Testis Cancer Flashcards by Kevin Chu

What is typical finding on scrotal ultrasound of a patient with testicular cancer.

Hypoechoic mass w/ vascular flow (occasionally without)

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What are risk factors for testicular cancer? Important in men with testicular microlithiasis.

Hx of UDT, familial hx of testicular cancer, personal hx of testicular cancer, prior dx of GCNIS

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What happens if indeterminate lesion (< 1 cm, non palpable), and normal tumor markers?

Repeat U/S in 6-8 weeks.
Counsel patient, can offer continued surveillance, orchiectomy, TSS with intra op frozen.
Only antibiotics if signs of infection.

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Where is the spermatic cord supposed to be ligated on a radical orchiectomy?

At the internal inguinal ring.

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What to be discussed with patient prior to orchiectomy?

sperm cryopreservation, hypogonadism, and TESTICULAR PROSTHESIS

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What to counsel patient on scrotal violation?

Higher chance of LOCALIZED recurrence (2.5%) - rarely do adjuvant tx such as excision of scar or radiation tx.

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What are indications for a partial orchiectomy?

Small lesion < 2cm.
Non palpable. Normal STM. These may be 50% benign.
Contraindication to radical, such as solitary testis, or bilateral lesions.

Need to discuss with patient what to do if GCT is found.

If GCNIS - must sample area outside lesion. Then discuss with patient closer surveillance.

Higher chance for local recurrence ~20%.

Need to discuss testicular atrophy, sub fertility and hypogonadism

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Is a person with testicular cancer have a higher chance of CA in contralateral testes? What are some risk factors?

YES

Risk factors - younger age of diagnosis, testicular atrophy, UDT

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What is management for patient with GCNIS

SDM

50% chance of developing GCT

Surveillance - if wishes fertility or testosterone production is important
Orchiectomy
Radiation - but will cause hypogonadism and subfertility, and still small risk of developing GCT

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Give me the TNM-S staging for testicular CA

Tis - GCNIS
T1 - within testis, no LVI, w/in TA
T2 - outsides testis (TUNICA VAGINALIS), LVI,
T3 - spermatic cord involvment
T4 - scrotal wall involvement

N0 - no nodes
N1 - < 2 cm
N2 - 2-5 cm
N3 - > 5cm

M0 - no mets
M1a - pulm mets, non-RP LN
M2a - visceral mets

S0 - normal
S1 - one is above normal
S2 - one is “intermediate” above normal
S3 - one is “poor” above normal

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Give me staging for testicular CA

stage IA - testis, no LVI
stage IB - testis, w/ LVI
Stage IIA - LN, < 2cm
Stage IIB - LN, 2-5cm
stage IIB - LN > 5cm
Stage IIIA - pulm
Stage IIIB - pulm but elevated STM
Stage IIIC - PULM OR non pulm or S3 elevated STM

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When is good, intermediate, and poor risk used?

For chemotherapy purposes.

Good - BEP x 3, EP x 4
Intermediate or Poor - BEP x 4

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Break down risk for sem vs non sem

Sem:
Good risk - pulm mets, normal AFP, other STM can be anything
Int risk - non-pulm visceral mets, normal AFP, other STM can be anything

Non-sem
Good risk - no non-pulm mets, AFP < 1000, BHCG < 5000, LDH < 1.5x
Int risk - no non-pulm mets, AFP 1-10k, BHCG 5k - 50000, LHD 1.5x - 10x
Poor - non-pulm mets, AFP > 10k, BHCG > 50K, LDH > 10x

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Can you make decision based off a borderline AFP or HCG (w/in 3x of normal)?

No - must continue to trend

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What is metastatic workup?

CT A/P W/ IV contrast (or MRI), with some chest imaging

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When should treatment decisions be made?

Within 10 days of HCG or AFP levels, as well as 4 weeks of imaging.

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Who are usual consultants for testicular CA?

med onc, rad onc, pathology, radiology

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What happens if you have equivocal imaging (not CLEAR) and STM are normal?

repeat imaging in 6-8 weeks. BE SURE.

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What is treatment option for sem - stage IIA or stage IIB LN </= 3 cm?

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SDM - XRT (dog leg field) or BEP x 3 / EP x 4

If toxicity of XRT and chemo are concern – then can offer RPLND

What are long term effects of chemo and radiation?

