Testicular Cancer

Question 1

How many cases occur every year, and how many deaths?

Answer 1

9,500 cases
400 deaths

Question 2

Risk factors for testicular cancer

Answer 2

-GCNIS
-Hx UDT (RR 6x, but falls to 3x if pexied before puberty)
-FMHx
-Personal Hx

Question 3

Most undifferentiated type of testicular cancer

Answer 3

embryonal - can become any other type of testicular cancer

Question 4

Which conditions elevate AFP?

Answer 4

Yolk sac or Embryonal testis cancer
Cancers - stomach, panc, biliary, liver, lung
Liver disease, ataxia telangectasia

Question 5

Half life of AFP

Answer 5

5 days (A-five-P)

Question 6

Management of AFP (general rules)

Answer 6

Stable levels <25 can be monitored

Question 7

Causes for elevated HCG

Answer 7

Choriocarcinoma, embryonal testis cancers
Some seminomas
Cancers - liver, biliary, panc, stomach, lung, breast, kidney, bladder
Pituitary masses

Question 8

HCG half life

Answer 8

24 hrs

Question 9

Testicular cancer Staging

Answer 9

0 - pTIS N0 M0 S0
1- pT1-4 N0 M0 SX
1A - pT1 N0 M0 S0
1B - pT2-T4 N0 M0 S0
IS - any pT N0 M0 S1-3
II - N1-3
IIA - any pT N1 M0 S0/1
IIB - any pT N2 M0 S0/1
IIC - any pT N3 M0 S0/1
III - M1
IIIA - M1a S0/1
IIIB - M0/1a with S2
IIIC - M0/1a with S3 OR M1B any S

Question 10

S staging

Answer 10

S0 - normal
S1 - LDH <1.x5 ULN or bHCG <5000 or AFP <1000
S2 - LDH 1.5-10x or bHCG 5k-50k or AGP 1k-10k
S3 - LDH >10x or HCG >50k or AFP >10k

Question 11

Early management of testis mass

Answer 11

Assume cancer until proven otherwise
Draw tumor markers
Scrotal US - repeat in 6 weeks if equivocal
Counsel about hypogonadism and infertility and offer banking
Unilateral orch
Offer prosthesis

Question 12

How many patients will recover sperm production after cisplatin?

Answer 12

50% at 2 years, 80% at 5 years

Question 13

Management of microlithiasis

Answer 13

Nothing unless risk factors or mass

Question 14

When should testis sparing surgery be offered?

Answer 14

mass <2cm, equivocal US, neg markers, solitary testis, bilateral masses
Counsel VERY carefully
Be sure to take multiple biopsies of ipsilateral testicle

Question 15

What is the risk of contralateral testicular cancer or GCNIS?

Answer 15

2%

Question 16

Management of GCNIS after TSS

Answer 16

Observation
Testicular radiation (18-20Gy)
NOT chemo

Question 17

Management after orch

Answer 17

Expert path review
Repeat markers, trend if <3x ULN
Only wait for nadir if it would change treatment
CT with IV contrast
Chest imaging (CT if high risk or NSGCT, CXR if CS1 sem)
Manage only with markers within 10 days and imaging within 4 weeks

Question 18

Non-sem IGCC risk stratification

Answer 18

good prognosis (92% 5 year survival)
-Testis/RP primary
-No non-pulm visceral mets
-Good markers (S1)

intermediate prognosis (80% 5 year survival)
-Testis/RP primary
-No non-pulm visceral mets
-S2 markers

Poor prognosis (48% 5 year survival)
-mediastinal primary OR
-non-pulmonary visceral mets OR
-S3 markers

Question 19

Sem IGCCC classification

Answer 19

Good (86% 5 year survival)
-Any primary
-No non-pulm visceral mets
-Normal AFP

Intermediate (72% 5 year survival)
-Non-pulm visceral mets

Question 20

Management of CS1 sem

Answer 20

Surveillance
(Radiotherapy)
(Carboplatin)

Question 21

CSIIA/IIB sem

Answer 21

LN <3cm - BEPx3 or EPx4, RT (30Gy dogleg), (RPLND)
LN >3cm - chemotherapy

Question 22

Management of IA NSGCT

Answer 22

Surveillance
(BEPx1)
(RPLND)

Question 23

Management of IB NSGCT

Answer 23

Surveillance
RPLND
BEPx1-2

Question 24

Management of CSI NSGCT and secondary somatic malignancy (teratoma) in the primary specimen

Answer 24

RPLND

Question 25

Management of CSIIA NSGCT

Answer 25

Normal markers - RPLND or BEPx3 or EPx4

Question 26

Management of IIB NSGCT

Answer 26

Normal markers - BEPx3 or EPx4 or (RPLND)

Question 27

RLPND nuances

Answer 27

Send to expert MIS RPLND is ok Bilateral if suspicious imaging Nerve sparing should be offered but should not compromise LND Complete retroaortic and/or retrocaval with lumbar division is important Remove ipsilateral gonadal veins Go to the crus of the diaphragm Go down to crossing of ureter to common iliac

Question 28

Post RPLND management

Answer 28

N1-3 teratoma or N1 - surveillance N2-3 - BEPx2

Question 29

Relapse rate for CSI seminoma with observation

Answer 29

13-19%

Question 30

CSI seminoma surveillance regimen

Answer 30

H&P q6months for 5 years Imaging every 5 months for 5 years Can forego routine surveillance after 5 years HCG only if preop HCG elevated No chest imaging necessary

Question 31

CSI NSGCT surveillance

Answer 31

Exam and markers and imaging q3mo for a year Exam and makers and imaging q4mo for a year Exam and markers q6months for a year Exam and markers q12 months for 2 years Imaging annually after second year

Question 32

Risk of late relapse after 5 years for CSI nSGCT

Answer 32

1%

Question 33

Survivorship for testicular cancer

Answer 33

Hypogonadism Fertility CV risk Secondary malignancy

Question 34

Management of post-chemo RP masses for sem

Answer 34

<3cm - surveillance >3cm - PET, resect or chemo

Question 35

How does testicular cancer spread?

Answer 35

Chorio - blood Others lymphatic through RP --> cisterna chyli --> thoracic duct

Question 36

Side effects of BEP

Answer 36

Bleo - pulm toxicity Etoposide - myelosuppression Cisplatin - renal toxicity

Question 37

Causes for elevated AFP

Answer 37

hepatitis, cirrhosis Yolk sac, embryonal, teratoma

Question 38

Causes for elevated HCG