Testicular Cancer FRCR CO2A Flashcards
(92 cards)
1
Q
What are the RFs for Testicular Cancers ?
A
- Cryptoorchidism and infertility
- Pesticides
- 10 fold increased relative risk in a brother of an affected relative
2
Q
What Syndromes are a/w Testicular Cancer
A
Klinfelter’s syndrome and Down Syndrome
3
Q
Association of cryptorchidism and Testicular Cancer
A
10 fold increase
4
Q
what are major types of Testicular Cancer
A
GCTs (Seminoma, Teratoma, Mixed tumor, spermatocytic seminoma)
NGCT (sex cord/stromal tumors, leydig cell tumors, sertoli cell tumors ) etc
5
Q
is there any role of screening in Testicular Cancer
A
No, Testicular Cancer pts should be tought about self examination bcoz they run high risk of 2nd c/l cancers
6
Q
whats the pattern of spread of Testicular Cancer
A
1st station Lns are the inter aortocaval nodes for right side tumors and left para aortic for lt sided tumors
7
Q
Classify GCTs
A
- ITGCN
- Teratoma or non seminoma
- seminoma, classical or spermatocytic
8
Q
whats are symptoms of advanced Testicular Cancer
A
fatigue, wt loss, back pain, dyspnoea due to lung mets or assoc PE, para aortic mass cause ureteric obstuction and HDUN and renal failure
9
Q
whats the mc clinical presentation of Testicular Cancer
A
painless testicular swelling
10
Q
Whats the presentation of mediastinal GCTs
A
Classic s/s of SVCO
11
Q
What investigations are done for Testicular Cancer
A
- markers: Beta HCG, AFP, LDH
- Testicular USG
- CECT of chest Abdomen and Pelvis
- MRI brain if choriocarcinoma or pt is poor prognostic group, particularly very high Beta HCG
12
Q
whats the significance of Beta HCG in Testicular Cancer
A
- arises from syncytiotrophoblastic elements and raised in 10 - 20% of pts with seminoma and around 35% of those with teratoma
- massive increase may suggest metastatic choriocarcinoma
13
Q
Whats the significance of AFP in Testicular Cancer
A
- arise from yolk sac elements
- 60% of pts who have teratoma but not in Patients with Seminoma
14
Q
whats the significance of LDH in Testicular Cancer
A
prognostic grouping
15
Q
what are prognostic categories for metastatic Testicular Cancer
A
- IGCCCG 1997
- 3 groups, Good prognosis, metastatic, 95% cure, Intermediate prognosis, metastatic, 80% cure, Poor prognosis, metastatic 50% cure
16
Q
who are included in good pronostic group
A
all of the following
1. AFP < 1000 ng/ml
2. B HCG < 5000 ng/ml
3. LDH < 1.5 ULN
4. Testicular primary site
17
Q
Who are included in intermediate prognostic group
A
Any of the following
1. AFP 1000 - 10000 ng/ml
2. B HCG 5000 - 50000 ng/ml
3. LDH 1.5 - 10 x ULN
4. primary site: retroperitoneal teratoma or any non testicular seminoma site
18
Q
Who are included in poor prognostic group
A
Any of the following
1. AFP >10000 ng/ml
2. B HCG >50000 ng/ml
3. LDH >10 x ULN
4. primary site: mediastinal teratoma, liver brain, bone mets (non pulmonary visceral mets disease)
19
Q
Which levels of markers are used for prognostic group allocation
A
post orchidectomy, not preoperative levels
20
Q
How is ITGCN managed?
A
- found in 5% along GCTs in c/l testes, 50% progression to cancer within few years
- RT (20 Gy/ 10#), may cause infertility and disrupt LEydig cell function, may require lifelong Testosterone replacement or
- routine biopsy of c/l testicle the time of orchidectomy for GCT or
- Testicular Self Examination and annual USG follow up
pt must decide
21
Q
How is Stage I seminoma treated
A
with adjuvant therapy, even when relapse risk is low, as it is very sensitive to both chemo and radio
22
Q
How is Stage I teratoma treated
A
Surgery f/b Surveillance, trend towards BEP in high risk pts, bcoz teratomas produce tumor markers more commonly than seminomas, surveillance is easier
23
Q
How is metastatic Testicular cancer treated
A
Combination Chemotherapy
24
Q
Why is stage I seminoma treated
A
15-20% relapse after orchidectomy, primarily within PA nodes
25
what are predictive factors for relapse of seminoma stage I
tumor size > 4 cm 25%
Rete testes invasion
LVSI but unreliable as it can appear as an artefact of slide preparation
26
what are treatment options for adjuvant treatment in stage I seminoma
Adjuvant RT to PA nodes
Adjuvant Chemotherapy with single cycle of Carboplatin AUC 7
27
How is survellance done in Stage I seminoma post Treatment?
