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03. Testis + Penile + Uretral Ca (1060) > 31 - testicular cancer > Flashcards

31 - testicular cancer Flashcards

1
Q

testicular ca RR and undescended testicle

A

6 x rr

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2
Q

RR of contralateral testicle ca in undescended testicle

A

1.7 x RR

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3
Q

tca and age of orchiopexy

A

increased risk the later in age of orchiopexy

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4
Q

greatest risk of testis cancer is?

A

prior history of testis ca

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5
Q

relative risk of germ cell testis ca with prior hx germ cell ca

A

25 x RR

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6
Q

3 genetic syndromes assd w testicular ca

A
  1. kleinfelter (47 xy), 2. mullerian duct syndrome, 3. downs
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7
Q

2 prenatal RF for testis ca

A
  1. estrogen exposure, 2. inverse relationship with birth order
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8
Q

where does ITGCN arise from in testicle

A

spermatogonia

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9
Q

genetic finding that is diagnostic of GCT

A

presence of extra copies of short arm of chr 21

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10
Q

do the majority of seminomas secrete hcg?

A

no

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11
Q

tumor marker found in seminoma

A

HCG - only 20%

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12
Q

what cells secrete HCG

A

synctiotrophoblasts

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13
Q

tumor markers in embryonal carcinoma

A

hcg and afp

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14
Q

tumor marker in yolk sac

A

AFP

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15
Q

pathognomonic finding in yolk sac

A

schiller-duval bodies

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16
Q

choriocarcinoma tumor marker

A

HCG

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17
Q

feature of choriocarcinoma tumor marker

A

very high HCG level

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18
Q

clinical feature of choriocarcinoma

A

small primary, wide spread hematologic mets (brain/ lungs)

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19
Q

malignant potential of teratoma in children

A

benign

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20
Q

when is teratoma found in adults

A

NSGCT

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21
Q

% gct are mixed

A

30-50%

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22
Q

malignant potential of epidermoid cyst

A

benign

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23
Q

what lines epidermoid cysts

A

squamous epithelium

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24
Q

mgmt of suspected epidermoid cyst

A

do open biopsy/ partial orchiectomy. if epidermoid cyst confirmed, then close. if malignant, orchiectomy

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25
Q

major difference between seminoma and nonseminoma and treatment

A

only nonseminoma can have teratoma, which has to be eradicated

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26
Q

afp half life

A

5 days

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27
Q

hcg half life

A

24-36 hrs

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28
Q

2 tumors producing AFP

A

embryonal and yolk sac

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29
Q

nl function of HCG

A

produced by placenta to maintain corpus luteum in pregnancy

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30
Q

low testosterone and tumor markers

A

high LH can cross react with HCG

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31
Q

HCG homologous to what other protein

A

b-subunit of LH

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32
Q

how to manage aberrantly elevated LH

A

give testosterone shot and re-test hcg

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33
Q

signifance of nl tumor markers

A

does not gaurantee eradication of all cancer cells

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34
Q

drainage of retroperitoneal lymphatics

A

mediastinum then chest

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35
Q

GCT clinical stage 1

A

all disease confined to testicle w nl tumor markers after orchiectomy

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36
Q

GCT clinical stage 1s

A

same as CS1 with elevated post orchectomy markers

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37
Q

NSGCT CS1s mgmt

A

chemo

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38
Q

clinical stage 2a vs 2b vs 2c for sem and non-sem germ cell tumor

A

retroperitoneal disease < 2 cm, 2-5 cm, > 5 cm

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39
Q

GCT clinical stage 3

A

supradiaphragmatic (including lungs) or visceral mets

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40
Q

tumor primary location and risk stratification in GCT

A

good and intermediate risk gonadal/retroperitoneal primary, poor risk is mediastinal or non-pulmonary visceral mets

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41
Q

AFP and risk stratification in GCT

A

good risk < 1000, intermediate risk 1000-10,000, poor risk > 10,000

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42
Q

HCG and risk stratification in GCT

A

good risk < 5000, intermediate risk, 5000-50,000, poor risk > 50,000

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43
Q

LDH and risk stratification in GCT

A

good risk > 1.5x nl, intermediate risk 1.5-10x nl, poor risk > 10x nl

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44
Q

good risk criteria

A
  1. gonadal/retroperitoneal primary, 2. no non-pulmonary mets, 3. AFP < 1000, HCG < 5000, LDH > 1.5 x nl
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45
Q

intermediate risk criteria

A
  1. gonadal/ retroperitoneal primary, 2. no non-pulm visceral mets, 3. AFP 1000-10,000, HCG - 5,000 - 50,000, LDH 1.5 x - 10x nl
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46
Q

poor risk criteria

A

any of the following: 1. mediastinal primary, 2. non-pulm visceral mets, 3. AFP > 10,000, HCG > 50,000, LDH > 10x nl

