Testicular Cancer Flashcards by Mario Luna

Testicular cancer

Testicular cancer is the most common malignancy among young men in North America and most Western European Countries.

TRUE or FALSE?

True.

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Testicular cancer

More than 95% of testicular cancers are germcell tumors.

TRUE or FALSE?

True.

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Testicular cancer

Which is more common? seminoma or nonseminoma?

they are almost equally distributed with a slight predominance of seminoma.

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Testicular cancer

Which type occurs in younger population?

nonseminomas

Seminomas are most commonly diagnosed between the ages of 30 and 34 years, whereas
nonseminomas are usually diagnosed 5 to 10 years earlier

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Testicular cancer

Which type is the most common in the elderly? (>60 y)

lymphoma

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Testicular cancer

Risk factors for developing testicular cancer

undescended testes (or history of)
infertility
exogenous hormonal disruptors
family history

-cannabis and muscle-building supplements *needs further validation

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Testicular cancer

Undescended testicle is a risk factor for developing testicular cancer.

There is also an increased risk in the undescended testicle.

TRUE or FALSE?

True

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Testicular cancer

Undescended testicle is a risk factor for developing testicular cancer.

Orchidopexy during the
prepubertal phase would be expected to reduce the risk of testicular cancer and is expected to approximate that of the general population.

TRUE or FALSE?

False.

orchidopexy during the
prepubertal phase would be expected to reduce the risk of testicular cancer.
However, the relative risk of developing testicular cancer remains higher than in
the general population even after early orchidopexy

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Testicular cancer

Undescended testicle is a risk factor for developing testicular cancer.

Differentiate the uterine theory from the position theory.

It is hypothesized that a common
etiologic agent predisposes both to testicular maldescent and subsequent
malignancy (uterine theory).

Nevertheless, it is also possible that the
maldescended testicle is subject to a hostile and malignancy-inducing
environment (position theory).

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Testicular cancer
Pathology

WHO divides germ cell tumors into two groups.
What are these?

GCNIS derived

Unrelated to GCNIS

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Testicular cancer
Pathology

Name some GCNIS derived tumors.

Germ cell neoplasia in situ
Seminoma
Seminoma with syncytiotrophoblast cells
Nonseminomatous germ cell tumors
Embryonal carcinoma
Yolk sac tumor, postpubertal type
Teratoma, postpubertal type
Teratoma with somatic-type malignancy
Trophoblastic tumors
Mixed germ cell tumors
Regressed germ cell tumor

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Testicular cancer
Pathology

Name some GCNIS unrelated tumors.

-Spermatocytic tumor
-Yolk sac tumor, prepubertal type
-Teratoma, prepubertal type
-Mixed teratoma and yolk sac tumor, prepubertal type
-Sex Cord–Stromal Tumors
(Leydig cell tumor
-Sertoli cell tumor
-Granulosa cell tumor
-Tumors in the fibroma–thecoma group
-Mixed sex cord–stromal tumor
-Unclassified sex cord–stromal -group
-Gonadoblastoma)

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Testicular cancer
Pathology

What serum marker is NOT elevated in pure seminoma?

AFP

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Testicular cancer
Pathology

Staining reaction of pure seminoma to PLAP?

+ in >90%

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Testicular cancer
Pathology

What is the most common component in mixed NSGCTs?

Embryonal carcinoma

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Testicular cancer
Pathology

What is the least common type of pure NSGCT and is present in about 4% of mixed tumors?

It is particularly
aggressive, almost always metastatic at diagnosis, often to brain, and is
associated with high levels of HCG.

trophoblastic tumors (choriocarcinoma)

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Testicular cancer
Pathology

What tumor unrelated to GCNIS tends to occur in an older age group, is confined to the testes, and is almost always cured by orchiectomy alone with rare metastasis?

It does not contain glycogen, stains negative for PLAP.

It has a unique amplification on chromosome 9 and is not associated with other germ cell tumors.

Spermatocytic tumor.

Previously known as spermatocytic seminoma, the spermatocytic tumor accounts for 2% of testicular tumors.
It tends to occur in an older age group at a mean age of 54 years.
The new nomenclature better differentiates this from seminoma, which reflects its different origin and natural history.
Spermatocytic tumor is confined to the testes, is not associated with elevated HCG levels, and is almost always cured by orchiectomy alone.
Bilaterality occurs in 10%, and metastasis is rare.
The cell of origin of the spermatocytic tumor is probably the postpubertal mature spermatogonia that acquires abnormal proliferative capacity.
Spermatocytic tumor does not contain glycogen, stains negative for PLAP and is not associated with GCNIS.
It has a unique amplification on chromosome 9 and is not associated with other germ cell tumors.