REgular CT scanning, every 3 - 6 months in 1st year then annual screening
or
MRI of PA region combined with CXR and tumor markers to decrease radiation doses
27
whats the pattern of relapse in stage i seminoma patients
1. treated with PA RT: Chest and pelvis
2. treated with Carboplatin: PA region
gives a rationale for combining them in Rx of stage II seminoma
28
How is stage II seminoma treated ?
1. stage IIa/IIb: DOG leg RT with a boost for bulky disease, 20% failure rate, unacceptably high, those require ChT or
2. A single course of carboplain befor RT
3. PA strip RT and Carboplatin single cycle
4. Stage IIC : tumor size 3 to 5 cm : combination chemotherapy
29
how does location of tumor help in treatment decision making for stage II seminoma
Right Side: can be treated with RT and single cycle of Carboplatin
Left Side: combination ChT as overlie the left kidney, which will get higher RT dose
30
Whats RT dose in adjuvant Seminoma treatmetn?
20 Gy/ 10# for stage I
30 Gy/ 15# for stage IIa/b
31
what is target volume for Stage I Seminoma
PA strip from around T11 to L5, lateral borders 4 to 4.5 cm from the midline, caution on left side
32
What is Dog Field RT
similar to PA field but extends inferiorly to include the I/L iliac nodes to the level of the obturator foramen
33
what are borders of Dog Field RT
lateral extends to the pelvic side walls, medially the bladder: central pelvic contents can be shielded
34
what are s/e of RT
1. nausea, can be managed with 5 HT3 antagonists
2. Infertility, Dog leg deliver 40 cGy of scattered radiation to the scrotum, chances of infertility
35
what advice should be given to patient before ChT or RT
Sperm banking and avoid conception for 6 to 12 months, possibility of teratogenic effect
36
HOw is stage I teratoma treated?
depends on LVSI status
37
How is Stage I teratoma without LVSI treated
1. Low risk of relapse, < 20%, managed by surveillance, relapse can be cured with ChT
38
How are pts of Stage I teratoma without LVSI followed up
1. tumor markers return to normal after surgery, monthly visits initially but after 6 to 12 months, intervals can be extended
every 2 month 2nd year, 3 month in 3rd year, 4-6 months in year four, five and then annually
39
what tests should be done on follow up for Stage I teratoma without LVSI
1. Tumor markers and CxR
2. follow up CT done at around 3 months and at 1 year
40
How is Stage I teratoma with LVSI treated
1. high chances of relapse 45%
2. 3 ways of managment
A. Surgical Staging (with 2 BEP for pN+ disease)
B. Adjuvant Chemotherapy with 1 - 2 cycles of BEP: reduce the relapse to 2%
C. Surveillance with 3 cycles of BEP who relapse
41
How are pts with borderline nodal enlargement on CT managed
PET scan is often misleading, not recommended
early repeat CT approx 6 to 12 weeks combined with regular marker estimations: usually provides enough information
42
How is metastatic GCTs treated?
BEP regimen 3 to 4 cycles
43
whats the s/e of Bleomycin
Pneumonitis, gradually increasing SOB and dry cough
44
Can Bleomycin be removed from BEP
No, reduces cure rates
45
Can Carboplatin replace cisplatin
no inferior results
46
How can cisplatin induced renal toxicity be reduced
with adequate hydration and magnesium replacement
47
How is residual mass post ChT in teratoma managed?
1. Observation not advised
2. may undergo subsequent malignant change within mature teratoma
3. RPLND : if viable malignancy is found, further chemo should be considered
48
How is residual mass post ChT in seminoma managed?
1. RT to patients with a PET positive Residual mass
2. PET negative: observation
49
what are options in 2nd L
VIP (Etoposide, Ifosfamide, cisplatin)
TIP (Paclitaxel, Ifosfamide, Cisplatin)
50
After how much time , follow up in Testicular GCTs be called off?
5 years except those with metastatic NSGCTs
51
What is spermatocytic seminoma
1. Benign and slow growing
2. older man, fewer than 5% of seminomas
3. No Ovarian Counterpart, not a/w usual RF for testicular cancer, not descended from germ cell carcinoma in situ
4. Metastatic disease virtually unknown
52
How are sex cord stromal tumors of Testes treated
Orchidectomy and staging CT, PA nodal disease found, surgery with node disssection
53
54
What percentage of all cancers does testicular cancer account for?
0.7%
## Footnote
This statistic reflects the overall incidence of testicular cancer.
55
How many new diagnoses of testicular cancer occur each year in the UK?
Fewer than 2000
## Footnote
This figure indicates the relatively low incidence rate of testicular cancer.
56
What is the age group with the highest incidence of testicular cancer?
Men under 35 years of age
## Footnote
Approximately half of cases occur in this age group.
