B8.051 Germ Cell Tumors Flashcards by Lauren Sinik

epidemiology of testicular cancer

males between age 15-45 years
<1% of all cancers in men
highest risk in scandinavia and switzerland, lowest in asia and africa

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risk factor for testicular cancers

cryptorchidism: 3-5x
klinefelter's syndrome (XXY)
infertility: 1-2x
family history: sibling history is 8-10x
prior history of testicular cancer increases risk of contralateral tumor
HIV

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lymphatic drainage of testicle region

scrotal skin drains to superficial inguinal nodes

testis drain to lumbar lymphatic nodes (para aortic)

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clinical presentation of testicular cancer

painless testicular swelling (60-70% of patients)
heavy sensation or testicular discomfort (30%)
acute pain is rare

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symptoms or signs of metastatic testicular disease

10% of patients

nausea, vomiting, abdominal pain (retroperitoneal LN)
cough, dyspnea (lung mets)
neck mass (supraclavicular LN)
bony pain (osseous metastases) +/- radiculopathy

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ddx of tender testicular mass

torsion
orchitis
epididymitis

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ddx of nontender testicular mass

hydocele: trans illumination +
varicocele: ‘bag of worms’ on palpation
inguinal hernia: indirect, extends to inguinal ring
spermatocele
malignancy: testicular cancer, lymphomas

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common course of testicular cancer

painless testicular mass
course antibiotics for 2-4 weeks
testicular US
radical inguinal orchiectomy

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imaging studies for evaluating testicular cancer

testicular US
-extremely sensitive in evaluating testicular masses (nearly 100%)
CT scan (chest, abdomen, pelvis)
-to determine adenopathy and visceral involvement

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tumor markers of testicular cancer

AFP
B-HCG
LDH

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AFP in testicular cancer

synthesized by fetal yolk sac, liver, and intestines
half life of 5-7 days
elevated in yolk sac tumors and teratomas

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false elevations of AFP

hepatic dysfunction

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B-HCG in testicular cancer

secreted by syncitiotrophoblastic cells
half life 1-1.5 days
elevated in seminomas and choriocarcinomas

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false elevations of B-HCG

tumor lysis after chemo
treatment related hypogonadism
marijuana use
presence of heterophile antibodies

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LDH in testicular cancer

nonspecific tumor marker
marker of overall tumor burden, growth, and overall proliferation
elevated in 60-80% of patients with advanced disease

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use of tumor markers in testicular cancer

tumor markers are prognostic, help examine disease burden

also help to monitor treatment, should normalize over time

cytogenetic changes in testicular cancer

isochromosome 12p is frequently seen with testicular germ cell tumors
diagnosed by karyotyping or FISH
may help determine whether it is a GCT for tumor of unknown primary

what is a radical orchiectomy

radical inguinal orchiectomy with high ligation of the spermatic cord at the level of internal ring

function of radical orchiectomy

establishes primary histo-pathologic diagnosis
local tumor control (testis/scrotal sac considered as sanctum for tumors)
AVOID SCROTAL INCISION OR BIOPSY

subtypes of testicular cancer

seminoma
non-seminoma
-seminona
-embryonal cell carcinoma
-yolk sac tumor
-choriocarcinoma
-teratoma

extragonadal GCT

rare, 10% of GCT
commonly occur in the mediastinum and retroperitoneum
pineal gland
**treated similarly to testicular tumors

tumors in those age 0-5

teratome - benign

yolk sac tumor - malignant

tumors in those age 15-45

seminoma or non-seminoma

typically malignant

tumors in those age >50

spermatocytic seminoma - usually benign

characterize spermatocytic seminoma

usually benign contained within testicle perform orchiectomy and follow over time not a big risk of mets

factors used in risk stratification of GCTs

seminoma vs non-seminoma extent of disease presence of non-pulmonary visceral disease elevated tumor markers post orchiectomy: B-HCG, AFP

risk classification

good intermediate poor

what is unusual about the risk stratification of seminomas

no poor risk group, only good and intermediate | respond well to treatment

treatment modalities for GCT

active surveillance (if markers normalize post-orchiectomy) chemotherapy retro-peritoneal lymph node dissection radiation therapy

chemo for testicular cancer

usually cisplatin based combo therapy

overall response to treatment in testicular cancer

highest response and cure rates of all solid malignancies response rate for stage 1 and 2 are 98-99% response rate for stage 3 is 90% response rate for salvage therapies is 60-70%

post treatment complications

``` bleomycin related pulm complications renal toxicity cardio toxicity infertility hematologic toxicity bone loss secondary malignancy ```

secondary malignancy in testicular cancer

most common cause of death in survivors | 1.9% for 10 years, 1.7% for 35 years

growing teratoma suyndrome

enlarging tumor with normalization of tumor markers post treatment teratomas are resistant to chemo and radiation

cure for growing teratomas

surgical resection is the only curative modality

clinical pearls regarding testicular cancer

1. any testicular mass is an indication for inguinal orchiectomy 2. testicular cancer spreads to retroperitoneal LN 3. if AFP is elevated, patient has a non-seminoma 4. surgery only treatment for teratoma 5. late recurrences can occur, so follow for a long period of time

survivorship of testicular cancer

majority survive (90%) - late relapse > 2 years after remission - metabolic syndrome - cardiovascular mortality - hypogonadism, infertility - psychosocial problems - fatige - osteopenia and osteoporosis - risk of secondary malignancies