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03. Testis + Penile + Uretral Ca (1060) > Testis cancer > Flashcards

Testis cancer Flashcards

1
Q

Nonguideline directed care of patients with testicular cancer is common, most frequently in the form om inappropriate imaging and overtreatment. What does it lead to?

A

Delayed definitive therapy
Unnecessary morbidity
Higher rates of relaps

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2
Q

How common is testicular cancer in western society?

A

3-10 cases per 100,000 males/year

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3
Q

Hur stor andel av urologisk cancer utgörs av testikelcancer?

A

5%

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4
Q

What is the most common type of testicular cancer and what are the two subgroups?

A

Germ cell tumours (90-95%)

Non-seminoma
Pure seminoma

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5
Q

Utredning för misstänkt testikeltumör?

A 
Kliniskt examination
-skrotum
- palpabel resistens i buken
-gynekomasti
-palp supraklavikulärt
Ultraljud
Tumörmarkörer
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6
Q

What are the Serum Tumour markers (STMs) for testicular cancer?

A

AFP: produced by yolk sac cells

hCG expression of trophoblasts

LDH (lactate dehydrogenase)

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7
Q

When is hCG elevated with testicular cancer?

A
  • all choriocarcinomas

- 50% embryonal carcinomas

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8
Q

What information can you gain from LDH (lactase dehydrogenase)-levels with testicular cancer?

A
  • less specific
  • proportional to tumour volume
  • elevated in 80% of advanced testicular cancer
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9
Q

What is the proper course of action with life threatening disseminated testicular cancer?

A

Lifesaving chemotherapy with delayed orchiectomy after completion of induction chemotherapy

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10
Q

When should you perform and orchiectomy after diagnosing testicular cancer?

A

Preferably within 24-48 hours and no later than 10 days

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11
Q

When should you consider performing organ-sparing surgery with testicular cancer?

A

Synchronous bilateral testicular tumours
Metachronous contralateral tumours
A tumour in a solitary testis with normal pre-operative testosterone levels

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12
Q

What are the riskfactors for contralateral testicular tumours?

A

testicular volume <12 mL

a history of cryptorchidism or poor spermatogenesis

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13
Q

When is a contralateral biopsy not necessary (when performing surgery for testicular cancer)?

A

In patients older than 40 years without risk factors

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14
Q

What information do you need for a complete staging and grading of testicular cancer?

A

Histopathology
Postoperative tumour markers
CT

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15
Q

What are the histopathological criteria for testicular cancer?

A
  • pT category
  • histological type
  • peri-tumoural venous and/or lymphatic invasion
  • presence of GCNIS
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16
Q

Mention a few Non-seminomal cancers of the testicle:

A 
Embryonal carcinoma
Yolk sac  tumour
Trophoblastic tumours
Teratoma, post-pubertal type
Teratoma with somatic-type malignancies
Mixed germ cell tumours
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17
Q

Mention two Benign tumours of the testicle:

A

Spermatocytic tumour

Teratoma, prepubertal type

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18
Q

Hur stor andel av testikelcancer utgörs av icke “Germ cell tumours”?

A

2-4% hos vuxna män

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19
Q

When should you perform a FDG PET CT with testicular cancer?

A

Only if you have a residual mass at least 6 week after chemotherapy when treating a seminoma

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20
Q

What are teh progsnostic risk factors for stage 1 testicular cancer?
(answer for both seminoma and non-seminoma)

A

Seminoma:
tumour size >4 cm
invasion of rete testis

Non-seminoma:
vascular invation in blood or lymphatic vessels
percentage of embryonal carcinoma >50%
proliferation rate >70%

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21
Q

What Germ Cell tumours doesn’t need any other therapy than orchiectomy?

A

Spermatocytic tumour

Prepubertal teratoma

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22
Q

What is the relapse risk with stage 1 seminoma?

A

15-20% in 5 years

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23
Q

How do you treat a relapse of testicular seminoma?

A

Chemotherapy

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24
Q

What is the overall cancer-specific survival rate of testicular seminomas?

A

97-100%

-even postponed therapy is efficient

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25
Q

What is the main drawback with surveillance instead of chemotherapy with testicular seminomas?

A

The need for more intesive follow-up

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26
Q

How should you treat stage 1 testicular seminoma?

A

Either:

Surveilance- at very low risk
-tumour size <4 cm without rete testis invasion

or

One-course carboplatin-based chemotherapy

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27
Q

How should you NOT treat stage one testicular seminoma?

A

Radiotherapy

Retroperitoneal lymph node dissection (RPLD)

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28
Q

Vad är uppföljningsprogrammet för stadium 1 testikel seminom?

A

DToch tumörmarkörer var 6:e månad i 2 år

DT och tumörmarkörer på slutet av år 3 och 5

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29
Q

When does a relaps in stadium 1 NSGCT (non seminoma germ cell tumour) most often occur?

A

80% in the first year

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30
Q

How often does stadium 1 NSGCT (non seminoma germ cell tumour) relapse?

A

30%

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31
Q

Where does stadium 1 NSGCT (non seminoma germ cell tumour) most often relapse?

A

60% in the retroperitoneum

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32
Q

How common is subclinical metastases in clinical stadium 1 NSGCT (non seminoma germ cell tumour)?

A

up to 30%

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33
Q

What is the result of surveillance vs Adjuvant chemotherapy in stadium 1 NSGCT (non seminoma germ cell tumour)?

A

Surveillance –> 30% recurrence/relapse

Adjuvant chemotherapy –> <2% recurrence/relapse

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34
Q

What is risk-adapted treatment in stadium 1 NSGCT (non seminoma germ cell tumours)?

A 
Low risk (stage 1A- pT1, no vascular invasion) --> surveillance
(if not willing one course of BEP)

High risk (stage 1B, pT2-4) –> one(two) courses of BEP

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35
Q

What does BEP stand for in the treatment for testicular cancer?

A

Cisplatin
Etoposide
Bleomycine

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36
Q

When should you perform a nerve-sparing retroperitoneal lymph node dissection on patients with stage 1 NSGC (non seminoma germ cell tumours)?

A

to highly selected aptients only:

those with contraindication to adjuvant chemotherapy and unwilling to accept surveillance

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37
Q

When should you perform a Brain scan (CT/MRI) on a patient with metastatic testicular cancer?

A

I case of symptoms
and patients with metastatic disease with multiple lung metastases
and/or high beta-hCG values.

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38
Q

Vilken utredning är obligat vid misstänkt metastaserad testikelcancer?

A 
UL testiklar
Tumörmarkörer
DT-thorax+buk
MRI kotpelare OM patienten har symptom
DT-hjärna/MR OM patienten har symptom eller multipla lungmetastaser och/eller högt beta-hCG
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39
Q

Vad är skillnaden mellan stadium M1a och M1b vid metastaserad testikelcancer?

