B8.051 Germ Cell Tumors Flashcards
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
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
lymphatic drainage of testicle region
scrotal skin drains to superficial inguinal nodes
testis drain to lumbar lymphatic nodes (para aortic)
clinical presentation of testicular cancer
painless testicular swelling (60-70% of patients)
heavy sensation or testicular discomfort (30%)
acute pain is rare
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
ddx of tender testicular mass
torsion
orchitis
epididymitis
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
common course of testicular cancer
painless testicular mass
course antibiotics for 2-4 weeks
testicular US
radical inguinal orchiectomy
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
tumor markers of testicular cancer
AFP
B-HCG
LDH
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
false elevations of AFP
hepatic dysfunction
B-HCG in testicular cancer
secreted by syncitiotrophoblastic cells
half life 1-1.5 days
elevated in seminomas and choriocarcinomas
false elevations of B-HCG
tumor lysis after chemo
treatment related hypogonadism
marijuana use
presence of heterophile antibodies
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
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
- any testicular mass is an indication for inguinal orchiectomy
- testicular cancer spreads to retroperitoneal LN
- if AFP is elevated, patient has a non-seminoma
- surgery only treatment for teratoma
- 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
