Flashcards in Testicular Deck (47):
Most common risk factor for testicular cancer?
What is recommended prophylaxis for cryptorchidism?
orchiectomy, esp when intra-abdominal
Relative risk of testicular cancer in 1st degree relatives
increases 6-10 fold
What is intratubular germ cell neoplasia?
carcinoma in situ, risk of progression is 50% at 5 years if untreated
Less common risk factors for testicular cancer?
Klinefelter & Down syndromes
exposure to exogenous estrogens in utero
peutz-Jegher syndrome and Carney complex (Sertoli cell)
Common presentation for testicular cancer?
painless mass, heavy sensation in lower abd or perianal region
What are the types of testicular tumors?
Germ cell (95%)
sex cord tumors
lymphoma, leukemia and plasmacytoma
What are two types of germ cell tumors?
Seminoma and nonseminomas
What is the most prevalent and specific cytogenetic abnormality in testicular cancer?
gain of 12p sequences; commonly i12p
What are key histologic and serum characteristics of the different germ cell tumor subtypes?
Seminoma (pure) - AFP normal; bHCG: normal to mildly elevated; i12p (50%) "min b oma)
Spermatocystic seminoma: i12p (0%)
NSGCTs: i12p (80%)
-Embryonal: AFP & bHCG normal to mildly elevated "um bro could be both"
-Choriocarcinoma: AFP normal, bHCG > 1000 IU/L "human ""chorionic"" gonadotropin "
-Yolk sac: AFP > 100; bHCG normal "fetal yolk"
What are key serum tumor markers (STMs) and how are they broken up into mild, mod & high risk? What is their half-life
AFP (4-5 days) [ 10,000] "A is a 10 f partner"
b-HCG (18-36 hours) [ 50,000 "beta is two human butt cheegs"
LDH () [10x ULN) "L is 1.5 pieces of wood"
Staging summary for testicular cancer?
Stage I: tumor only
Stage II: regional node involvement & mild STMs
Stage III: metastatic or high STMs
- IIIA: nonregional lymph nodes, pulm mets and/or mild STMs
- IIIB: nonregional lymph nodes, pulm mets and/or mod STMs
- IIIC: non pulm mets or marked STMs
What are prognostic catergories for Seminoma?
- Good: non pulmonary visceral mets; I-IIIB
- Int: non pulmonary visceral mets: IIIC
What are prognositic catergories for NSGCT?
What is likelihood of cure in Stage I seminoma?
close to 100%
What is criticial question when determining adjuvant therapy following resection for Stage I seminoma>
Is the patient compliant? - relapse rate of 15-20%; down to 5% if given chemo (carbo AUC 7 1-2 cycles or RT (20-25 Gy, PA-strip)
What adjuvant therapy for Stage I Seminoma is preferred but withheld usually?
RT, due to secondary malignancies, 18.2% cumulative risk at 25 years; (PA-strip preffered field over hockey-stick and dog-leg)
What is advantage of single dose of carbo (AUC 7) over RT for Stage I seminoma?
Less incidence of new contralateral GCT (0.2% vs 1.2%) 80% risk reduction
What is relapse rate for Stage I Non-seminoma? How many are upstaged to Stage II following RPLND
Late recurrences for testicular cancer are common with and uncommon with?
common in seminoma and uncommon in non-seminoma
What are two important factors in Stage I Non-seminoma that predict for relapse and favor adjuvant intervention?
presence of LVI (lymphovascular invasion) * (strongest)
embryonal component predominant
What imaging modality is not recommended for NSGCTs
What is recommended for adjuvant therapy in high risk Stage I Non-seminoma?
RPLND (preferred in US, avoid chemo toxicity, advantage of upstaging) versus chemo (BEP x 1-2, preferred in Europe due to low relapse rate of
Key question for Stage I Non-seminoma s/p RPLND?
Compliance; if yes surveillance; if no BEP x 2 for pN1 or pN2 disease and BEP x3-4 for pN3 disease
Most common complication of nerve sparing RPLND?
infertility due to retrograde ejaculation
Post-orchiectomy adjuvant therapy for Stage I Non-seminoma with positive STMs?
BEP x 3 or EP x 4
What does Stage II germ cell tumor imply and how is therapy different from Stage I?
Retroperitoneal node involvement; surveillance is not an option
What is recommended for adjuvant therapy in Stage II seminoma?
IIA: RT (30-35Gy - preffered), or chemo
IIB: Chemo (BEP x 3 - preffered) or RT
IIC: Chemo only (BEP x 3, or EP x 4)
Only situation where single agent carboplatin (AUC 7) is an option?
Stage I Seminoma
What regimen did BEP replace? Advantage
PVB; not as good in bulky disease and the vinblastine can result in considerable neuromuscular toxicity
BEP 3 versus 4 cycles
4 cycles is reserved for Seminoma Int risk and Non-Seminoma Int or Poor risk.; 3 is good for good risk, good?
What determines choice between BEP and EP?
Pulmonary function (older); or atheletes
Rule of thumb for residual masses in testicular germ cell tumors?
NSGCTs: always resect
Seminoma: resect based on size criteria of > 3; if well delineated or positive PET after 6 weeks (preferred method)
What is recommended for adjuvant therapy in STM negative Stage II Non-seminoma post-orchiectomy?
* similar to seminoma except RPLND replaces RT
IIA: RPLND or chemo
IIB: Chemo (BEP x 3 - preffered) or RPLND
IIC: Chemo only (BEP x 3, or EP x 4)
For Stage IIA STM negative Non Seminoma; s/p adjuvant RPLND; if residual disease is present, what determines adjuvant plan?
-pN2: BEP or EP x2 over surviellance
-PN3: BEP x 3 or EP x 4
For Stage IIC STM negative Non Seminoma; s/p adjuvant chemo; if residual disease is present, what determines adjuvant plan?
residual mass > 1 cm: RPLND
For Stage II STM positive Non Seminoma what is adjuvant recommendation?
BEP x3 or EP x 4
Why do some providers recommend RPLND after chemotherapy for Stage II or III NSGCTs regardless of response?
Growing teratoma syndrome (teratoma's are relatively resistent to chemotherapy): presents with clinical discordance, dropping STMs and stable or increasing mass
For post-chemo NSGCTs patients with positive STMs or residual mass with viable tumor (not fibrosis or teratoma), what is given?
2 cycles of:
VIP (etop/ ifos/ cis),
VeIP (vinblas/ ifos/ cis),
TIP (paclitaxel/ ifos/ cis)
For Stage III disease what regimen shows similar efficacy to BEP x 4 cycles but increased hematologic and GU toxicity? In what scenario is this regimen preffered?
What non-invasive method can help differentiate teratoma from fibrosis?
None; only through surgical resection with path analysis
What is strongest predictor of fibrosis for residual pulmonary disease in Stage III NSGCTs?
necrosis in retroperitoneum on RPLND prior to thoractomy (89% of cases on retrosepctive multicenter study of 215 patients)
For GCTs that relapse within 4 weeks of receiving a cisplatin based therapy or during therapy are classified as? What are there options then?
What is 2 years out?
platinum refractory or absolutely refractory
- GEMOX based or HDCT
- paclitaxel or ifosfamide based
Extragonadal seminomas have what prognosis and are managed how?
Prognosis similar to gonadal primaries and managed similarly.
Extragondal germ cell turmor are usually what subtype?
non-seminoma; pure seminoma is extremely rare
Extragonadal non-seminoma have what prognosis and are managed how?
worse than gonadal counterparts; mediastinal are worst, automatically poor prognosis despite marker and disease burden