A

M1a: metastaser i regionala lymfkörtlar och/eller i lungorna
M1b: andra metastaser

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40
Q

Vad innebär stadium 1 testikelcancer?

A

Sjukdom begränsad till testikeln

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41
Q

Vad innebär stadium II testikelcancer?

A

Retroperitoneala lymfkörtelmetastaser
IIA <2 cm
IIB 2-5 cm eller fler än 5st
IIC >5 cm

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42
Q

Vad innebär stadium III testikelcancer?

A

IIIA lymfkörtelmetastaser som inte är regionala
IIIB lungmetastaser
IIIC metastaser till andra organ

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43
Q

Which patients with metastatic testicular cancer have a poor prognosis?

A

Not any patients with seminoma

Patients with non-seminoma and:
mediastinal primary
non-pulmoary visceral metastases
AFP >10,000 ng/mL or
hCG >50,000 IU/L (10,000 ng/mL9 or
LD > 10 x ULN
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44
Q

What is the standard treatment for stage IIA/B seminoma

A

Radiotherapy

2:hands alternativ är BEPx3

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45
Q

What is the standard treatment for stage IIA/B NSGCT (non seminoma germ cell tumour)?

A

Chemotherapy

and RPLND of residual disease

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46
Q

What is the one exception to chemotherapy for stage IIA/B NSGCT (non seminoma germ cell tumour)?

A

Stage IIA NSGCT & pure teratoma without elevated markers
–> nerve sparing RPLND or surveillance

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47
Q

What is the cure rate of non-seminoma stage IIA testicular cancer?

A

98%

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48
Q

Which factors correlate with preserved fertility after chemotherapy for testicular cancer?

A

cisplatin-dose
FSH
age

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49
Q

What can you expect when it comes to fertility after chemotherapy for testicular cancer?

A

Most men with normal pre-treatment sperm analysis will return to normal by 3 years after chemo

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50
Q

When is the spermatogenesis at its lowest after chemotherapy for testicular cancer?

A

10-14 months after chemotherapy

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51
Q

How common it late realapse (>2 years) in
seminoma?
non-seminoma?

A

seminoma 1,4%

non-seminoma 3,2%

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52
Q

What are the differential diagnosises when a patient has a late relapse of testicular cancer?

A 
Metastases from a new contralateral primary
A new primary EGGCT
Metastases from a new non - GCT primary
Transformed teratoma
Growing teratoma
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53
Q

How do you treat late relapse (>2 years) NSGCT?

A

Surgery
if incomplete result of surgery –>salvage chemotherapy

rapidly rising hCG –> induction salvage chemotherapy before surgery

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54
Q

How common is bilateral tumors at diagnosis?

A

1-2%

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55
Q

What is the predominate histology of testicular cancer?

A

Germ cell tumour (GCT)

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56
Q

Epidemiological risk factors for testicular cancer?

A

Testicular dysgenisis syndrome (cryptochidism, hypospadia, decreased spermatogenisis evidenced by sub or infertility)

Familial history of testicular tumours among first grade relatives

Presence of a contralateral tumour

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57
Q

What are the serum tumour markers for testicular cancer?

A

LDH lactate dehydrogenase

hCG human chorionic gonadotrophin

AFP alpha-fetoprotein

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58
Q

Gene that determines gonadal transition to a male

A

SRY

Under the influence of the SRY gene (sex-determining region of the Y chromosome), in the 7th to 8th week, cells in the genital ridge differentiate into seminiferous tubules containing spermatogonia and Sertoli cells. Without the SRY protein, ovarian follicles form.

The Sertoli cells begin to secrete Müllerian-inhibiting substance (MIS), acting locally and causing the Müllerian ducts to regress between 8-10 weeks, thus contributing to normal male phenotypic development.

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59
Q

Which cells produce testosterone?

A

Leydig cells

In the 9th-10th weeks, Leydig cells differentiate from genital ridge cells in response to SRY protein and are located between the seminiferous tubules. These cells begin to produce testosterone. There is a rise in both serum and testicular testosterone that peaks at 13 weeks before beginning to decline.

Between the 8th and 12th week, testosterone secretion stimulates the virilization of the wolffian ducts into the vas deferens, seminal vesicles, and ejaculatory ducts.

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60
Q

Table of timing of male gonadal development

A
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61
Q

Normal adult testis size and volume

A

On average, the normal adult testis measures 4-5cm long, 3cm wide, and 2.5cm deep with volume ranging 12-30ml.

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62
Q

Three types of histologic cells in testis

A

Seminiferous tubules, Sertoli cells, Leydig cells

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63
Q

Arterial blood supply to testis

A

Three:
1. Gonadal/Testicular
- Arises inferior to SMA, directly off of aorta
2. Cremasteric
- Arises from inferior epigastric artery
- Anastomoses with testicular artery within testis
3. Vasal

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64
Q

Left Testicle Lymphatic Drainage

A

The primary drainage pattern on the left is to the para-aortic and preaortic lymph nodes, followed by the interaortocaval nodes.

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65
Q

Right Testicle Lymphatic Drainage

A

On the right side, primary drainage is to the interaortocaval nodes, followed by the precaval and preaortic nodes.

It is more common for the lymphatic drainage of the right testis, and rare with left-sided tumors, to cross the midline and exhibit bilateral lymph node metastases

Drainage is right to left!

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66
Q

Layers of the scrotum and spermatic cord encountered during surgical exploration, progressing from superficial to deep

A

Skin, dartos, external spermatic fascia, cremasteric fascia, cremasteric muscle, internal spermatic fascia, tunica vaginalis (parietal then visceral), tunica albuginea

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67
Q

T staging of testicular tumors

A
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68
Q

N staging of testicular cancer

A
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69
Q

M staging of testicular cancer

A
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70
Q

Serum Tumor Marker Staging

A
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71
Q

Stage Grouping

A
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72
Q

Risk Classification for Sem and Non-Sem

A
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73
Q

Treatment options for stage IA and IB pure seminoma

A

(i) Surveillance (preferred)
(ii) Retroperitoneal Radiotherapy
(iii) Chemotherapy with carboplatin (1 or 2 cycles)

More than 80% of patients with stage I seminoma are cured with orchiectomy alone, therefore surveillance is the preferred approach, and the disease specific survival for stage I disease is 99% irrespective of the management strategy used.

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74
Q

AUA Guideline Algorithm for treatment of early testicular cancer

A
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75
Q

Surveillance for Stage IA and IB Seminoma

A
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76
Q

Risk factors for predicting relapse

A

In an analysis of over 600 patients, rete testis invasion and tumors ≥ 4 cm were identified as risk factors for predicting relapse.