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Testicular Cancer
Natural History

What sided tumors usually have a propensity to have contralateral spread?

Right-sided

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Testicular Cancer
Natural History

Where is the primary lymphatic drainage of testicular tumors?

retroperitoneal lymph nodes

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Testicular Cancer
Natural History

Left SCF is more commonly involved than right SCF.

TRUE or FALSE?

True.

From the retroperitoneal nodes, the lymph drains into the cisterna chyli,
thoracic duct, posterior mediastinum, and left supraclavicular fossa. The thoracic
duct drains into the left subclavian vein in the left supraclavicular region. In 5%
to 10% of patients, drainage into the right supraclavicular area can occur.

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Testicular Cancer
Natural History

What anatomic variant/involvement will result in involvement of pelvic/iliac/inguinal nodes?

involvement of tunica vaginalis or scrotum

hernia repair (it alters the drainage as well)

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Testicular Cancer
Natural History

Most common site of distant metastases in NSGCT?

Lungs

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Testicular Cancer
Workup and Staging

Brain MRI is done when symptoms are present, except in what histology/subtype where it is part of routine diagnostic procedures?

choriocarcioma

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Testicular Cancer
Workup and Staging

What are the ultrasound findings suggestive of malignancy?

solid intratesticular mass with internal vasculature

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Testicular Cancer Workup and Staging When to do contralateral testicular biopsy?

suspicion of GCNIS <30 years old and atrophic contralateral testis (30% risk)

Testicular Cancer Prognostic Factors What is an adverse prognostic factors for all stages of testicular cancer?

increased age

Testicular Cancer Prognostic Factors What is the most common predictor of recurrence for stage I seminoma?

rete testis invasion | >4 cm (T)

Testicular Cancer Prognostic Factors What are the prognostic factors for NSGCTs?

extensive embryonal component LVSI

Testicular Cancer Staging (AJCC) T Tumor limited to the testis and epididymis, + LVSI

Testicular Cancer Staging (AJCC) T involvement of the tunica vaginalis

T2 "two"nica vaginalis

Testicular Cancer Staging (AJCC) T Tumor limited to the testis and epididymis, no LVSI

Testicular Cancer Staging (AJCC) T Intratubular

Tis

Testicular Cancer Staging (AJCC) T +scrotum

T4 scro4um

Testicular Cancer Staging (AJCC) T +spermatic cord

3 Sperma"three"c cord

Testicular Cancer Staging (AJCC) N1

≤2 cm

Testicular Cancer Staging (AJCC) N2

2-5 cm

Testicular Cancer Staging (AJCC) N3

>5 cm

Testicular Cancer Staging (AJCC) M1a

Non regional node or pulmonary metastasis

Testicular Cancer Staging (AJCC) M1b

non pulmonary visceral metastasis

Testicular Cancer Staging (AJCC) S0

normal serum markers

Testicular Cancer Staging (AJCC) S1

LDH <1.5 x N HCG <5k AFP <1k

Testicular Cancer Staging (AJCC) S2

LDH 1.5 to 10 x N HCG <50,000k AFP <10,000k and more than S1

Testicular Cancer Staging (AJCC) S3

LDH >10 x N HCG >50,000 AFP >10,000k

Testicular Cancer Staging (AJCC) What stage T1, N0, M0 S0

IA (IB if T2) (IS if S-1-3) as long as N0, M0,

Testicular Cancer Staging (AJCC) What stage T1, N1, M0 S0/1

IIA all N+, with any T, but M0 and S0/1 are stage II. N1 = IIA N2 = IIB N3 = IIC

Testicular Cancer Staging (AJCC) What stage T4, N2, M0 S0/1

IIB all N+, with any T, but M0 and S0/1 are stage II. N1 = IIA N2 = IIB N3 = IIC

Testicular Cancer Staging (AJCC) What stage T3, N3, M0 S0/1

IIC all N+, with any T, but M0 and S0/1 are stage II. N1 = IIA N2 = IIB N3 = IIC

Testicular Cancer Staging (AJCC) What stage Any T, Any N, M1a?

IIIA or B. | A for S0/1 (B for S2)

Testicular Cancer Staging (AJCC) What stage Any T, Any N, M1b

IIIC

Testicular Cancer IGCCCG prognostic grouping NSGCT good prognosis?

