What is the most common testicular cancer type and why does it represent the model of a curable malignancy?
Testicular Germ Cell Tumours
95% of testicular malignancies.
• Sensitive tumour markers.
• Accurate prognosis classification.
• Logical series of management trials.
• High cure rates in both seminomas and non-seminomas.
What are the two main types of germ cell testicular tumours?
2)Non-seminoma (Further divided into 5 subsets)
What cancer is the most common solid neoplasm in young men (aged 20-34yrs) and the second most common in men aged 35-40?
Germ Cell Testicular Tumour
At what ages are seminomas rare?
Under 10 and over 60.
Give five risk factors for developing Germ Cell Testicular Tumour.
2) Testicular Atrophy
3) Inguinal Hernia
5) Syndromes with abnormal testicular development
What is CIS testes?
• Carnicoma in situ of testes •
- 50% develop invasive cancer at 5 years.
-Spontaneous disappearance is never observed.
- If left untreated will probably be invasive in all cases.
What is the clinical presentation of testicular cancer?
• Painless swelling of testes.
• 30-40% dull ache or heaviness.
• 10% have acute testicular pain.
• Enlargement in an atrophic teste.
• 5% gynaemastica.
What are the investigations used to diagnose testicular cancer?
•MRI (High specificity but expensive)
• Serum tumour markers
Which tumour markers are tested for in testicular cancer?
• AFP - Raised in 50-70% of NSGCT, but not raised in pure seminomas.
• ß-hCG - Raised in 40-60% of NSGCT and 30% of seminomas.
• LDH is less specific but more commonly raised in seminomas.
What is Alpha-FP? What is it a marker of?
It is a tumour marker and an embryonal protein.
• Not produced in pure seminomas, but can be produced by NSGCT.
• Also produced in liver damage and is a marker of hepatocellular carcinoma.
What is ß-hCG? What is it a marker of?
• It is a product of trophoblastic tissue in placaenta.
• Also used as a tumour marker and is produced by both seminomas and non-seminomas.
• Also produced by upper GI, bladder and bronchial carcinoma.
How does the staging work for testicular cancer?
• pT (Primary Tumour) •
- pT0 - No evidence of tumour
- pTis - In situ carcinoma
- pT1 - Limited to testis and epididymis
- pT2 - Limited to testis and epididymis with invasion into vascular/lymphatic invasion.
- pT3 - Invades spermatic cord
- pT4 - Invades scrotum
What is the management of a stage I seminoma?
• 15-20% will have sub-clinical metastases in the retro-peritoneum so will relapse.
• Adjuvant radiotherapy.
• Adjuvant Chemotherapy.
What are the common types of extra-testicular mass?
• Epididymal cyst
Where do testicular tumour metastasise to?
Which nodes are involved in advanced penile cancer?
What is the chemotherapy used for testicular cancer and what is the cure rate?
BEP - bleomycin, etoposide and cisplantin.
Cures 90% of patients.
What is the mechanism of most chemotherapy drugs and how does this affect cancer cells?
They interfere with DNA synthesis or cell replication.
Tumour cells rapidly divide, therefore are most susceptible to this effect, though the theraputic window is often very narrow.
What are alkylating agents?
These are chemotherapy drugs that for covalent bonds with DNA, preventing DNA replication.
E.g- Mechloratamine, Cyclophosphamide, ifosfamide, melphalen.
Hormone treatment is one of the most important therapies for which type of cancer?
• Breast cancer, anti-oestrogens are used as oestrogens have been shown to cause the growth of breast cancer.
What are the four aims of systemic therapy of cancer?
• Primary therapy for curative therapy
- testicular cancer, ALL, Hodgkins lymphoma.
- To reduce the extent of surgery, e.g. breast, bladder, larynx.
• Adjuvent- Therapy after local radical treatment.
- Breast, colon, lung, prostate
• Management of advanced disease -
- Prolonging survival, paliative.
What are the three branches for systemic therapy of cancer?
1) Stop proliferation - cytotoxic drugs.
2) Block growth signals - Anti-hormones, targeted treatment.
3) Prevent/reduce complications and side-effects.
- Treatment of bone disease
What is the most commonly diagnosed cancer in males?
• Prostate cancer.
What is the 5 and 10 year survival from prostate cancer?
• 5 yr - >8 in 10
• 10 yr - nearly 7 in 10
What is the link between disease stage at diagnosis and survival from prostate cancer?
Organ-contained disease - 90% at 5 yr
Metastatic - 30% at 5 yr
What are the risk factors for developing prostate cancer?
• Age (increases exponentially after 50)
• Race (highest in europe and north america)
• Family History
• Dietary fat intake
What are the symptoms for prostate cancer?
• Often very little in early disease, symptoms are often indicative of advanced or metastatic disease.
• Local - Obstructive voiding, Irritative symptoms, Blocked ejaculatory ducts, Impotence.
• Metastatic - Bony pain, Anaemia, Lymphodema, Renal failure.
What is the clinical utility of a PSA result?
• Not specific enough - 1 in 3 men with an abnormal PSA will not have prostate cancer.
• Not sensitive enough - Up to 20% of men with prostate cancer will not have a raised PSA.
What occurs when a patient has both an abnormal PSA and DRE?
Refer to urology.
Perform urine test to rule out UTI and repeat PSA within a few weeks.
What is the treatment of localised cancer in patients with a life expectancy of greater than 10yrs?
• Active surveilance
• Radical Prostatectomy +/- hormone ablative therapy.
• Radical Radiotherapy +/- hormone ablative therapy.
What are the options for treating men with metastic protstate cancer?
• Hormone ablative therapy - the vast majority of men respond.
• Techniques such as orchidectomy, Anti-androgens, Abiraterone is the latest therapy.
What is the management of bony complications in men with hormone refractory prostate cancer?
• Biphosphonates - Inhibit the action of osteoclasts and is effective in relieving skeletal pain in 30% of patients.