage I seminoma?

close to 100%

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What is criticial question when determining adjuvant therapy following resection for Stage I seminoma>

Is the patient compliant? - relapse rate of 15-20%; down to 5% if given chemo (carbo AUC 7 1-2 cycles or RT (20-25 Gy, PA-strip)

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What adjuvant therapy for Stage I Seminoma is preferred but withheld usually?

RT, due to secondary malignancies, 18.2% cumulative risk at 25 years; (PA-strip preffered field over hockey-stick and dog-leg)

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What is advantage of single dose of carbo (AUC 7) over RT for Stage I seminoma?

Less incidence of new contralateral GCT (0.2% vs 1.2%) 80% risk reduction

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What is relapse rate for Stage I Non-seminoma? How many are upstaged to Stage II following RPLND

30%

Late recurrences for testicular cancer are common with and uncommon with?

common in seminoma and uncommon in non-seminoma

What are two important factors in Stage I Non-seminoma that predict for relapse and favor adjuvant intervention?

presence of LVI (lymphovascular invasion) * (strongest)

embryonal component predominant

What imaging modality is not recommended for NSGCTs

PET-CT

What is recommended for adjuvant therapy in high risk Stage I Non-seminoma?

RPLND (preferred in US, avoid chemo toxicity, advantage of upstaging) versus chemo (BEP x 1-2, preferred in Europe due to low relapse rate of

Key question for Stage I Non-seminoma s/p RPLND?

Compliance; if yes surveillance; if no BEP x 2 for pN1 or pN2 disease and BEP x3-4 for pN3 disease

Most common complication of nerve sparing RPLND?

infertility due to retrograde ejaculation

Post-orchiectomy adjuvant therapy for Stage I Non-seminoma with positive STMs?

BEP x 3 or EP x 4

What does Stage II germ cell tumor imply and how is therapy different from Stage I?

Retroperitoneal node involvement; surveillance is not an option

What is recommended for adjuvant therapy in Stage II seminoma?

IIA: RT (30-35Gy - preffered), or chemo IIB: Chemo (BEP x 3 - preffered) or RT IIC: Chemo only (BEP x 3, or EP x 4)

Only situation where single agent carboplatin (AUC 7) is an option?

Stage I Seminoma

What regimen did BEP replace? Advantage

PVB; not as good in bulky disease and the vinblastine can result in considerable neuromuscular toxicity

BEP 3 versus 4 cycles

4 cycles is reserved for Seminoma Int risk and Non-Seminoma Int or Poor risk.; 3 is good for good risk, good?

What determines choice between BEP and EP?

Pulmonary function (older); or atheletes

Rule of thumb for residual masses in testicular germ cell tumors?

NSGCTs: always resect Seminoma: resect based on size criteria of > 3; if well delineated or positive PET after 6 weeks (preferred method)

What is recommended for adjuvant therapy in STM negative Stage II Non-seminoma post-orchiectomy?

* similar to seminoma except RPLND replaces RT IIA: RPLND or chemo IIB: Chemo (BEP x 3 - preffered) or RPLND IIC: Chemo only (BEP x 3, or EP x 4)

For Stage IIA STM negative Non Seminoma; s/p adjuvant RPLND; if residual disease is present, what determines adjuvant plan?

Node status: - pN1: surviellance - pN2: BEP or EP x2 over surviellance - PN3: BEP x 3 or EP x 4

For Stage IIC STM negative Non Seminoma; s/p adjuvant chemo; if residual disease is present, what determines adjuvant plan?

residual mass > 1 cm: RPLND | if

For Stage II STM positive Non Seminoma what is adjuvant recommendation?

BEP x3 or EP x 4

Why do some providers recommend RPLND after chemotherapy for Stage II or III NSGCTs regardless of response?

Growing teratoma syndrome (teratoma's are relatively resistent to chemotherapy): presents with clinical discordance, dropping STMs and stable or increasing mass

For post-chemo NSGCTs patients with positive STMs or residual mass with viable tumor (not fibrosis or teratoma), what is given?

``` 2 cycles of: EP, VIP (etop/ ifos/ cis), VeIP (vinblas/ ifos/ cis), TIP (paclitaxel/ ifos/ cis) ```

For Stage III disease what regimen shows similar efficacy to BEP x 4 cycles but increased hematologic and GU toxicity? In what scenario is this regimen preffered?

VIP | -lung disease

What non-invasive method can help differentiate teratoma from fibrosis?

None; only through surgical resection with path analysis

What is strongest predictor of fibrosis for residual pulmonary disease in Stage III NSGCTs?

necrosis in retroperitoneum on RPLND prior to thoractomy (89% of cases on retrosepctive multicenter study of 215 patients)

For GCTs that relapse within 4 weeks of receiving a cisplatin based therapy or during therapy are classified as? What are there options then? What is 2 years out?

platinum refractory or absolutely refractory - GEMOX based or HDCT platinum resistant - paclitaxel or ifosfamide based

Extragonadal seminomas have what prognosis and are managed how?

Prognosis similar to gonadal primaries and managed similarly.

Extragondal germ cell turmor are usually what subtype?

non-seminoma; pure seminoma is extremely rare

Extragonadal non-seminoma have what prognosis and are managed how?

worse than gonadal counterparts; mediastinal are worst, automatically poor prognosis despite marker and disease burden

What malignancy is reported with mediastinal non-seminomas?

leukemia, esp megakaryocytic lineage