For patients with 0, 1, or 2 of these risk factors the recurrence rates were 12%, 16%, and 32%, respectively.

NCCN recommends against a risk-adapted approach and supporting surveillance as the preferred strategy for all stage I patients.

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77
Q

Stage I Seminoma Surveillance NCCN and AUA

A
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78
Q

Types of testicular cancer

A

The vast majority are classified as germ cell tumors (95%), while the remaining are predominately sex cord/stromal tumors (mainly Leydig cell and Sertoli cell tumors). Germ cell tumors (GCT) are further designated as seminoma or non-seminoma germ cell tumors (NSGCT).

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79
Q

Risk factors for developing testicular cancer

A

Cryptorchidism, personal or family history, intra-tubular germ cell neoplasia (ITGCN).

It is felt that most GCTs arise from ITGCN and its presence is a major risk factor as 50% of men with ITGCN will develop a GCT within 5 years.

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80
Q

Histologic Subtypes of Testicular Cancer

A

Germ Cell Tumors:
- Seminoma
- Nonseminomatous Germ Cell Tumors: Embryonal, Choriocarcinoma, Teratoma, Yolk Sac (Endodermal Sinus Tumor)

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81
Q

Does Seminoma produce AFP? bHCG?

A

NO AFP
5% produce bHCG (because 5% contain syncytiotrophoblasts, which secrete bHCG)

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82
Q

Most common GCT in children/infants?

A

Yolk Sac (Endodermal Sinus Tumor)

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83
Q

Do Yolk Sac tumors produce AFP? bHCG?

A

Generally will produce AFP
NEVER bHCG

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84
Q

Classic pathologic finding of Yolk Sac Tumors?

A

Schiller-Duval bodies

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85
Q

Does choriocarcinoma produce AFP? bCHG?

A

NEVER AFP
Yes bHCG, usually high

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86
Q

Do pure teratomas produce AFP? bHCG?

A

Pure teratoma will produce neither, but pure teratoma is very rare in adults

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87
Q

What to do for evaluation of initial presentation of testicular mass?

A

Testicular US
- Homogeneous mass more likely to be seminoma
- Heterogeneous mass more likely to be NSGCT

No role for further imaging OF THE TESTIS at time of presentation

Microlithiasis: just recommend routine self-exam

Obtain tumor markers at time of diagnosis, prior to any intervention (AFP, LDH, bHCG)

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88
Q

AFP:
- Half life?
- Which testicular cancers produce?
- Why else elevated?
- What is a true elevation?

A

5-7 days

NOT PRODUCED by seminoma

Normal <10

Elevated in 50-80% of NSGCT

Embryonal carcinoma and yolk sac tumors produce AFP, seminoma and choriocarcinoma do not.

AFP may also be elevated in patients with liver disease, hepatocellular carcinoma, and stomach/pancreas/biliary duct/lung cancers.

Mildly elevated AFP may not represent germ cell tumor, thus the decision to treat a patient should not be made for an AFP level < 20.

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89
Q

bHCG:
- Half life?
- Which testicular cancers produce?
- Why else elevated?
- What is a true elevation?

A

Half life 24-36 hours

Elevated in 20-60% of NSGCT and 15% of seminomas

bHCG is elevated in embryonal carcinoma/choriocarcinoma/seminoma. Elevations may also be observed in liver, biliary, pancreas, stomach, lung, breast, kidney, and bladder cancers as well as secondary to marijuana use.

Significant hypogonadism may also cause low level elevation of HCG and these patients can be challenged with testosterone injections which normalize their HCG levels.

90
Q

LDH:
- Half life?
- Which testicular cancers produce?
- Why else elevated?
- What is a true elevation?

A

Half life is 24 hours

Non-specific marker of GCT

Patients should not be treated due to elevated LDH alone

91
Q

Role of miRNA in testicular cancer?

A

miR-371a-3p is the promising blood-based biomarker

Reliably detects all macroscopic GCT histologies, except for teratoma

miR-371a-3p holds promise in the following clinical scenarios:
1) patients with inconclusive testicular masses 2) surveillance after orchiectomy for early detection of relapse
3) response monitoring during chemotherapy 4) management of post-chemotherapy residual masses
5) surveillance after curative intent

short half-life of <24 hours

92
Q

Staging: Tis

A

Germ Cell Neoplasia in Situ

93
Q

Staging: T1

A

Confined to testis
NO LVI
Can be into epididymis
Can involve tunica albuginea but not vaginalis

94
Q

Staging: T2

A

Testis with or without epididymal involvement
+LVI OR into tunica vaginalis

95
Q

Staging: T3

A

Into spermatic cord
+/- LVI

96
Q

Staging: T4

A

Into scrotum
+/- LVI

97
Q

Staging: Clinical Nodes
N1

A

1-5 lymph nodes, all less than 2cm

98
Q

Staging: Clinical Nodes
N2

A

> 5 LNs (less than 5 cm)
OR
LN 2-5 cm in size

99
Q

Staging: Clinical Nodes
N3

A

LNs >5cm

100
Q

Staging: M1a

A

Distant mets
- Nonregional LNs
OR
- Pulmonary nodules/mets

101
Q

Staging: M1b

A

Distant mets OUTSIDE of nonregional LNs or lung

102
Q

Staging: Serum Tumor Markers
S1

A

AFP - <1k
bHCG - <5k
LDH - <1.5x normal

103
Q

Staging: Serum Tumor Markers
S2

A

AFP - 1k-10k
bHCG - 5k - 50k
LDH - 1.5 -10x normal

104
Q

Staging: Serum Tumor Markers
S3

A

AFP - >10k
bHCG - >50k
LDH - >10x normal

105
Q

Role of PET CT in testicular cancer

A

ONLY in seminoma to assess response to chemotherapy/determine if residual masses are active cancer
6-8 weeks after treatment

106
Q

Risk factors for developing testis cancer including germ cell neoplasia in situ (GCNIS)?

A

history of UDT/cryptorchidism (4-6x, reduced by 2-3 x if orchidopexy prior to puberty)

family history

personal history of testis cancer

107
Q

Risk of occult systemic disease for stage one testis cancer is lowest for :

A

pure seminoma vs. NSGCT

108
Q

Pure seminomas are more sensitive to chemotherapy and radiation relative to NSGCT?

A

YES

109
Q

The most undifferentiated type of NSGCT is?

A

embryonal carcinoma AND has totipotential capacity (differentiate into other NSGCT - yolk sac, choriocarcinoma, teratoma)

110
Q

Why is presence of teratoma important for management?

A

Although histologically benign, may contain genetic anomalies found in malignant GCT → uncontrollable growth and invasion or transformation into somatic-type malignancies

universally resistant to chemo and radiation

ONLY curable by surgical resection

111
Q

What are the testis cancer tumor markers and their associated histologies?

