228. Testis Cancer

Question 1

What covers the testis and epididymus?

What is the arterial supply of testis/epididymus?

What is the venous return?

How to identify Leydig cells on histo?

Answer 1

covered by Tunica Albuginea

Arterial: testicular a. (from aorta); vasal a. (from superior vesicular a. following ductus deferens)

Venous: pampiniform plexus = gonadal veins = IVC (r side), L renal vein = IVC

Leydig cells: produce T, Crystal of Reinke = precipitate cholesterol moieties

Question 2

Testis Cancer Epidemiology

• prevalence
• type
• geography
• RF
• most common bilateral histology
• survival

Answer 2

25% adult tumors are urogenital, testis cancer is 4th most common UG one (low deaths due to high tx)
age: 15-35yo
95% GCT, most unilateral
Geo: N America, EU, S America

RF: race (Euro, Scandinavian, White), Cryptorchidism, Gonadal Dysgenesis, Past hx GCT, subfertility, FamHx, genetics (KIT mutations, Y-Ch microdeletions), HIV Immunosuppression, Drug/Marijuana
Bilateral: rare, usually seminoma, 90% survival

High survival/good prognosis

Question 3

Testicular GCT Etiology

• precursor
• 2 paths of tumorigenesis

Answer 3

90% arise in testis
Precursor: intratubular germ cell neoplasia (GCNIS) - likely begins in utero
Tumorigenesis: 1. Primordial germ cell acquires mutation in KIT = causes i(12p) duplication = seminoma
2. Nondisjunction in mature germ cells = i(12p)

No correlation between i(12p) and prognosis

Question 4

Testis Cancer: Sx/Dx

• sx
• dx
• tumor markers (3) - half life

Answer 4

Sx: mass/swelling, pain, reactive hydro/hematocele, gynecomastia/mastodynia, mets disease (chest pain, SoB, cough, abd/back pain, CNS sx)

Dx: self-exam (mass with induration/pain), Negative transillumination, Scrotal US (dense hypoechoic mass, hypervascularized)

b-hCG: product on syncytiotrophoblasts, half life 18-36 hours, elevated in pts with testis cancer (15% pure seminoma)

AFP: yolk sac elements, half life 5-7 days, falsely positive in liver dysfx

LDH: least precise, high in all GCTs, variable half life due to pt isoenzyme

Question 5

Initial Mgmt of Primary tumor and alternative options indications

Answer 5

1. Sperm Bank (future fertility)
2. Radical (inguinal) Orchiectomy

Partial Orchiectomy: higher recurrence risk, no change in androgen fx/infertility due to complete orchiectomy
- only if: absent contralateral testis, tumor <2cm, benign, polar location

Question 6

Staging of Testis Cancer (I, II, III)

What is the lymph drainage for R and L testis?

Answer 6

I: confined to testis (IS: microscopic mets - elevated tumor markers)

II: retroperitoneal mets (IIA <5 nodes <2cm; IIB >5 nodes 2-5cm; IIC any node >5cm)

III: supra-diaphragmatic or visceral mets

Lymph
Right side: pre-caval, interaortocaval, pre-aortic
L side: para-aortic, pre-aortic, interaortocaval

Question 7

Post Orchiectomy Mgmt of Seminoma for each stage

Answer 7

I: surveillance (80-90% relapse in retroperitoneum within 12-18months), may consider low-dose adjuvant chemo/xrt

IIA/nonbulky IIB: radiation tx (standard of care)
R side: interaortacaval, precaval, paracaval, ipsilateral iliac
L side: paraaortic, ipsilateral iliac

Bulky IIB/III: Chemo, PET Scan if residual mass >3cm

Question 8

Post-orchiectomy Mgmt of Non-Seminoma GCT for stages
- biggest RF for recurrence

Complications of Chemo

Mgmt of late relapse

Answer 8

I: surveillance
Biggest RF driving mgmt: lymphovascular invasion (IB) - Chemo +/- RPLND due to high chance recurrence

Chemotx:
Bleomycin: pulm fibrosis, raynaud’s
Etoposide: N/V, myelosuppression, alopecia
Cisplatin (P): N/V, nephrotoxicity, neuropathy, ototoxicity, infertility, alopecia
High risk Secondary Malignancy and CVD SE

RPLND: dx and tx; minimize chemo/radiation, high risk of ejaculatory dysfx (damage hypogastric nerve) - need NERVE SPARING TECHNIQUE;

Late Relapse: >2 years, why you never terminate follow up, tumor marker AFP high, primary mgmt is SURGICAL REMOVAL

Question 9

Gonadal Stromal Tumors

• epidemiology
• CP
• malignancy
• management
• types: demo, tumor marker, gross

Testicular Lymphoma

• demo
• CP
• histo
• most common type

Answer 9

Stomal tumors RARE: 5% all testis tumors
CP: palpable mass, abnormal T/E (virilization, gynecomastia, loss of libido)
90% benign
Mgmt: NO CHEMO, surveillance is benign, surgery if malignant

Leydig Cell: more common, 5-10yo or 30-35yo; tumor cells produce androgen/E (gynecomastia, precocious puberty), gross: golden-brown or grey-white cut surface

Sertoli Cell: rarer, any age, low androgen/E production, gross: well-circumscribed, homogenous, solid, firm grey-white mass

Lymphoma: older pt (60-80), most common cause of testis mass in men >60yo, CP: diffuse enlargement (not discrete mass)
histo: infiltrating lymphoma cells b/w tubules
Most cases: diffuse large B cell lymphoma