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cardiotoxicity, GI toxicity, hematologic toxicity, secondary malignancy

infertility, peripheral neuropathy, high-pitch hearing loss, cardiovascular disease, and secondary malignancies

What is treatment for sem - stage IIB LN > 3

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Chemo - BEP x 3 / EP x 4

What is treatment for non sem with any elevated STM?

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Chemo - according to risk status

What is treatment for non sem - stage IA?

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Preferred - surveillance (relapse rate - ~20%)
Option - RPLND vs BEP x 1

Risk factors for relapse is embryonal or LVI

What is treatment for non sem - stage IB?

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Surveillance vs RPLND vs BEP 1-2x (relapse rate is ~50%)

What is treatment for non sem - w/ teratoma in orchiectomy specimen?

RPLND Why?? Because teratoma is not chemo-sensitive -

What is treatment for non sem - stage IIA? with normal STM

RPLND vs chemo (BEP x 3 / EP x 4)

What is treatment for non sem - stage IIB? with normal STM

chemo (BEP x 3 / EP x 4) RPLND is done in patients with teratoma or contraindication to chemo

If a patient has had inguinal surgery, what does that mean?

Don't do RPLND

What is treatment for non sem - stage IIC or IIIA?

chemo (BEP x 3 / EP x 4)

What is treatment for non sem - stage IIIB or IIIC

BEP x 4 or VIP x 4W

What nodes does a bilateral RPLND template encompass? When should it be performed?

para-aortic, retroaortic, pre-aortic, para-caval, pre-caval, retro-caval interaortocaval, left common iliac, right common iliac, ipsilateral gonadal vessel When there is suspicious LN on imaging or intraop, as well as if with teratoma

What is cephalad and caudal extent of RPLND

cephalad - crus of diaphragm - level of the renal arteries caudal - where ureters cross the iliac vessels

What should happen after RPLND in NSGCT patients?

As long as not pure teratoma - surveillance vs chemo (BEP x 2 / EP x 2). PN1 or PN1-PN3 teratoma - surveillance PN2-3 - BEP x 2 / EP x 2

What is surveillance for stage I GCT?

HP x 6 months x 2 years CT A/P x 6 months x 2 years Annually afterwards x 3 years CXR and STM PRN

What is surveillance for stage I NSGCT

HP + STM x 3 months x 1 year HP + STM x 4 months x 1 year HP + STM x 6 months x 1 year HP + STM x 12 months x 2 year CT + CXR is similar the first two years, then annually afterwards If with LVI consider shorter imaging intervals.

What are chances for relapse in stage I GCT?

< 1 % in 5 years

What are signs of testicular Ca?

Painless scrotal swelling, testicular pain, testicular mass, gynecomastia, abd mass, respiratory problems

How do you manage post chemo seminoma residual mass?

Most of these are fibrosis. Smaller than or equal to 3 cm - observe Greater than 3cm - PET scan at 6 weeks!! If positive consider RPLND vs second line chemo

What is chance of being upstaged on RPLND?

30% from stage I to II

What is common clinical sign post RPLND?

Postoperative tachycardia. Just ensure EKG and fluid status are adequate

What is surveillance for patient post RPLND, NSGCT, stage IIA or IIB

HPI and STM q2 mths x 1 yr, q3 x 1 yr, q4 x 1 yr, q6 x 1 yr, then yearly A/p CT baseline at 3 months, then clinically as indicated. CXR q3 months x 1 yr, q6 months x 1 yr, then annually

What are special situations in which AFP, bHCG, or LDH are elevated?

AFP - liver disease BHCG - marijuana users, solitary testis (inject testosterone and retest) LDH - bulky disease in seminoma

What are chances of finding cancer in a post chemo RPLND for a non sem with residual mass?

20% - persistent cancer 40% teratoma 40% fibrosis

Things to be aware of in post chemo RPLND

Lungs are more at risk due to chemo - can get ARDS. Resect whatever it takes to get tumor out.

What to do with post chemo residual mass in NSGCT?

Must resect! Unless less than 1cm or 10% of prior. Must wait until STM normalize to do surgery - otherwise you will need to continue more chemotherapy until it does.

Talk to me about scrotal violation.

Sem - radiation to the hemiscrotum + nodes - if treatment is desired NsGCT - resect out the scar and spermatic cord, whether at RPLND or separate procedure. If chemo is performed, don’t need to excise.

Testis Cancer Flashcards

(46 cards)