Testicular Cancer
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109 terms
Terms | Definitions |
|---|---|
 What are risk factors for testis cancer? | Cryptorchidism, CIS, +FH, gonadal dysgenesis, AIS, metachronous testis cancer |
| What is the risk of developing GCT if you have CIS? | 50% in 5 years |
| T/F Trauma is a risk factor for testis cancer | F Either are atrophy, diethylstilbestrol, and OCP |
| What is the primary nodal landing site of a left testicular tumor? | Para-aortic - pre-aortic - interaortocaval Rare to cross to the right |
| What is the primary nodal landing site of a right testicular tumor? | Interaortocaval - paracaval - pre-aortic Can cross to left |
| What type of testis tumor has early hematogenous spread? | Choriocarcinoma Yolk sac can met hematogenously as well |
| Cryptorchidism is more common on what side? | Right that is why testis tumors are more common on the right. The higher the testis the higher the risk of malignancy |
| Gynecomastia is the presenting symptom in 30-50% of what types of testis tumors | Leydig and Sertoli cell |
| Inguinal or pelvic node involvement of testis cancer is more common when? | Cryptorchid pts, scrotal wall involvement, prior inguinal surgery, epididymal or cord involvement |
| Seminoma accounts for what percentage of testis tumors? | 45% |
| What is the updated term for anaplastic seminoma? | Seminoma with high mitotic index. Often presents with mets and acts aggressive but stage for stage same outcome as classic |
| What type of testis tumor presents at an older age, rarely metastasizes, and has an indolent course | Spermatocytic seminoma Rarely associated with sarcomas |
| What is the pathologic feature of spermatocytic seminoma | Cells of varying size (typically 3) that resembles maturing spermatogonia |
| What do tumor markers look like with pure seminoma? | Never secretes AFP 10-15% have elevated bHCG due to synsciotrophoblasts |
| What are two predictors of occult mets in NCGCT? | Embryonal component and LVI |
| What does embryonal carcinoma look like histologically? | Epithelial-like cells, papillary projections, "nasty looking tumor" |
| What do tumor markers look like with embryonal? | Pure may have elevated AFP or bHCG |
| What is a classic histologic feature of yolk sac tumors? | Schiller-duval bodies- papillary structure with fibrovascular core |
| What do tumor markers look like with yolk sac tumors? | May secrete AFP and bHCG |
| What is the classic histologic feature of choriocarcinoma? | Syncytiotrophoblasts (multiple nuclei, eosinophilic cytoplasm) and cytotrophoblasts (single nucleus, clear cytoplasm) |
| What type of testis tumor may present with distant met spread only? | Choriocarcinoma |
| T/F prepubertal teratoma is usually malignant | F |
| What tumor markers are secreted with teratoma? | None routinely |
| What genetic change exists in postpubertal pts that makes teratoma have potential for metastatic spread? | They are hypotriploid, demonstrating a chromosome imbalance, namely gain of 12p |
| What is the most common testis tumor in children? | Teratoma |
| Mixed germ cell tumors make up what % of overall testis tumors? | 60% |
| T/F teratomas are radio- and chemo-sensitive | F |
| How are MGCT that contain seminoma treated? | As NSGCT |
| Testicular CIS is a precursor of what? | All invasive germ cell tumors except spermatocytic seminoma peds testis tumors |
| What patients are at risk of CIS? | h/o contralateral testis cancer, cryptorchidism, extragonadal germ cell tumor, intersex or sexual ambiguity |
| What ultrasound finding on a contralateral testis in someone with invasive germ cell tumor increases the risk of CIS? | Microlithiasis |
| Chemo cures what % of CIS? | 66% Orchiectomy and radiation (25Gy) are 100% |
| Where is AFP synthesized? | Fetal yolk sac, liver, intestines |
| At what age are AFP levels normalized? | By 1 year of age should be <10ng/ml |
