Testicular Cancer

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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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