*all Testis/retroperitoneal primary No non pulmonary visceral metastases Serum markers - S1

Testicular Cancer IGCCCG prognostic grouping NSGCT intermediate prognosis?

*all Testis/retroperitoneal primary No non pulmonary visceral metastases Serum markers - S2

Testicular Cancer IGCCCG prognostic grouping NSGCT poor prognosis?

*ANY ``` Mediastinal primary or Nonpulmonary visceral metastases or AFP > 10,000 ng/mL HCG > 50,000 IU/L or LDH > 10x normal ```

Testicular Cancer IGCCCG prognostic grouping seminoma poor prognosis?

``` no such thing. only good and intermediate. any primary site Normal AFP any HCG, any LDH ``` difference is pulmonary mets. intermediate if + good if –

Testicular Cancer What is the initial surgical procedure that is both diagnostic and therapeutic?

radical (inguinal) orchiectomy. *** In this procedure, the involved testis is removed en bloc with the spermatic cord, enclosed by the tunica layers through an inguinal incision, minimizing the chance of tumor spillage. Historically, it had been thought that scrotal violation (transscrotal orchiectomy, open testicular biopsy, or fine needle aspiration) compromised prognosis. Scrotal violation is associated with a slight increase in local recurrence rate compared with inguinal orchiectomy (2.9% vs. 0.4%, respectively) but is not associated with any difference in distant recurrence rates or overall survival

Testicular Cancer What are the options after a diagnosis of stage I seminoma has been made?

observation or single agent carboplatin (1-2 cycles) or RT to paraaortic +/- pelvic nodes

Testicular Cancer What is the schedule if stage I patients will be under surveillance and no adjuvant treatment?

assessments every 4 to 6 months in the first 2 years, six monthly assessments in years 3 to 5, and annual assessments until year 10.

Testicular Cancer What is included in the "dog-leg" or "hockey-stick" traditional field for adjuvant RT in stage I seminoma?

the paraaortic and ipsilateral pelvic lymph nodes. lower border of dog leg is midpelvis.

Testicular Cancer Stage I Seminoma Where is the most common site of relapse in patients treated with adjuvant paraaortic RT?

ipsilateral pelvic (GTCSG and MRC trials) lower common iliac or upper external iliac nodes

Testicular Cancer Stage I Seminoma Where is the most common site of relapse in patients treated with adjuvant carboplatin?

retroperitoneum/paraaortic area

Testicular Cancer Stage II Seminoma What is the treatment of choice for non-bulky IIA/B disease?

RT to the paraaortic and ipsilateral pelvic nodes

Testicular Cancer Stage II Seminoma Is there a benefit in doing prphylactic SCF RT in stage IIA/B patients as it is the most common site of relapse after infradiaphragmatic RT?

None. In the past, some authors recommended prophylactic supraclavicular irradiation. However, the proportion of patients destined to relapse exclusively in the supraclavicular fossa is <5%, and results with infradiaphragmatic irradiation alone with chemotherapy as salvage are excellent.

Testicular Cancer Stage II Seminoma Is single agent carboplatin still an option for stage IIA/B disease?

No. High failure rate (18%) -GTSG. It can be used as neoadjuvant but the results are not definitive.

Testicular Cancer Stage II Seminoma What is the treatment of choice for IIC disease?

systemic treatment. RT remains an option but relapse >30% is considered high. -Chung et al.

Testicular Cancer Stage II Seminoma If RT is an option for stage IIC (>5 cm nodes) disease, when can you do it and when do you consider systemic treatment?

The choice of modality is also influenced by the size and location of the retroperitoneal nodal mass. If the mass is centrally located and does not overlie most of one kidney or significantly overlap the liver, primary radiation therapy remains an option. If the location of the mass is such that the irradiation volume covers most of one kidney or significant volumes of the liver, then the potential morbidity of radiation therapy can be avoided by chemotherapy

Testicular Cancer Stage III Seminoma What is the standard treatment?

3 courses of BEP (bleomycin, etoposide and cisplatin) or 4 courses of EP.

Testicular Cancer Stage II Seminoma What is the standard RT dose for stage IIA/B non bulky disease?

25-35 Gy

Testicular Cancer What size of residual mass is suspicious (and proven by most centers) to harbor microscopic / viable cancer cells?

>3 cm

Testicular Cancer Upon completion of chemotherapy, there is a residual mass >3 cm that is well-defined and with discrete borders merging into surrounding structures and resembling a fibrous plaque. What is the next step?