A

alpha fetoprotein (AFP) → yolk sac and embryonal (chorio and seminoma do NOT produce) → ½ life 5-7 days

human chorionic gonadotropin (hCG) → chorio and embryonal and syncytiotrophoblastic cells in seminoma → ½ life 24-36 h

lactate dehydrogenase (LDH) → nonspecific, best for estimating disease bulk

112
Q

Staging for testis cancer is based on:

A

pathologic stage of tumor

post orchiectomy tumor markers

staging by PE and imaging

113
Q

Testis TNM

A
114
Q

Testis TNM stage:

A
115
Q

Testis Risk Categories:

A
116
Q

A solid mass on PE or imaging is:

A

GUIDELINE STATEMENT 1

malignant neoplasm until proven otherwise

117
Q

When finding solid mass on PE or imaging, what is first step?

A

GUIDELINE STATEMENT 2

serum tumor. markers (AFP, hCG, and LDH) prior to any treatment

118
Q

Prior to intervention for testicular mass, patients should be counseled:

A

GUIDELINE STATMENT 3

risk of hypogonadism and infertility

offered sperm banking (consider prior to orchiectomy if unclear status of contralateral or known subfertility)

119
Q

What type of scrotal imaging should be used?

A

GUIDELINE STATEMENT 4

scrotal ultrasound with doppler (for unilateral or bilateral masses)

120
Q

What workup is required for testicular microlithiasis?

A

GUIDELINE STATEMENT 5

testicular microlithiasis in absence of solid mass and risk factors doe snot confer and increased risk of malignant neoplasm and doesn’t require further evaluation

121
Q

Patient with normal tumor markers (hCG and AFP) and indeterminate findings on PE or US, what is next step?

A

GUIDELINE STATEMENT 6

Repeat imaging 6-8 weeks

(< 2 cm 50-80% are not cancer → benign tumors, infarcts, Leydig cell nodules)

122
Q

In initial workup of testicular lesion, any other imaging modalities besides US?

A

GUIDELINE STATEMENT 7

MRI should NOT be used in initial eval and dx of testicular lesion suspicious for neoplasm

123
Q

Lesion determined by US and PE suspicious for malignancy, next steps after tumor markers?

A

GUIDELINE STATEMENT 8

with normal contralateral testis

inguinal orchiectomy (testis sparing not recommended, trans-scrotal discouraged)

GUIDELINE STATEMENT 9

testicular prosthesis should be discussed prior to orchiectomy

124
Q

What is recommended when a patient underwent a scrotal orchiectomy and found to have a testis neoplasm?

A

GUIDELINE STATEMENT 10

increased risk of recurrence and may be considered for adjunctive tx (excision of scar or RT) for local control

125
Q

Discuss role of testis sparing surgery, considerations, and surgical considerations?

A

GUDIELINE STATMENT 11A

tss through inguinal incision in pts wishing to preserve gonadal fx with masses < 2 cm and (1) equivocal US/PE and negative hCG and AFP (2) congenital, acquired or functionally solitary testis, or (3) b/l synchronous tumors

GUIDELINE STATMENT 11B

counseled regarding (1) high risk of local recurrence (2) need for monitoring with PE/US (3) role of adjuvant RT to testis to reduce local recurrence (4) impact of RT ons perm and testosterone (5) risk of testicular atrophy and need for tRT and/or subfertility/infertility

GUIDELINE STATMENT 11C

in addition to suspicious mass, multiple bx of ipsi testis normal parenchyma (GCNIS) should be obtained and evaluated by GU pathologist

126
Q

In patients with hx of GCT or GCNIS the risk of second primary tumor in contralateral testis is:

A

GUIDELINE STATEMENT 12

Rare but significant increase risk

(2%overall, 70% metachronous, 30% synchronous)

127
Q

In patient with GCNIS on testis biopsy or malignant neoplasm after TSS, what are recommendations and options:

A

GUIDELINE STATEMENT 13A

with GCNIS or s/p TSS → inform patients of r/b of surveillance, radiation, or orchiectomy

GUIDELINE STATEMENT 13B

recommend surveillance in pts who prioritize preservation of fertility and testicular androgen production

GUIDELINE STATEMENT 13C

recommend RT (18-20 Gy) or orchiectomy in patients who prioritize reduction of cancer risk taking into account the less risk of hypogonadism with RT

128
Q

Discuss utility of serum tumor markers in treatment planning:

A

GUIDELINE STATEMENT 14

Nadir makers should be repeated at appropriate T ½ time interval after orchiectomy for staging and risk stratification

GUIDELINE STATEMENT 15

for pts with elevated AFP or hCG post orchiectomy, clinicians should monitor tumor markers to establish nadir levels before treatment only if nadir would influence treatment

129
Q

In metastatic GCT (Stage IIC or III) planning for chemo what is the regimen based on?

A

GUIDELINE STATEMENT 16

IGCCCG risk stratification based on serum tumor markers (hCG, AFP, LDH) prior to chemo, staging imaging studies, and tumor histology from orchiectomy. Any post-pubertal male, should be treated as an adult

130
Q

Describe Good Prognosis risk category for Seminoma and Non-Seminoma GCT:

A

Non-Seminoma

Testis/retroperitoneal primary, no non-pulmonary visceral mets, good markers

(AFP < 1000, hCG < 5000, LDH < 1.5 x norm)

56% of non-seminomas

5 yr PFS 89%

5 yr OS 92%

Seminoma

any primary site, no non-pulmonary visceral mets, normal AFP, any hCG, any LDH

90% seminomas

5 y PFS 82%

5 y OS 86%

131
Q

Describe Intermediate Prognosis for Seminoma and Non-Seminoma GCT:

A

Non-Seminoma

testis/retroperitoneal primary, no non-pulmonary visceral mets, intermediate markers

(AFP > ,1000 < 10,000, hCG > 5,000 and < 50,000, and LDH > 1.5 x N and < 10 x N)

28% non-seminomas

5 y PFS 75%

5 yr OS 80%

Seminoma

any primary site, non-pulmonary visceral mets, normal AFP, any hCG, any LDH

10% seminomas

5 y PFS 67%

5 y OS 72%

132
Q

Describe Poor Prognosis for Seminoma and Non-Seminoma GCT:

A

Non-Seminoma

mediastinal primary, non-pulmonary visceral mets, poor markers

(AFP > 10,000, hCG > 50,000, LDH >10 x N)

16% of non-seminomas

5 y PFS 41%

5 y Survival 48%

Seminoma

No patients classified as poor

133
Q

Post orchiectomy elevated (AFP and hCG - 3 x normal), what should be done before treatments?

A

GUIDELINE STATEMENT 17

A rising trend should be confirmed before management decisions are made as false positive elevations may occur

134
Q

Patients with newly diagnosed GCT, what imaging should be done?