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47
Q

5 yr survival for good risk

A

90%

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48
Q

5 yr survival for intermediate risk

A

80%

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49
Q

5 yr survival for poor risk

A

50%

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50
Q

treatment for good risk

A

BEP x 3

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51
Q

when is BEP x 3 not given for good risk - 2

A

smoking hx and older pts

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52
Q

what to give instead of BEP x 3 in good risk

A

EP x 4

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53
Q

2 options for chemo in intermediate risk

A

BEP x 4 or BEP x 3 + EP x 1

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54
Q

poor risk chemo

A

BEP x 4 only

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55
Q

3 reasons for inguinal vs scrotal orchiectomy

A
  1. lower chance of cutting into tumor by accident, 2. removal of lymphatics draining primary, 3. prevent aberrant lymphatic drainage if tumor is spilled
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56
Q

partial orchiectomy indications

A
  1. contralateral abscent testis, 2. tumor < 2 cm, 3. polar tumor location
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57
Q

when to do adjuvant radiation in partial orchiectomy

A

if CIS present - done to reduced recurrence if done routinely

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58
Q

adjuvant tx post partial orchiectomy

A

20 gy to eradicate CIS

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59
Q

purpose of partial orchiectomy

A

maintains leydig cell function, not fertility

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60
Q

basics of stage 1, 2, 3 in staging system

A

1 - no evidence of mets, 2 - retroperitoneal mets, 3 - chest mets or disseminated mets

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61
Q

physical exam potion of clinical staging - what lymph nodes are palpated

A

cervical and axillary

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62
Q

what kind of visceral metastasis does not = poor prognosis

A

pulmonary

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63
Q

lymphatic drainage based on gonadal vein drainage - Left

A

left GV drains to L renal vein –> lymphatic drainage to left peri-aortic area

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64
Q

lymphatic drainage based on gonadal vein drainage - right

A

right GV drains to IVC –> lymphatic drainage to inter-aorta-caval region

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65
Q

2 main things setting apart seminoma from non seminoma on followup

A

seminoma does not have teratoma and seminoma is radiosensitive

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66
Q

incidence of occult retroperitoneal mets in seminoma

A

20%

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67
Q

2 equivelant mgmt options for CS 1 seminoma

A

abdominal EBRT for occult mets vs observation

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68
Q

% CS 1 patients with sem vs non-sem who will relapse due to micromets during observation

A

15% for sem vs 30% for non-sem

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69
Q

mgmt of seminoma who recur on observation

A

chemo with BEP x 3 or EP x 4

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70
Q

% of seminoma who will need chemo on observation for mets

A

20%

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71
Q

dose of retroperitoneal radiation for CS 1 seminoma

A

20 gy

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72
Q

how long do you watch patients with seminoma on surveillance

A

5 yrs

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73
Q

2 RF for retroperitoneal spread in seminoma

A

rete testis invasion and tumor > 4 cm

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74
Q

dog leg radiation for seminoma

A

not done

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75
Q

newer mgmt option for CS1 seminoma

A

carboplatin to all patients. still investigational

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76
Q

rationale for carboplatin in all CS1 seminoma

A
  1. seminoma sensitive to carboplatin, 2. low morbidity, 3. and easy to administer
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77
Q

CS 2 seminoma substratification

A

> 5 cm (bulky) or < 5 cm (nonbulky)

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78
Q

location of mets and CS 2 seminoma

A

retroperitoneal only

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79
Q

non bulky cs2 seminoma treatment

A

radiation therapy (felt to be less morbid than chemo)

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80
Q

cure with radiation alone in nonbulky cs 2 seminoma

A

90%

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81
Q

mgmt of recurrence after radiation in nonbulky cs 2 seminoma

A

chemo

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82
Q

cure of radiation + chemo in nonbulky cs 2 seminoma

A

95-99%

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83
Q

bulky CS 2 sem mgmt

A

chemo - BEP x 3 (or EP x 4)

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84
Q

rationale for chemo in bulky CS 2 sem

A

high risk of occult micromets outside retroperitoneum with bulky disease. chemo is systemic

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85
Q

CS 3 sem mgmt

A

chemo - bep x 3 (or ep x 4)

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86
Q

cure rate with chemo in CS3 sem

A

95%

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87
Q

post chemo mass in seminoma - initial mgmt

A

observation with imaging as 85% chance of necrosis only

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88
Q

postchemo mass in pure sem- imaging?