Resect! positive histology can be found in 50%

Testicular Cancer Upon completion of chemotherapy, there is a poorly defined residual mass >3 cm. What is the next step?

Resecting is hazardous as it may risk great vessel, ureteric, or small bowel injury. It may be observed. However, in the best set-up, a FDG-PET may be requested as its sensitivity in >3 cm masses is 100%.

Testicular Cancer Upon completion of chemotherapy, there is a poorly defined residual mass >3 cm. This was avid on FDG-PET What is the next step?

RT Resecting is hazardous as it may risk great vessel, ureteric, or small bowel injury.

Testicular Cancer When do you perform FDG-PET after systemic treatment?

FDG-PET should be performed 6 weeks after day 21 of the last chemotherapy cycle, as earlier imaging has a higher risk of false-positive results.

Testicular Cancer What is the treatment for progressive disease after primary and salvage treatment?

second-line chemotherapy

Testicular Cancer In some cases, disease may be bilateral and bilateral orchiectomy is effective. However, testis-sparing approach is an emerging alternative. When can you do it?

tumors <2 cm in size | negative margins

Testicular Cancer What is the PORT dose for testis-sparing procedures?1

18-20 Gy to the residual testicle to eradicate GCNIS (which is found in >80% of cases).

Testicular Cancer Patients with GCNIS almost invariably progress to invasive cancer. TRUE or FALSE?

true. it's a precursor lesion

Testicular Cancer Anatomy left sided tumors involve the preaortic and paraaortic nodes and nodes at renal hilum first before the interaortocaval... right sided involve the interaortocaval/precaval first before the preaortic... TRUE or FALSE?

True

Testicular Cancer What nodes are included in the CTV for stage I?

interaortocaval preaortic and paraaortic. +/- ipsilateral common and external iliac. left renal hilar (for left-sided tumors) Remember, the left involves the preaortic first. The right goes to the interaortocaval first.

Testicular Cancer What nodes are included in the CTV for stage II?

all included in stage I )interaortocaval preaortic and paraaortic) + ipsilateral common and external iliac. left renal hilar (for left-sided tumors)

Testicular Cancer What are the borders of the traditional dog-leg (assuming that pelvic nodes are to be treated)?

Superior - T9-T10 Inferior - above the obturator foramen lateral - covers the transverse process at the paraaortic area and the renal hilum for left sided tumors.

Testicular Cancer What are the borders of the traditional dog-leg (assuming that pelvic nodes are NOT to be treated)?

Superior - T9-T10 "Inferior - L5-S1 disc space" lateral - covers the transverse process at the paraaortic area and the renal hilum for left sided tumors.

Testicular Cancer What are the borders of the "modified" and modified dog-leg?

superior - T10-T11 | inferior - superior aspect of the acetabulum or bottom of L4 if pelvic nodes are not to be treated

Testicular Cancer Authors found, after analyzing 90 patients, that almost all detected nodes in stages I and II were contained within a ___cm posterior and lateral margin and a ___cm anterior margin from the arterial vasculature.

2.5 and 2.1-

Testicular Cancer What are the commonly used RT dose for stage I?

North America 25/1.25/20 | UK 20/2/10 or 30/2/15

Testicular Cancer What are the commonly used RT dose for stage II?

25/1.25/20 +10/5-8 boost to residual >2-3 cm. Alternative: 30/2/15 for IIA 36/2/18 for IIB

Testicular Cancer What is the threshold dose for transient aspermia after RT as reported by Hahn et al?

>65 Gy no aspermia below 50 Gy. Recovery of sperm in the semen occurred in most within 30 to 80 weeks of radiation therapy

Testicular Cancer What hormone is elevated in men after dog leg RT, highest within 6 months and return to normal within 3 years?

FSH

Testicular Cancer Radiation therapy (mean dose _____Gy to bone marrow) without chemotherapy was associated with a threefold elevated risk of leukemia.

Radiation therapy (mean dose 12.6 Gy to bone marrow) without chemotherapy was associated with a threefold elevated risk of leukemia

Testicular Cancer There is a risk for secondary leukemia even for patients just observed. TRUE or FALSE?

TRUE Although treatment factors are strongly implicated in the development of second primary malignancies following treatment, an excess risk of second cancers is seen even among testicular cancer patients who have just been observed. An increased rate of spontaneous chromosomal translocations is seen in lymphocytes of patients with early-stage seminoma compared to healthy controls

Testicular Cancer Flashcards

(88 cards)