A

GUIDELINE STATEMENT 18

CT scan A/P with IV contrast or MRI (if CT contra)

GUIDELINE STATEMENT 19A

Chest imaging

GUIDELINE STATMENT 19B

In setting rising of post-orchiectomy markers, mets on CT A/P, CXR or PE, A CHEST CT

GUIDELINE STATMENT 19C

Stage 1 seminoma, CXR (superior specificity) over Chest CT

GUIDELINE STATEMENT 19D

NSGCT Chest CT over CXR (especially if recommended adjuvant tx)

GUIDELINE STATEMENT 20

Newly dx GCT, do NOT obtain PET for staging

135
Q

In newly dx GCT, how do you guide management decisions?

A

GUIDELINE STATEMENT 21

assign of TNM category

(image chest, A/P, post orchiectomy nadir AFP, hCG, and LDH)

GUIDELINE STATEMENT 22

Imaging w/in 4 weeks

Markers w/in 10days

136
Q

Management decisions for newly dx GCT should be made with whom and based on which histology?

A

GUIDELINE STATEMENT 23

Multidisciplinary team (urology, med onc, rad onc, pathology, radiology)

GUIDELINE STATEMENT 24

Expert review of pathology in clinical scenarios where treatment decisions impacted

(review of expert alters subtype in 4-6%, 27% pathology reports revised)

137
Q

In newly dx patients post orchiectomy with normal STM and equivocal findings on imaging for mets, how do you decide on tx?

A

GUIDELINE STATEMENT 25

Consider repeating imaging 6-8 weeks to clarify extent of dz before tx

138
Q

Recommended tx for Seminoma GCT stage 1:

A

GUIDELINE STATEMENT 26

Surveillance after orchiectomy (<20% recurrence)

adjuvant RT and carboplatin-based chemo are less preferred (3-9% recurrence)

139
Q

Recommended tx for pts w/Seminoma GCT and Stage IIa/b with LN < 3 cm? For IIB w/LN > 3 cm?

A

GUIDELINE STATEMENT 27

IIA/B LN < 3 cm: recommend RT(dog leg up to 30 Gy) or multi-agent cisplatin-based chemo (4 cycles EP or 3 cycles BEP) based on SDM

IIB LN >3 cm: chemotherapy recommended

140
Q

Long term chemotherapy for GCT a/e:

A

cardiovascular, gastrointestinal, hematologic, infertility, secondary malignancy, neurologic, renal, pulmonary

141
Q

Recommended tx for patients with NSGCT with elevated or rising post orchiectomy serum AFP and hCG:

A

GUIDELINE STATEMENT 28

risk appropriate multi-agent chemotherapy

142
Q

Recommended treatment for Stage 1A NSGCT:

A

Reminder: IA pT1N0M0S0(beyond seminiferous tubules, still in testicle)

GUIDELINE STATEMENT 29

Surveillance preferred

RPLND or BEP x 1 (decline surveillance or non-compliance)

143
Q

What are independent risk factors for relapse in NSGCT?

A

LVI and embryonal carcinoma

144
Q

Recommended treatment for Stage 1B NSGCT:

A

Reminder IB: pT2-T4N0M0S0

GUIDELINE STATEMENT 30

surveillance, RPLND, or 1-2 BEP based on SDM

145
Q

Patients with stage 1 NSGCT and any secondary somatic malignancy (teratoma with malignant transformation) in primary tumor, what is recommended tx:

A

GUIDELINE STATEMENT 31

RPLND

(teratoma has capacity to de-differentiate into somatic malignancy including sarcomas and carcinomas)

146
Q

Patient with stage IIA NSGCT and S0, recommended tx:

A

Reminder IIA: any pTN1 (<5 nodes, < 2 cm) M0 S0 or S1 (in this question S0)

GUIDELINE STATEMENT 32

RPLND (benefit avoid chemo/remove teratoma) or chemotherapy

147
Q

Patient with stage IIB NSGCT and S0, recommended tx:

A

Reminder: Stage IIB: Any pT, N2 (1 but <5 nodes with >2cm <5 cm, OR grown outside LN, OR > 5 nodes), M0S0 (this case) or S1

GUIDELINE STATEMENT 33

Risk-appropriate BEP vs. possible RPLND (select patients, S0)

148
Q

Who should perform RPLND and how?

A

GUIDELINE STATMENT 34

referral to experience surgery at high volume center

GUIDELINE STATEMENT 35

experience and expertise with MIS can consider, acknowledge lack of long-term oncologic data

149
Q

Describe an RPLND with curative intent:

A

GUIDELINE STATEMENT 36

*full b/l template with pts with suspicious LN on CT or intra-op or teratoma

*full b/l or modified template may be performed in clinically neg nodes

*right modified template may omit para-aortic LN below IMA (omission para-aortic LN above IMA controversial)

*left modified template may omit paracaval, precaval, and retrocaval LN (omission of interaortocaval LN controversial)

*nerve-sparing should be offered to preserve ejaculatory function

*nerve-sparing should NOT compromise quality of dissection

*complete retroaortic and/or retrocaval LND w/dissection and division of lumbar vessels should be performed within planned template

*ipsilateral gonadal vessels removed in ALL patients

*cephalad extent is crus of diaphragm to level of RA, caudad extent crossing of ureter over ipsilateral common iliac

150
Q

After primary RPLND, what is recommended mgmt based on staging features:

A

GUIDELINE STATEMENT 37

Surveillance or chemo with stage II (not pure teratoma)

pN1 and/or pN1-3 pure teratoma → surveillance

pN2-3 → multi-agent chemotherapy (BEP)

151
Q

What is surveillance protocol for Stage I seminoma:

A

GUIDELINE STATEMENT 38

H&P, cross-sectional imaging of abd +/- pelvis q 4-6 mo x 2 y, q6-12 mo yrs 3-5

routine chest and STM as indicated clinically

152
Q

What is surveillance protocol for Stage I NSGCT:

A

GUIDELINE STATEMENT 39

After Orchiectomy: H&P and STM (AFP, hCG, +/- LDH) q2-3 mo x 1 year, q 2-4 mo in year 2, q 4-6 mo in year 3, q 6-12 mo years 4-5, >5 if indicated

GUIDELINE STATEMENT 40

CXR + CT A +/- P q 3-6 mo year 1 (start 3 mo), q 4-12 mo in year 2, once year 3-5

Men with higher risk of relapse should be imaged at shorter intervals (e.g. LVI)

153
Q

Patients who relapse should be treated according to what? Stage 1 GCT on surveillance have what risk of relapse > 5 years?