57
What are two main risk factors for testicular cancer?
Previous history of testicular cancer, Cryptorchidism
## Footnote
Cryptorchidism increases the risk by 2-4 fold.
58
What percentage of testicular malignancies are germ cell tumors?
>90%
## Footnote
Germ cell tumors include seminomas and teratomas.
59
What is the risk of progression to malignancy for intratubular germ cell neoplasia at 5 years?
50%
## Footnote
This risk can be prevented with radiotherapy.
60
What is the primary presentation of the majority of testicular tumors?
Painless, firm swelling of the testis
## Footnote
This is observed in approximately 75% of cases.
61
What investigations are included in preoperative assessment for testicular cancer?
Testicular ultrasound, chest X-ray, tumor markers
## Footnote
Tumor markers include AFP, beta-HCG, and LDH.
62
What should be done if AFP is raised or beta-HCG is >200?
Treat as a non-seminomatous germ cell tumor (NSGCT)
## Footnote
These markers help classify the type of tumor.
63
What is the primary management for testicular cancer?
Radical inguinal orchidectomy
## Footnote
This procedure should be performed within one week after diagnosis.
64
What is the recommended action if a patient has advanced life-threatening testicular cancer?
Start chemotherapy without delaying orchiectomy
## Footnote
In certain cases, treatment can begin if the clinical picture and markers are diagnostic.
65
What should be considered for patients if chemotherapy is planned?
Sperm storage
## Footnote
This is important due to the risk of infertility from treatment.
66
Fill in the blank: The majority of testicular tumors present with a _______.
painless, firm swelling of the testis
67
True or False: The majority of testicular cancer patients present with lower back pain.
False
## Footnote
Most present with a painless, firm swelling, not back pain.
68
What percentage of teratomas have one or more raised tumor markers?
75%
## Footnote
This indicates the relevance of tumor markers in diagnosis.
69
What is the expected time frame for repeating postoperative tumor markers?
A minimum of 7 days after orchiectomy
## Footnote
This helps measure treatment response and monitor for recurrence.
70
71
What percentage of patients with seminoma present with stage I disease?
>80%
## Footnote
This stage has a survival rate of >99%.
72
What are the two risk factors for recurrence in seminoma?
* Rete testis invasion
* Tumour size >4 cm
73
What is the 5-year relapse rate for seminoma with no risk factors?
12%
74
What is the current treatment approach for stage I seminoma?
Active surveillance irrespective of risk factors
75
What are the treatment options if active surveillance is not an option for stage I seminoma?
* Single dose of carboplatin (AUC 7)
* Para-aortic radiotherapy (20 Gy in 10 fractions)
76
What is the definition of Stage IA testicular cancer?
pT1N0M0 – Tumour limited to testis and epididymis with no LVI or tunica vaginalis invasion
77
What is the definition of Stage IB testicular cancer?
pT2–4N0M0 – Tumour limited to testis and epididymis with LVI or tunica vaginalis invasion
78
What characterizes Stage IIA testicular cancer?
Any T, N1 (≤2 cm regional node) M0
79
What is the prognosis for patients with non-seminomatous tumours with an AFP level <1000 ng/ml?
Good prognosis
80
What chemotherapy regimen is used for good prognosis patients in stage IIC/III?
Three cycles of PEB
81
What is the recommended follow-up for patients with residual masses greater than 3 cm?
PET scan or frequent follow-up or resection
82
What is the relapse treatment for patients who relapse after radiotherapy?
Chemotherapy
83
What is the survival rate for patients who are platinum-sensitive and relapse after 3 months of initial chemotherapy?
Standard options are VIP, TIP, or VelP
84
What is the prognosis for patients who are truly platinum-resistant?
Approximately 10% survival
85
What is the risk of relapse for stage I patients with vascular invasion?
40-50%
86
What are the components of the PEB chemotherapy regimen on a 3-day schedule?
* Cisplatin 50 mg/m2 Days 1–2
* Etoposide 165 mg/m2 Days 1–3
* Bleomycin 30 mg on Days 1, 8, 15
87
What is the definition of the dog-leg field in radiotherapy for testicular seminoma?
* Superior: top of T11 vertebra
* Inferior: lower border of ipsilateral acetabulum
* Ipsilateral border: renal hilum and include iliac nodes
* Contralateral border: transverse process of vertebrae
88
What is the fate for testicular intraepithelial neoplasia (TIN) if untreated?
70% of TIN progress to testicular cancer in 7 years
89
What is the long-term survival rate for seminoma?
>90%
90
What is the follow-up protocol after active treatment for testicular cancer?
* Frequent clinical examination
* Estimation of tumour markers
* Chest X-ray
* CT-scan up to 5 years
91
Fill in the blank: The treatment options in proven TIN include _______ and active treatment with radiotherapy.
surveillance
