Case 17: oesophageal, pancreatic, prostate, testicle Flashcards

Question

Testicular cancer

Answer 1

- Relatively rare - Two main subtypes: Seminomas (40-60%) and non-seminomatous germ cell tumours (NSGCT 30-50%) also known as Teratoma. These are both Germ cell tumours - Non germ cell tumours: Leydig cell tumour and sarcoma - Commonly affects young Caucasian men (15-35) - Very good prognosis even in metastatic disease - Prognosis: 95% survival

Answer 2

- Seminomas: No reliable tumour marker but beta-HCG in 20%. Any tumour that produces AFP is considered mixed even if the pathology suggests pure seminoma. 50% of germ cell tumours. Slow growth. Responds better to radiation and chemo - Non-seminomas: disease spreads earlier so more likely to present with advanced disease. AFP and hCG markers are elevated in majority. More prone to early metastasis - Mixed: Beta-hCG and AFP - Intratubular germ cell neoplasia is the precursor to germ cell tumours

Answer 3

- Infertility - <45 - Caucasian - HIV - Cryptorchidism: undescended testis - Family history - Klinefelter's syndrome, Down syndrome - History of testicular torsion - Mumps orchitis - 80% of testicular cancer express 12p gain - Family history

Answer 4

- A painless lump is the most common presenting symptom - Lump: Hard, irregular, not fluctuant, no transillumination. Can cause enlargement of testicle - Can have scrotal pain or back pain - Pain is present in a minority of men - Other possible features include hydrocele, gynaecomastia (Leydig cell tumour) - Weight loss, fatigue - Can present similar to epididymo-orchitis but persists after antibiotics

Answer 5

- Lung cancer or PE: dyspnoea, cough - Mediastinal mass: SVC obstruction - Retroperitoneal disease: Ureteric obstruction, abdo mass, abdo or back pain - CNS symptoms - Liver capsular pain - Advanced disease: weight loss, fatigue - Where might testicular cancer spread to: lymphatics, lungs, liver, brain

Answer 6

- Scrotal US: confirms diagnosis - Staging CT chest/abdomen/pelvis: look for areas of spread and stage the cancer. Performed after orchidectomy - AFP, hCG and LDH (elevated in germ cell tumour) - CXR: bilateral hilar lymphadenopathy, cannonball mets - CT brain if multiple lung metastases and/or serum hCG >10,000 - Genetic analysis if appropriate: Trisomy 8 and Kleinefelter's syndrome - Biopsy tumour and histology

Answer 7

- Serum tumour markers (AFP, hCG, LDH): are measured pre-orchidectomy, 24hrs post orchidectomy and weekly until normal. - Suggests absence of residual disease if hCG normalises in 24hrs and AFP in 4-6 days - In non-seminomas increased tumour markers suggest worse prognosis - Beta-hCG tends to be elevated in metastatic seminoma, testicular choriocarcinoma and non-seminomas (can falsely elevate due to marijuana) - LDH raised in seminomas and non-seminomas, associated with growth rate - AFP rises in teratomas (not seminomas)

Answer 8

- Metastasis: distant nodes and non pulmonary organs - Non-seminomas: how much serum tumour markers are elevated - Tumours originating in the mediastinum and not the testis - Histology: Non-seminoma have worse outcomes - Even patients with widespread metastasis including the brain can have curable disease and should be treated with intent

Answer 9

- Stage 1: no evidence of metastasis, isolated to testicle - Stage 2: infradiaphragmatic nodal involvement - Stage 3: supradiaphragmatic nodal involvement - Stage 4: extralymphatic involvement, spread to other organs

Answer 10

- Benign epididymal masses are relatively common - Epididymo-orchitis or orchitis (if not resolving within 3 weeks should be referred for urological assessment) - Lymphoma/leukaemic infiltrate

Answer 11

- Non painful enlargement or change in shape or texture of the testis - US

Answer 12

- Treatment depends on whether the tumour is a seminoma or a non-seminoma - Orchidectomy: prosthesis can be inserted - Sperm banking: to save sperm - Chemotherapy and radiotherapy - Seminoma’s tend to respond well to radiation and chemotherapy, have better prognosis - Non-seminomas can have teratomatous elements which are resistant to chemo and may need surgery for cure.