A

GUIDELINE STATMENT 41

pts with relapse on surveillance should be fully restaged and treated based on new TMN-s status

GUIDELINE STATEMENT 42

Stage I GCT on surveillance < 1% late relapse after 5 y, annual serologic and radiographic assessment should be performed as indicated based on clinical concerns

154
Q

How should survivors of GCT be monitored for hormonal status and long term sequelae of treatment?

A

GUIDELINE STATEMENT 43

monitor for s/s hypogonadism, if present serum AM testosterone and LH

GUIDELINE STATEMENT 44

survivors s/p chemo and/or RT → elevated risk CVD, establish PCP to manage modifiable risk factors (diet, exercise, smoking, lipids, BP, glucose)

GUIDELINE STATEMENT 45

survivors s/p chemo and/or RT → elevated risk secondary malignancy, establish PCP for checkups and cancer screening

155
Q

What are important questions to ask a young man who presents with scrotal swelling?

A

urethral discharge/unprotected sex

dysuria/hematuria

back pain (myalgia)

hx of UDT

Shortness of breath

trauma

constitutional sxs (weight loss/night sweats)

headache

pain

156
Q

What are important aspect of physical exam with suspected testicular mass?

A

lung exam

testis/spermatic cord

hydrocele

gynecomastia

inguinal exam

abdominal exam

157
Q

what are all possible elements of post orchiectomy workup and why?

A

MRI brain if headache or neuro sxs

sperm banking if not done prior

repeat STM

CT A/P

CXR (ok if CT A/P normal and STM normal after orchiectomy) vs. CT (poor prognostic features or sob)

Bone scan: clinical features warrant ALP + scan (pain, fracture?)

158
Q

what is the primary mechanism of spread of testicular tumors?

A

lymphatic

159
Q

what is important testing to conduct prior to chemo, if lung mets or pulm sxs/hx?

A

PFTs

If abnormal avoid Bleomycin

160
Q

What are short term and long term a/e of Bleomycin?

A

Pulmonary fibrosis

Raynaud’s

161
Q

What are short term and long term a/e of Etoposide?

A

Myelosuppression

162
Q

What are short term and long term a/e of Cisplatin?

A

Neurotoxicity

Nephrotoxicity

Ototoxicity

163
Q

Describe risks and concerns for consent for post-chemo RPLND?

A

risks retrograde ejaculation, vascular injury, blood txfn, possible grafting of vessels, nephrectomy. chylous ascites, ileus, bowel/ureteral injury

*minimize perioperative FiO2 and fluid overload (Bleo)

164
Q

Describe operative steps of RPLND?

A
  1. Transabdominal midline incision (xiphoid to below umbilicus)
    1. (can do robotic if can justify)
  2. Incise posterior peritoneum from ileocecal valve to ligament of Treitz
  3. Mobilize right colon, small bowel, and duodenum off RP to expose great vessels with clear exposure of renal veins; IMV can be divided to facilitate mobilization of left colon mesentery if necessary
  4. Split and roll technique with ligation/division of all lumbar vessels to allow complete mobilization of great vessels to facilitate a complete dissection; L3 most important for ejaculation (sympathetic chains just above common iliacs
  5. Complete resection of remainder of right spermatic cord
  6. Nerve sparing can be attempted if no compromised of oncologic principles/complete resection, but not required
165
Q

Describe template for post chemo RPLND:

A

lateral → right and left ureter

Inferior → ureter crossing iliac

Superior → renal vessels (suprahilar not routinely required)

166
Q

How do you diagnose chylous ascites?

A

CT A/P shows fluid ascites, air in small and large bowel

JP triglycerides elevated (like 1000)

167
Q

What are the management steps for chylous ascites?

A

1st line: diuretic with fluid & salt restriction and low fat diet with medium chain fatty acid supplement

2nd line: if persistent for weeks, NPO/TPN

168
Q

What do you do for 3 cm RP mass after RPLND for NSGCTin patient with known teratoma?

A

High dose chemo/BMT

VeIP (etoposide, ifosfamide, cisplatin, mesna)

TIP (paclitaxel, ifosfamide, cisplatin, mesna)

169
Q

What is treatment for stage Ib (pT2N0M0S0) seminoma?

A

Surveilance, XRT or chemo - Carboplatin 1 (preferred) or 2 cycles

170
Q

What are the side effects of carboplatin?

A

short term myelosuppression

long term secondary malignancy and heart disease

171
Q

What are side effects of RT?

A

short term: nausea, emesis, diarrhea, leukopenia

long term: dyspepsia, PUD, oligospermia, secondary malignancy

172
Q

Patient with recurrent seminoma s/p EP x 4, with residual RP mass (originally 6 cm now 4 cm). Next steps? If positive, next steps?

A

PET scan (CT PET)

> 6 weeks after completion chemo

Next steps:

RPLND vs. Surveillance (controversy, both acceptable per NCCN)

173
Q

What are common presentations in testicular carcinoma?

A
  1. Painless testicular enlargement–most common
  2. Testicular mass–firm lump or nodule
  3. Testicular pain–heaviness, aching, acute pain~10%
  4. Gynecomastia–%5
  5. Abdominal mass or pain
  6. Respiratory problems
174
Q

When performing orchiectomy for testicular mass, when would you recommend biopsy of contralateral side?

A

US abnormal

UDT or poor spermatogenesis

Marked atrophy (volume <12)

175
Q

Half lives of STM?

A

BhCG 24-46 h (check 1 week)

AFP 5-7 days (check 4 weeks)

LDH 4 days

176
Q

Treatment options for IB seminoma?

A
  1. Surveillance: best option with low risk (tumor size < 4 cm, no rete testis invasion, recurrence as low as 6%); need compliance, concern for radiation (CTs)
  2. EBRT: seminoma very radiosensitivity, long term radiation toxicity < 2% (cardiac disease doubled, risk secondary malignancy); para aortic field and ipsi nodes (“dog leg”) 20 Gy in 10 fx; relapse 1-3%
  3. Single dose carboplatin: noncompliant patients; equivalent relapse to RT, short term a/e thrombocytopenia and GI toxicity
177
Q

Describe surveillance for IB seminoma post orchiectomy? After RT or chemo?

A

Orchiectomy:

HPI: 1 year: q3-6 mo, 2-3 year: q6-12 mo, 4-5 year: 1 x year

A/P CT: at 3, 6, 12 mo, 2-3 year q 6-12 mo, 4-5 year: q 12-24 mo

CXR: if clinically indicated, sxs consider CT

Chemo/RT

HPI: 1-2 year: q6-12 mo, 3-5 year 1 x year

A/P CT: 1-3 year: q1 x year, 4-5 year not indicated

CXR: if clinically indicated, sxs consider CT

178
Q

Tx of IIA seminoma? And IIB?