A

do pet scan

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89
Q

pet scan agent for sem

A

FDG

90
Q

role of PET scan in sem

A

can distinguish necrosis from active cancer (teratoma is not present in sem)

91
Q

do we still resect post-chemo masses > 3 cm in pure sem

A

only if pet is positive

92
Q

mgmt of + pet in sem

A

post chemo RPLND or high dose chemo

93
Q

pet and NSGCT

A

not useful

94
Q

why is pet useless in NSGCT

A

cant distinguish teratoma from necrosis. no teratoma in seminoma

95
Q

postchemo mass in NSGCT - % necrosis

A

45%

96
Q

postchemo mass in NSGCT - % teratoma

A

45%

97
Q

postchemo mass in NSGCT - % active ca

A

10%

98
Q

NSGCT CS1s mgmt

A

chemo

99
Q

why chemo in CS1s NSGCT

A

ct scan negative and likly have disease beyond retroperitoneum

100
Q

NSGCT - % with active cancer in cs1

A

30%

101
Q

% relapse after RPLND in NSGCT

A

30%

102
Q

NSGCT surveilance - % relapse

A

30%

103
Q

3 benefits to RPLND in stage 1

A
  1. stage retroperitoneum, 2. 50-75% pts cured, 3. less chemo
104
Q

2 probs with RPLND in stage 1

A
  1. 70% overtreated, 2. extra-retroperitoneal mets not treated and will need chemo
105
Q

CS 1 s mgmt

A

systemic chemo

106
Q

CS 1 s- why chemo

A

have systemic disease from persistently elevted markers and neg imaging

107
Q

what sexual action is affected with non-nerve sparing rplnd

A

ejaculation only. orgasm and sensation are nl

108
Q

ejaculation rate for full bilateral templace

A

0

109
Q

ejaculation rate for modified nerve sparing

A

99%

110
Q

left standard template

A

left peri-aortic region and left gonadal vein

111
Q

right standard template

A

right peri-caval, interaortocaval and right gonadal

112
Q

left modified template - medial border

A

interaortocaval LN above IMA

113
Q

right modified template - medial border

A

left (contralateral) peri-aortic LN (above IMA)

114
Q

why are modified templates based on IMA

A

below IMA can effect the nerves

115
Q

chemo for NSGCT CS 1 at relapse

A

bep x 3 or ep x 4

116
Q

% fertility after chemo

A

25-50%

117
Q

cardiovascular side effect with chemo

A

7x OR + HTN

118
Q

neuro side effect with chemo

A

numbness, tingling, reynauds

119
Q

surveilance - pure seminoma recurrence mgmt vs nsgct recurrence mgmt

A

pure sem - chemo or rad and thats it, nsgct 30% who recur and get chemo will still need surgery

120
Q

advantage of surveilance in CS 1 NSGCT

A

only those with spread will need treatment

121
Q

disadvantage to surveilance in NSGCT

A

1/3 given chemo will need surgery when they recur

122
Q

main reason to avoid chemo in nsgct

A

fertility, other reasons (nausea, immune status) less significant. also now evidece of late toxicity

123
Q

CS 1 nonseminoma - primary chemo option

A

BEP x 2

124
Q

pro/cons to chemo in CS1

A

good cure rate, however overtreatment in 70%

125
Q

CS1 - % with micromets at rplnd who will relapse postop

A

30%

126
Q

adjuvant chemo in rplnd in CS 1?

A

BEP x 2

127
Q

problem with adjuvant chemo after primary rplnd in CS 1

A

only 30% will have micromets, 70% overtreated

128
Q

CS 2 or 3 - initial mgmt in NSGCT

A

70% cured with chemo

129
Q

% with residual mass in CS 2/3 nsgct

A

30%

130
Q

mgmt of residual mass in post chemo stage 2/3 NSGCT

A

rplns because 55% have cancer or teratoma

131
Q

retroperitoneal mass cutoff for RPLND vs primary chemo

A

> 5-6 cm treated with chemo because of high (50%)likelyhood of extra-retroperitoneal disease

132
Q

< 5-6 cm retroperitoneal mass and surgery cure rate in CS 2

A

50-70% cured with surgery and can be primary treatment

133
Q

each initial tx (chemo or rplnd) requires the other about x %

A

30%

134
Q

postchemo rplnd template

A

always full bilateral template

135
Q

postchemo rplnd for nonseminoma - mgmt if cancer is found

A

give 2 rounds adjuvant chemo

136
Q

when does late relapse usually happen

A

2 yrs after initial sccessful mgmt

137
Q

how does late relapse usu present

A

elevated afp

138
Q

tx of late relapse

A

always surgery unless unresectable or multifocal disease

139
Q

what is despiration surgery

A

rplnd with elevated markers post chemo

140
Q

seminoma CS1s mgmt

A

radiation (20 gy to periaortic and ipsilateral iliac) or single agent carboplatin