Answer 13

- Beta hCG: within 24 hours - AFP: within 5 days - Follow up with monitoring of tumour markers and imaging

Answer 14

- Stage 1: radical inguinal orchiectomy with clamping of the spermatic cord to prevent inguinal seeding. Dont need pre-op biopsy. Just monitor cancer markers. In seminoma adjuvant radiotherapy is used in the lymph nodes. In non seminoma 2 cycles of BEB chemotherapy can reduce relapse - Stage 2A and B seminoma: radiotherapy to the lymph nodes. After orchiectomy you dissect their lymph node to confirm staging. They may then receive adjuvent chemo - For stage 3 and above you delay orchiectomy as chemo is the mainstay of treatment. You perform orchiectomy post chemo once tumour markers are stabilised - Chemo: cycles of bleomycin, etopside and cisplatin (BEP)

Answer 15

- Embryonal carcinomas - Yolk sac tumours - Choriocarcinomas - Teratomas - Mixed germ cell tumours

Answer 16

- Infertility: should be offered sperm storage but many can still conceive naturally. Recommended wait at least 3 months post chemo to conceive naturally - Secondary leukaemia: non-lymphocytic, especially with platinum based chemo and radiotherapy - Restrictive lung disease: with cisplatin based chemo, rarely causes toxic pulmonary effects, if this happens stop the drug - Hypogonadism (testosterone replacement may be required) - Peripheral neuropathy - Hearing loss - Lasting kidney, liver or heart damage - Increased risk of cancer in the future - Psycho-sexual: anxiety, depression, body image issues

Answer 17

- Cardiac arrest/arrhythmia's: hypocalcaemia, hyperkalaemia, hyperphosphataemia - Acute renal failure: urate nephropathy, hyperuricaemia - DIC: cell death, activation of coagulation cascade, intravascular haemolysis (high LDH)

Answer 18

- Prevention: adequate hydration and urine output. Allopurinol or rasburicase as urate oxidase inhibitors - Management: Requires adequate hydration and strict management of electrolytes but using a low K+ diet, oral and rectal resonium, IV calcium gluconate, IV bicarbonate, insulin/glucose, furosemide, forced hydration and in some cases haemodialysis.

Answer 19

- 3% of ovarian cancers are germ cell tumours - Affects young women and adolescent girls - Monitor with AFP and hCG, CA!”% is often normal

Answer 20

- mediastinal: chest pain, SOB, cough, SVC obstruction, dysphagia, hoarseness. Presents in 30’s - retroperitoneal: few symptoms until advand - pineal region (brain): raised ICP, neurological symptos, endocrine dysfunction - sacrococcygeal - Associated with Klinefelter’s (especially mediastinal)

Answer 21

- gonadal examination and ultrasound to look for a hidden primary - CT chest abdo pelvis - biopsy of tumour - Placental ALP - Treatment: chemo and radiation

Answer 22

- Surface derived tumours - Germ cell tumours - Sex cord stromal tumours - Metastasis

Answer 23

- Serous cystadenoma: most common benign ovarian tumour, often bilateral. Cyst lined by ciliated cells - Serous cystadenocarcinoma: malignant, often bilateral. Psammoma bodies seen (collection of calcium). Most common ovarian cancer - Mucinous cystadenoma: benign, cyst lined by mucus secreting epithelium - Mucinous cystadenocarcinoma: malignant. May be associated with pseudomyxoma peritonei - Brenner tumour: benign, Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium. Typically have 'coffee bean' nuclei. - Epithelial origin

Answer 24

- Serous (46%): Fallopian tube epithelium – majority of tumours - Mucinous (35%): GI tract or endocervical epithelium - Endometrioid (8%): Proliferative endometrium - Clear cell (3%): Gestational endometrium – relatively rare, aggressive, CA-125 often not raised in this type - Squamous cell (<1%) - Transitional cell (Brenner): Urinary tract epithelium (rare)

Answer 25

- Most common in adolescent girls and account for 15-20% of tumours - Teratoma- the mature teratoma (dermoid cyst) is the most common and is benign. Immature teratoma is malignant. Account for 90% of germ cell tumours, contain a combination of ectodermal i.e. hair, mesodermal i.e. bone and endodermal tissue - Dysgerminoma- most common malignant germ cell tumour. Histological appearance similar to a testicular seminoma. Associated with turners syndrome. Typically secretes hCG and LDH - Yolk sac tumour: typically secretes AFP, schiller-duval bodies on histology - Choriocarcinoma- malignant. Rare tumour that is part of the spectrum of gestational trophoblastic disease. Typically, have increased hCG levels. Characterised by early haematogenous spread to the lungs

Answer 26

- Around 3-5% of ovarian tumours, often produce hormones - Granulosa cell tumour: malignant, produces oestrogen, leading to precocious puberty if in children or endometrial hyperplasia in adults. Contains Call-Exner bodies (small eosinophilic fluid filled spaces between granulosa cells) - Sertoli-Leydig cell tumour: benign, produces androgens causing a masculinizing effect. Associated with Peutz-Jegher syndrome - Fibroma- benign. Associated with Meigs syndrome (ascites, pleural effusion). Solid tumour consisting of bundles of spindle shaped fibroblasts. Typically occur around the menopause, classically causing a pulling sensation in the pelvis.