What are risk factors for testis cancer?
Cryptorchidism, CIS, +FH, gonadal dysgenesis, AIS, metachronous testis cancer
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?
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
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
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 does embryonal carcinoma look like histologically?
Epithelial-like cells, papillary projections, "nasty looking tumor"
What is a classic histologic feature of yolk sac tumors?
Schiller-duval bodies- papillary structure with fibrovascular core
What is the classic histologic feature of choriocarcinoma?
Syncytiotrophoblasts (multiple nuclei, eosinophilic cytoplasm) and cytotrophoblasts (single nucleus, clear cytoplasm)
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
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?
What tumors are associated with elevated AFP?
Yolk sac, embryonal, teratoma
Never elevated in pure seminoma or chorio
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
When is a PET scan useful in testis cancer?
For evaluating post-chemo residual mass in seminoma (Stage II and III)
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 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 the M staging for a testis tumor?
M1a - nonregional nodal or pulm mets
M1b - distant other mets
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
What study is required if you suspect someone has an extragonadal germ cell tumor?
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
When is a full bilateral template indicated?
Palpable nodes found in a modified template
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
Tumor size >4-6cm
Rete testis invasion
What increases the risk for micromets and relapse after clinical stage I nonseminoma?
Elevated tumor markers
MIB-1 staining (measures IHC Ki-67)
Absence of yolk sac elements
Tumor size >4-6cm
If you have stage 1 seminoma and opt for radiation how is it administered?
25Gy to para-aortics
What are contraindications to XRT for seminoma?
Previous abd XRT
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 do you see grossly and microscopically with Leydig cell tumors?
What are the 3 histologic elements of gonadoblastoma?
Interstitial cells (Leydig cells)
How do gonadoblastomas present?
4/5 are phenotypic females. Present with amenorrhea and lower abd pain
What is the presentation of lymphoma of the testis?
Painless enlargement of the testis
What is the treatment of paratesticular rhabdomyosarcoma?
Chemo (vincristine, cyclophosphamide, dacto)