Germ cell tumours

Question 1

cancer markers in testicular cancer

Answer 1

not diagnostic in any cancers EXCEPT germ cell cancers
raised alpha fetoprotein, B-HcG and LDH

B-Hcg:
rapidly raised B-HcG leads to morning sickness in pregnancy, and will do the same if rapidly raised in testicular cancer
if not raised doesn’t rule out cancer
15% raised B-HcG in seminoma
will also be raised in cannabis users
>10,000 suggest cerebral disease, so CThead

AFP:
will initially rise at the start of chemo - normal response to effective chemo
false positive with alcohol

LDH:
not diagnostic
gives reflection of tumour burden - bigger = higher LDH
predictor of tumour lysis syndrome

Question 2

germ cell cancer

Answer 2

short doubling time
requires prompt treatment
susceptible to radio/chemo

even with metastatic disease, is still curable if treated appropriately

relapses occur early on, much more likely in NSGCT, particularly in the first year. intensive surveillance in the first year, reducing year in year afterwards

after relapse, patients can still be cred in some circumstances

Question 3

investigations

Answer 3

perform before removal of testis

test again after, if not reducing, suggests metastatic disease - check contralateral testis, lungs (cannonball mets) etc

Question 4

histological subtypes

Answer 4

seminoma: spread via local invasion, lymphatics, v rarely blood. no poor prognosis in seminoma
non seminomatous germ cell tumour (NSGCT): spread via local invasion, lymphatics (unpredictable lymph node involvement) and much more likely via blood - spread to brain/lungs/liver

Question 5

tumour lysis syndrome

Answer 5

hyperuricaemia
hyperkalaemia
hyperphosphataemia
hypocalcaemia

can cause acute death
due to sudden release of hormones
endocrine emergency

cardiac arrest, acute renal failure, DIC

prevention (high LDH indicates risk):
adequate hydration, alkalinise urine
allopurinol
beware ACE-i (hyperkalaemia), spironolactone, NSAIDs (renal)
avoid high K food eg bananas

precipitating factors:
chemo/radio
steroids
immune modifiers
surgery
spontaneous

management:
correct electrolytes
haemodialysis

raised urate (monitor after starting chemo) should increase suspicion of tumour lysis

Question 6

complications

Answer 6

bleomycin can lead to pulmonary fibrosis
do not use high flow O2 in anyone who has had bleomycin chemo for 18 months as will cause fibrosis

for women, pregnancy is not recommended in the first 2 years after chemo, due to the problems with surveillance (eg B-HcG will be raised)

late toxicity of chemo is more of a problem due to the high survival rate