A

IIA:

Traditional (preferred): EBRT to para-aortic and ipsi iliac PLN → 30 Gy

OR

Primary chemotherapy: EP x 4 or BEP x 3 for multiple positive LN

IIB:

Preferred: Primary chemotherapy: EP x 4 or BEP x 3

RT in non-bulky cases include para-aortic and ipsi iliac LN → 36 Gy

179
Q

For stage IIC or III seminoma what determines tx?

A

Risk factors

Good risk: any primary site, no non-pulm visceral mets, normal AFP, any hCG or LDH

Intermediate risk: any primary site, non-pulmonary visceral mets, normal AFP, any hCG or LDH

Poor risk: no seminoma is poor risk

180
Q

Treatment for good risk IIC or III seminoma? intermediate risk?

A

Good risk: Primary chemo EP x 4 or BEP x 3

Intermediate risk: BEP x 4 or VIP x 4 or clinical trial

181
Q

How do you manage post-chemo residual mass for seminoma?

A

Likely fibrosis or necrosis

< 3 cm → surveillance

>3 cm → PET scan > 6 weeks after chemo, if + RPLND or chemo (conventional dose VeIP or TIP, or high dose chemo)

182
Q

risk factors for testicular carcinoma?

A

gonadal dysgenesis

h/o prior testis tumor

CIS or intraepithelial germ cell neoplasia

UDT (intra-abd → seminoma, inguinal after pexy → NSGCT)

HIV

FHx

Infertility with Klinefelter’s

Hypospadias

183
Q

Name primary GCT (relative frequency) and non-GCT?

A

Primary Germ Cell Tumors: seminoma (60%), embryonal carcinoma (20%), teratocarcinoma (15%), teratoma (5%), chorio (1%), yolk sac (<1%)

Non Germ Cell Tumors: only 10% malignant, orchiectomy and surveillance: Leydig cell tumor, Sertoli cell tumor

184
Q

Describe path of testicular carcinoma spread?

A

Primarily via Lymphatics

RP node mets → cisterna chyli → thoracic duct → supra-diaphragmatic nodes → extra-nodal/distant mets

**exception is chorio or yolk sac which can demonstrate hematogenous spread

185
Q

Describe nodal spread pattern for right testis tumor? left testis tumor?

A

Right: Interaortocaval → precaval → preaortic → right common iliac → right external iliac

Left: paraaortic → preaortic → left common iliac → interaortocaval → precaval → paracaval

*lymphatic spread goes from right to left in RP

186
Q

What are treatment options for stage IB NSGCT?

A
  1. Surveillance (only pT2)
    1. Patient needs to be very compliant with rigorous surveillance
    2. >50% embryonal may increase risk of relapse and make surveillance inferior to tx
    3. LVI most important factor to predict occult mets
    4. SWENOTECA trial, all men stage I NSGCT no LVI underwent surveillance, BPE x 1, or BEP x 2, recurrence 12%, 1%, 0%
  2. Chemo
    1. 1 cycle BEP or 2 cycles (teratoma resistant, risk of infertility, secondary cancer, cardiac dz)
  3. NS-RPLND (appropriate for stage I and IIA
187
Q

Risk of teratoma at RPLND? if in orchiectomy and if not?

A

In orchiectomy: 2-19%

Not in orchiectomy: 5-7%

188
Q

What are the types of RPLND? Templates?

A
  1. Standard: includes full b/l dissection from above the RV to below aortic bifurcation, anejaculation approached 100% since sympathetic ganglia were sacrificed
    1. Superior: L adrenal, renal veins, below SMA
    2. Inferior: aortic bifurcation, IMA is sacrificed
    3. Medial: to contralateral ureter
    4. Lateral: renal hilum, ureter, iliac bifurcation
  2. Limited: area overlying aorta below IMA spared, most post-ganglionic sympathetics preserved, ejaculation 80-90% pts
    1. Superior: L adrenal, renal veins, below SMA
    2. Inferior: above IMA (IMA spared)
    3. Medial: lateral to aorta
    4. Lateral: renal hilum, ureter, iliac bifurcation
  3. NS-RPLND: preserves branches sympathetic chain over aorta, 100% ejaculation; not usually recommended for grossly pos nodes, usually performed in combo with limited dissection
189
Q

What percentage of IB are upstaged to stage II on RPLND?

A

30%

190
Q

If LN are grossly positive on RPNLD (stage IIB: >2 cm < 5 cm) what intraoperative template adjustment is made?

A

bilateral suprahilar dissections extending 4-6 cm above renal arteries to expose crura of diaphragm, IMV ligated, SMA identified and preserved, cisterna chyli is clipped

Superior: first hepatic vein (IVC)

Inferiorly: renal arteries

Laterally: medial aspect of adrenal glands

If nodes + near IMA → extend to lower aorta and contralateral common iliac (retrograde lymph spread)

If nodes + superior to IMA → lower aorta preserved

191
Q

Potential complications of RPLND?

A
  1. IVC laceration: proximal and distal control, oversew with 4-0 Prolene, hold pressure, if cannot control, consult vascular
  2. IMA injury: ligate if necessary since collateral circulation (marginal artery of Drummond)
    1. IMA supplies distal half of transverse colon, descending colon, sigmoid, and rectum
    2. SMA supplies proximal half of transverse colon, ascending colon, and small bowel
  3. Cisterna Chyle laceration: located right of L1-L2, ligate if recognized intraop, unrecognized will result in chylous ascites
    1. Dx by paracentesis, NPO, TPN or low fat, high protein, medium chain triglycerides diet, possible somatostatin analogues
192
Q

NSGCT stage IA, IB without risk factors, IIA, IIB treated with primary RPLND, what is tx for various nodal stages?

A

N0 → surveillance

N1 → surveillance (preferred) or chemotherapy (EP x 2)

N2 0→ chemotherapy (preferred - EP x 2) or surveillance

N3 → chemotherapy (BEP x 3 or EP x 4)

193
Q

NSGCT IIA/IIB s/o RPLND, WITHOUT adjuvant chemo surveillance?

A

H&P and markers: 1 year: q2 mo, 2 year

194
Q

NSGCT IIA/IIB s/o RPLND, WITH adjuvant chemo surveillance?

A
195
Q

NSGCT Stage I s/p RPLND or chemo, surveillance?

A
196
Q

NSGCT Stage 1 primary active surveillance w/o risk factors?

A

Risk factors: LVI, invasion of spermatic cord or scrotum, embryonal

197
Q

NSGCT Stage 1 primary active surveillance w/ risk factors?

A

Risk factors: LVI, invasion of spermatic cord or scrotum, embryonal

198
Q

NSGCT II/III after complete response to chemo +/- RPLND?

A
199
Q

What can cause AFP elevation?