| What factors can cause AFP elevation? | Liver failure, liver cancer, MJ, antiepileptics, EtOH |
| What tumors are associated with elevated AFP? | Yolk sac, embryonal, teratoma Never elevated in pure seminoma or chorio |
| What is the half life of AFP? | 5-7 days |
| What are the two subunits of HCG? | Alpha - similar to LH, FSH, prolactin Beta - 70% homologus to LH |
| If HCG is elevated and you don't believe it what can you do? | Give testosterone and recheck because hypogonadism can cause elevated LH and falsely elevated HCG |
| What is the half-life of HCG? | 24-36 hours |
| What tumors is HCG elevated in? | Choriocarcinoma, seminoma, and embryonal |
| What is a marker of tumor bulk? | LDH Half life is 4 days |
| How long post-orch should tumor markers normalize? | HCG - 1-2 weeks LDH - 3 weeks AFP - 5 weeks |
| What does a testicular tumor look like on u/s? | Hypoechoic mass |
| When is a PET scan useful in testis cancer? | For evaluating post-chemo residual mass in seminoma (Stage II and III) |
| When is a chest CT needed in testis cancer? | If abd CT shows tumor |
| Where is the primary lymphatic drainage above the RP in testis cancer? | Cisterna chyli, thoracic duct, and left supraclavicular LN |
| What is a tumor marker for advanced testis cancer that is rarely used? | Placental alkaline phosphatase (PLAP) |
| What is a T1 testis tumor? | Limited to testis and epididymis, no LVI, may include tunica albuginea but not vaginalis |
| What is a T2 testis tumor? | Limited to testis and epididymis, LVI or tunica vaginalis involvement |
| What is a T3 testis tumor? | Direct cord invasion |
| What is a T4 testis tumor? | Direct scrotal invasion |
| What is an cNI and a pN1 testis tumor? | cN1 - single or multiple <2cm pN1 - mass </=2cm or </=5 positive nodes no >2cm |
| What is an cN2 and a pN2 testis tumor? | cN2 - single or multiple 2-5cm pN2 - mass 2-5cm or >5 positive nodes no >5cm |
| What is an cN3 and a pN3 testis tumor? | cN3 - mass >5cm pN3 - mass >5cm |
| What is the M staging for a testis tumor? | M1a - nonregional nodal or pulm mets M1b - distant other mets |
| What is S1 testis tumor? | LDH - <1.5x normal and hCG - <5000 and AFP - <1000 |
| What is S2 testis tumor? | LDH - 1.5-10x normal or hCG - 5000-50000 or AFP - 1000-10000 |
| What is a S3 testis tumor | LDH - >10x normal or hCG - >50000 or AFP - >10000 |
| Describe stage I testis cancer | IA - pT1 N0 M0 S0 IB - pT2-4 N0 M0 S0 IS - pT1-4 N0 M0 S1-3 |
| Describe stage II testis cancer | IIA - any T N1 M0 S0/1 IIB - any T N2 M0 S0/1 IIC - any T N3 M0 S0/1 |
| Describe stage III testis cancer | IIIA - any T any N M1a S0/1 IIIB - any T N1-3 M0 S2 any T any N M1a S2 IIIC - any T S3 or any S and M1b |
| Does the degree of hCG prior to orchiectomy have any effect on outcome or prognosis? | No |
| What study is required if you suspect someone has an extragonadal germ cell tumor? | Scrotal ultrasound |
| If low stage seminoma and h/o scrotal orchiectomy what should you do? | Radiation portal should extend to cover ipsilateral groin and scrotum |
| If low stage nonseminoma undergoing RPLND and h/o scrotal orchiectomy what should you do? | Simultaneous excision of scar and cord Could also excise cord and scar at time of post-chemo RPLND |
| What are the landmarks for original RPLND? | Sup - renal art/vein Lat - medial border of ureter/gonadals Post - psoas muscle Inf - lower aspect of common iliacs |
| What is the modified template? | Goal is to preserve ejaculations Dissect inf hypogastric plexus at level of IMA Limit dissection distal to IMA on unaffected side |
| Which side are results of modified template better in terms of preservation of ejaculation | Right |
| Where are you most likely to injure the cysterna chyli? | Around right diaphragmatic crus |
| How do you treat chylous ascites? | Perc drain Med chain fatty acids, low fat diet TPN |
| When is a full bilateral template indicated? | Post-chemo RPLND Palpable nodes found in a modified template |