141
Q

what differentiates stage 1a from 1b in TNM for Sem and Non-Sem

A

1B is confined to testicle with LVI or tunica vaginalis involvement

142
Q

mgmt of nsgct stage 2a with S1 vs S0

A

S1 gets chemo (BEP x 3 or EP x 4), S0 has option for RPLND, chemo (BEP x 3 or EP x 4), or surveillance if highly motivated

143
Q

Most common presentation of testes ca.

A

localized seminoma

144
Q

Most common age range at presentation

A

20-35 y.o.

145
Q

Risk factors for testes cancer

A

Cryptorchidism
Family or personal hx of testes cancer
Intra-tubular germ cell neoplasia

146
Q

Must perform orchiopexy before ____ to decrease testicular cancer rates

A

puberty

147
Q

Seminomas often have ____ that produce bHCG

A

synctiotrophoblasts

148
Q

Choriocarcinoma

VERY HIGH ____

Spreads via ____

Hemorrhagic ____ mets

A

v high bHCG

Hematogenous spread

hemorrhagic brain mets

149
Q

____ tumors are chemo/rads resistant

A

Teratoma

150
Q

____ tumors are most commonly in pre-pubertal children

A

Yolk Sac

151
Q

Imaging study for testicular mass

A

scrotal u/s

152
Q

Tumor markers should be followed up ____ s/p orchiectomy

A

4-5 weeks

153
Q

Staging imaging

A

CT abd/pelvis

CXR (low risk) vs CT chest

154
Q

Tumor confined to testes + epididymis w/o LVI

p___

A

pT1

155
Q

Tumor confined to testes + epididymis w LVI OR tunica vaginalis invasion

p___

A

pT2

156
Q

Tumor invading spermatic cord

p___

A

pT3

157
Q

Tumor invading scrotum

p___

A

pT4

158
Q

Nodal disease
only applies to RP nodes

N1 - ___ cm

A

N1 - <2cm
N2 - 2-5 cm
N3 - >5 cm

159
Q

Seminoma with <3cm Tumor confined to testes + epididymis w/o LVI

p___

A

T1a

160
Q

Seminoma with >3cm Tumor confined to testes + epididymis w/o LVI

p___

A

T1b

161
Q

Seminoma confined to testes is always clinical stage ____

A

T1

T1a - pT1
T1b - pT2-4

162
Q

Seminoma with RP nodal mets & S0-1 is clinical stage ___

A

T2

T2a - cN1
T2b - cN2
T2c - cN3

163
Q

Seminoma with distant mets is clinical stage ___

A

T3

T3a - S1
T3b - S2
T3c - S3

164
Q

Half life of AFP

A

5-7 days

165
Q

AFP is NEVER elevated in ____

A

seminoma

166
Q

Half life of bHCG

A

24-36h

167
Q

Half life of LDH

A

24 hrs

168
Q

Yolk sac has elevated ___ tumor marker

A

AFP

169
Q

Seminoma - localized or with pulmonary mets

____ risk disease

A

Good

170
Q

Seminoma with non-pulmonary mets

____ risk disease

A

Intermediate

171
Q

Non-seminoma with S1 tumor markers

____ risk disease

A

Good

172
Q

Non-seminoma with S2 tumor markers

____ risk disease

A

Intermediate

173
Q

Non-seminoma with S3 tumor markers OR mediastinal primary OR non-pulmonary mets

____ risk disease

A

Poor

174
Q

Right testes tumors spread to ____ LNs

A

inter-aortocaval

175
Q

Left testes tumors spread to ____ LNs

A

Para-aortic

176
Q

ITCGN ___% develop testes cancer

A

50

177
Q

ITCGN Treatment

A

Surveillance
Orchiectomy (100% cure)
XRT (100% cure)
Chemo (66% cure)

178
Q

Relapse rates for seminoma

Surveillance only - ___%
1 round of Carboplatin - ___%

A

Surveil - 14%

Chemo - 4%

179
Q

Median time to relapse for seminoma s/p orchiectomy

A

1.5 years

180
Q

Strongest risk factors for non-seminoma relapse

A

LVI

Embryonal tumors

181
Q

Relapse rates for seminoma (without risk factors)