A

hepatoma, pancreas carcinoma, bronchogenic carcinoma

elevated in fetal yolk sac tumor, embryonal, teratocarcinoma

infants < 1 yo

Liver dysfunction (hepatitis, cirrhosis)

200
Q

What can cause bhCG elevation?

A

chorio, seminoma, teratocarcinoma, embryonal

cross reacts with FSH, LH, TSH

marijuana users

201
Q

What can cause LDH elevation?

A

seminoma and non-seminoma

Isoenzyme 1 is most useful

monitor treatment when AFP and bhCG normalized

useful for “bulky” seminoma

202
Q

Stage IIC NSGCT, how do you determine the number of chemo cycles?

A
  1. Good risk: treat with EP x 4 or BEP x 3

AFP < 1,000, HCG < 5,000, LDH < 1.5 X N (S0 or S1)

  1. Intermediate risk: treat BEP x 4

AFP 1,000-10,000, HCG 5,000-50,000, LDH 1.5-10 x N (S2)

  1. High risk: treat BEP x 4 or VIP x 4

AFP > 10,000, HCG >50,000, LDH 10 x N (S3)

Mediastinal primary

203
Q

Potential complications and treatment from RPLND?

A
  1. ARDS → bleomycin → increases w/ increased FIO2 and over-hydration
    1. Ventilate patients with RA and do not use FIO2 > 25-30%
    2. Use colloid to crystalloid ratio 2:1
    3. Prefer RBC over crystalloid
  2. Mass invades duodenum → perform duodenal resection
  3. IMA is encased in tumor → divide IMA as long as marginal artery intact
  4. Ureter is encased or invaded by tumor → nephroureterectomy
  5. Tumor invades aorta, IVC, lilac vessels → excise and replace affected vessels, perform vascular patch
  6. Psoas muscle involved by tumor → resect psoas fascia and affected muscle
  7. Tumor thrombus present in IVC below renal veins → ligate vena cava below renal veins, pts will develop temporary lower extremity edema
  8. Tumor invades the wall of IVC below the renal veins → legate the vena cava below renal veins, pts will develop temporary lower extremity edema
  9. Sigmoid mesentery is adherent to mass → resect the mesentery and mesenteric vessels, make sure the marginal artery and vein remain intact
204
Q

What chemotherapy regimens are used in salvage setting for testicular cancer?

A
  1. VeIP (VP-16, Ifosfamide, Cisplatin) → mesna to protect bladder from Ifosfamide, 30% durable responses
  2. TIP (Paclitaxel, Ifosfamide, Cisplatin) → mesna to protect bladder from Ifosfamide, 25% durable responses
  3. Gemcitabine/Ifosfamide/Cisplatin → small study reporting 54% response rate
  4. High dose chemotherapy → with autologous peripheral blood derived stem cell support, unfavorable prognosis group (incomplete previous response, high markers, high volume, extratesticular primary, late relapse)
    1. 2 cycles of high dose Carboplatin plus Etoposide, w/ or w/o Cyclophosphamide (or Ifosfamide) → 20% durable responses
205
Q

Follow up regimen after salvage chemotherapy for testicular cancer?

A

CXR and markers q3 mo x 2 years, then q6 mo x 3

CT A/P q 6 mo

206
Q

How do you manage post chemotherapy residual mass for NSGCT? Seminoma?

A

NSGCT → residual mass should be excised as completely as possible if > 1 cm

Markers have to normalize before RPLND, if elevated → further chemotherapy

Seminoma → residual mass > 3 cm and normal markers → PET CT vs. surveillance → Indeterminate → repeat PET 6-8 weeks vs. bx → Positive → RPLND vs. bx

207
Q

If there is mixed pathology seminoma and nonseminoma, how do you treat?

A

NSGCT recommendations

208
Q

what are primary landing sites for left and right testicular tumors?

A

Left → para-aortic → preaortic

Right → interaortocaval → precaval → right iliac

209
Q

describe the nerve sparing elements of RPLND? why important?

A

prevent anejaculation or other ejaculatory dysfunction

ID and preserve sympathetic trunks (L1-4) as they course posterior to the IVC on the right and anterior to aorta on the left, they coalesce just inferior to the IMA at inferior hypogastric plexus

210
Q

What are treatment options for scrotal contamination in testis cancer?

A
  1. Stage 1 pure seminoma → extend RP radiation to include ipsi scrotum and inguinal nodes (risk of azoospermia)
  2. Stage 1 NSGCT → widely excise previous scar and spermatic cord at time of RPLND, or separate procedure if no RPLND, perform formal hemiscrotectomy in case of gross contamination but ill not eliminate risk of relapse
  3. Advanced dz → tx with full dose platinum chemo → examine inguinal nodes at f/up

**contamination increased recurrence but not OS

211
Q

Which nodal status is chemo indicated for post RPLND Stage IA/B or IIA/B treated with primary RPLND? Which regimens?

A
212
Q

Follow up post primary RPLND in need of adjuvant chemotherapy?

A

CXR and markers q3 mo x 2 years, the q 6 mo x 3 years

CT scan q 6 mo

213
Q

Treatments for clinical stage IIA NSGCT with negative markers?

A

Primary NS-RPLND

OR

Primary chemotherapy EP x 4 or BEP x 3

214
Q

Treatments for clinical stage IIB NSGCT with negative markers?

A
215
Q

Treatments for clinical stage IIA NSGCT with persistent markers elevation?

A

Primary chemotherapy → BEP x 3, EP x 4

216
Q

Treatments for clinical stage IIB NSGCT with positive markers?

A

Primary chemotherapy: BEP x 3, EP x 4

217
Q

Primary chemotherapy for early clinical stages with persistent marker elevation:

A
218
Q

What is growing teratoma syndrome?

A

RP masses that contain teratomas enlarge (sometimes quickly) in the face of normal STM. Usually benign, but warrant surgical excision, if left alone may spread and compromise vital organ function (bowel, ureters, vessels) by local invasion

219
Q

Why can testis tumors cause gynecomastia?

A

NSGCT can produce elevated levels of estradiol

Leydig cell tumors promote peripheral conversion of testosterone to estrogen (but will not cause elevation in STM)

220
Q

What if you remove a testicular tumor in a patient with clinical symptoms (e.g. gynecomastia), elevated STM, and a supraclavicular node, and the pathology shows scar and no active malignancy?

A

“burned” out testis tumor or extragonadal

Must perform excisional bx or FNA of supraclavicular node

221
Q

Describe risk classification post-orchiectomy for NSGCT and seminoma

A
222
Q

Post orchiectomy for NSGCT, with NED, with isolated bHCG elevation, what can be the cause?

A

Elevated LH

Single testicle → low testosterone → anterior pituitary increased LH which has cross reactivity with bhCG

Give testosterone injection and retest (if goes down, no further action)

03. Testis + Penile + Uretral Ca (1060) (9 decks)

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