| When is a bilateral modified template indicated? | All clinical stage IIA or IIB nonseminoma |
| When is a unilateral modified template indicated? | Clinical stage I nonseminoma |
| What is the treatement for stage IS NSGCT and seminoma? | BEP x 3 or EP x 4 - NSGCT 35-40 Gy to RPLN + ipsalateral iliac nodes |
| What increases the risk for micromets and relapse after clinical stage I seminoma? | Elevated tumor markers LVI Tumor size >4-6cm Rete testis invasion |
| What increases the risk for micromets and relapse after clinical stage I nonseminoma? | Elevated tumor markers >50% embyonal MIB-1 staining (measures IHC Ki-67) LVI Absence of yolk sac elements T2-4 Tumor size >4-6cm |
| What percentage of stage I nonseminoma relapse on surveillance? | 25-35%, majority within one year |
| What can teratoma undergo malignant transformation to? | Sarcoma or adenocarcinoma |
| What is the chemo regimen for NSGCT stage IB? | BEP x 2 |
| What percent of seminoma have stage I disease at presentation? | 70% |
| What percentage of NSGCT have mets at presentation? | 70% |
| What percentage of stage I seminoma relapses on surveillance? | 15% |
| If you have stage 1 seminoma and opt for radiation how is it administered? | 25Gy to para-aortics Relapse 0-7% |
| What are contraindications to XRT for seminoma? | Previous abd XRT IBD Horseshoe/pelvic kidney Renal hilar nodes (don't want to radiate kidneys) |
| If you have IIA or IIB seminoma how is radiation administered? | 30-35Gy to the para-caval, para-aortics, and ipsalateral iliacs. If they have contraindications to XRT then do BEP x 3 or EP x 4 |
| Stage IIc and III seminoma is treated how? | Good risk - BEP x 3 or EP x 4 Intermediate risk (non-pulm visceral mets and elevated labs)- BEP x 4 |
| What is the most common non germ cell tumor of the testis? | Leydig cell (1-3% or all testis tumors) |
| What is a presenting symptom of Leydig cell tumor? | Virilization, gynacomastia, decreased libido |
| What do you see grossly and microscopically with Leydig cell tumors? | Yellow/brown well-circumscribed Reinke crystals |
| What % of Leydig tumors are malignant? | 10% Only true diagnosis of malignant is metsj |
| What is the most common testis tumor in dogs? | Sertoli cell |
| What is the treatment of Sertoli cell tumors? | Inguinal orch RPLND if mets |
| Who gets gonadoblastoma? | Pts with gonadal dysgenesis |
| What are the 3 histologic elements of gonadoblastoma? | Sertoli cells Interstitial cells (Leydig cells) Germ cells |
| How do gonadoblastomas present? | 4/5 are phenotypic females. Present with amenorrhea and lower abd pain |
| How do you treat gonadoblastoma? | Radical orchiectomy with removal of contralateral streak gonad |
| What is the outcome of a patient with adenocarcinoma in the rete testis? | Death within 1 year |
| What is the histologic finding of Epidermoid cyst? | Desquamated keritanized epithelium in cyst |
| What is the most common testis tumor in men >50 years of age? | Lymphoma |
| What is the presentation of lymphoma of the testis? | Painless enlargement of the testis 50% bilateral Constitutional symptoms |
| Who gets leukemia of the testis? | Common site of relapse for boys with ALL |
| What are large calcified Sertoli tumors associated with? | Peutz-Jeghers and Carney syndromes |
| What is the most common tumor of paratesticular tissue? | Adenomatoid tumor |
| What is seen on histology with adenomatoid tumors? | Vacuoles within epithelial cells |
| What is the treatment of adenomatoid tumors? | Excise but they are benign |
| What is commonly found with a firm painless scrotal mass and hydrocele? | Mesothelioma |
| What is the treatment of paratesticular rhabdomyosarcoma? | Inguinal orch Radiation Chemo (vincristine, cyclophosphamide, dacto) |
| How does leiomyosarcoma of the testis present? | Distant spread from heme mets 25 reported cases Treat with inguinal orch with high cord ligation |
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