Surveillance only - ___%
BEP x1 - ___%

A

15%

1%

182
Q

Relapse rates for seminoma (with risk factors)

Surveillance only - ___%
BEP x1 - ___%

A

40%

3%

183
Q

Treatment if node + at time of primary RPLND

N1 - ____
N2 - ____
N3 - ____

A

N1 - surveillance

N2 - EPx2 or BEPx2

N3 - BEPx3 or EPx4

184
Q

To preserve antegrade ejaculation after RPLND, spare ___ nerves

A

L1-L3 post-ganglionic sympathetic nerves

behind the IVC

185
Q

Bleomycin adverse effects

A

pulmonary toxicity

186
Q

Which stages of non-seminoma do you offer primary RPLND?

A

Stage IIA/B

  • do not perform with elevated tumor markers*
  • potential reduces chemo burden*
187
Q

Which stages of seminoma can you offer RT?

A

Stage IIA/B - nodal positive disease, 2-5 cm

188
Q

Must wait at least ____ s/p chemo to perform PET CT

A

6 weeks

189
Q

Seminoma s/p chemo

Next step if no mass or <3cm mass - ____

A

Surveillance

190
Q

Seminoma s/p chemo

Next step if >3cm mass - ____

A

PET CT

  • Negative - surveillance
  • Positive - resection
191
Q

Seminoma s/p chemo

Next step if tumor growth or tumor marker elevation - ____

A

2nd line chemo

TIP/VeIP

192
Q

Non-seminoma s/p chemo

Next step if no mass or <1cm mass with normal tumor markers - ____

A

Surveillance or RPLND

193
Q

Non-seminoma s/p chemo

Next step if >1cm mass with normal tumor markers - ____

A

post-chemo RPLND

194
Q

Non-seminoma s/p chemo

Next step if persistent elevated tumor markers - ____

A

2nd line chemo

TIP/VeIP

195
Q

Long term risks of chemo for testes ca patients

A

Cardiovascular disease

2ndary cancers

196
Q

Management of post-chemo distant mets

A

resect if possible

197
Q

Offer all patient ____ prior to treatment to maintain fertility

A

sperm banking

198
Q

Treatment after trans-scrotal orchiectomy

A

Observe vs excise scar vs RT

199
Q

pTX

A

Primary tumour can not be assessed

200
Q

pT0

A

No evidence of primary tumour

201
Q

pTIS

A

Intratubular germ cell neoplasia (carcinoma in situ)

202
Q

pT1

A

Tumour limited to testis and epididymis without vascular/lymphatic invasion. Tumour may invade tunica albuginea but not tunica vaginalis

203
Q

pT2

A

Tumour limited to testis and epididymis with vascular/lymphatic invasion, or tumour extending through tunica albuginea with involvement of tunica vaginalis

204
Q

pT3

A

Tumour invades spermatic cord with or without vascular/lymphatic invasion

205
Q

pT4

A

Tumour invades scrotum with or without vascular/lymphatic invasion

206
Q

NX

A

Regional lymph nodes cannot be assessed

207
Q

N0

A

No regional lymph node metastasis

208
Q

N1

A

Metastasis with a lymp node mass 2 cm or less in greatest dimension or multiple lymph nodes, none more than 2 cm in greatest dimension

209
Q

N2

A

Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension; or more than 5 nodes positive, none more than 5 cm; or evidence of extranodal extension of tumour

210
Q

N3

A

Metastasis with a lymph node mass more than 5 cm in greatest dimension

211
Q

MX

A

Distant metastasis cannot be assessed

212
Q

M0

A

No distant metastasis

213
Q

M1

A

Distant metastasis

214
Q

M1a

A

Non-regional lymph node(s) or lung metastasis

215
Q

M1b

A

Distant metastasis other than non-regional lymph nodes and lung metastasis

216
Q

SX

A

Serum marker studies not available or not performed

217
Q

S0

A

Serum marker study levels within normal limits

218
Q

S1

A 
LDH <1,5xN
and
hCG < 5 000
and 
AFP < 1 000
219
Q

S2

A 
LDH 1,5-10xN
or
hCG  5 000-50 000
or
AFP 1 000-10 000
220
Q

S3

A 
LDH >10xN
or
hCG  >50 000
or
AFP >10 000
221
Q

following adult male germ cell tumor (GCT) subtypes arise from germ cell neoplasia in situ (GCNIS)

A

a. embryonal tumor. b. choriocarcinoma. c. classic seminoma. e. teratoma.

03. Testis + Penile + Uretral Ca (1060) (9 decks)

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