Lecture 8 PART 1: Testicular Cancer

Question 1

How is choriocarcinoma spread?

Answer 1

hematogenous (NOT LYMPHATIC) and so it can have early mets to lung

Question 2

How do patients with testicular cancer present?

Answer 2

1) most common painless enlargement testis (majority unilateral)
2) 10% asymptomatic-detect after trauma
3) gynecomastia from hCG

FUN FACTOIDS

1) 3-6 month delay in presentation
2) often misdiagnosed as epididymitis

Question 3

What are the metastatic symptoms of testicular cancer?

Answer 3

1) abdominal pain, back pain, cough, hemoptypsis, dyspnea, anorexia, nausea/vomit, bone pain, neck mass, neurologic, lower extremity edema, gynecomastia
2) abdominal pain in young man (vs appendicitis)
3) testicular cancer on differential for retroperitoneal mass vs lymphoma

Question 4

What do you see on physical exam for testicular cancer?

Answer 4

1) testicular mass- firm, non-tender, ROCK HARD
2) maybe hydrocele-need scrotal ultrasound
3) distant adenopathy (lymph enlargement)- supraclavicular, axillary, inguinal
4) gynecomastia in 5% due to hCG

Question 5

What should you suspect if you see HIGH AFP?

Answer 5

• NSGCT (non-seminomatous germ cell tumor)
  1) yolk sac tumors
  2) embryonal cancers
  3) NEVER SEMINOMA!

Question 6

What should you suspect if you see HIGH hCG?

Answer 6

1) choriocarcinoma

2) 15% of seminoma (since they have syncytiotrophoblasts)

Question 7

What does LDH reflect?

Answer 7

tumor burden

Question 8

What kinds of imaging should you do for testicular cancer?

Answer 8

1) Scrotal Ultrasound-confirm mass testicular (intra or extra-testicular) and solid, really good to use if hydrocele, no one goes to OR without ultrasound to confirm mass
* **before or after orchiectomy****
2) Abdomen/Pelvis CT-for retroperitoneal lymphadenopathy/distant mets
3) Chest X-Ray-evaluate for pulmonary mets

Question 9

How do you treat a primary testicular tumor?

Answer 9

1) radical inguinal orchiectomy (removing testes) +/- testicular prosthesis

• NEVER PERFORM TESTICULAR MASS BIOPSY!
• ANY SOLID INTRATESTICULAR MASS CONSIDERED NEOPLASTIC UNTIL PROVEN OTHERWISE!

Question 10

What are some chemo drugs given in testicular cancer?

Answer 10

1) Bleomycin
2) Etopside
3) Cisplatin
4) Ifosfamide

BECI

Question 11

What are side effects of Bleomycin?

Answer 11

Pulmonary Fibrosis (main)
-also lowered pulmonary reserve, lowered FiO2(

Question 12

What are side effects of Etopside?

Answer 12

1) Renal Insufficiency (mild)
2) myelosuppression
3) alopecia
4) secondary leukemia-dose dependent

Question 13

What are side effects of Cisplatin?

Answer 13

1) Renal insufficiency
2) nausea/vomit
3) neuropathy
4) 35% ototoxicity

Question 14

What are side effects of Ifosfamide?

Answer 14

Hemorrhagic cystitis

Question 15

When do you use radiation therapy?

Answer 15

THINK Seminoma!

*Not used for NSGCT (non-seminomatous germ cell tumor)

Question 16

Testicular cancer and fertility

Answer 16

• patients with testicular cancer are sub fertile

- NOT problem with erection rather sympathetic nerves may be injured which could lead to ejaculation problems

Question 17

How do you treat low stage Seminoma?

Answer 17

1) exquisitely radiosensitive
2) low stage (1,2)= adjuvant radiotherapy vs surveillance (90% survival and cure rate)
3) last resort: chemotherapy
4) do NOT use RPLND-retroperitoneal lymph node dissection

Question 18

How do you treat high stage Seminoma?

Answer 18

1) Bleomycin
2) Etoposide
3) Cisplatin (BEC)
4) 90% complete response and 90% residual masses are fibrosis
5) surgery difficult and rarely needed

Question 19

How do you treat low stage NSGCT (non-seminomatous germ cell tumor)?

Answer 19

1) stage 1: retroperitoneal lymph node dissection vs surveillance vs chemo
2) 75% stage 1-orchiectomy cures
3) Stage 2 (invades tunica vaginalis)- presence of lymphovascular invasion and >40% embryonal component are predictive of higher risk of micro mets
4) high tumor markers even after orchiectomy should be treated with chemotherapy

***NO RADIATION THERAPY FOR NSGCT vs Seminoma!

Question 20

How do you treat high stage NSGCT and teratoma?

Answer 20

1) high stage (2C, 3)=chemotherapy
2) post-chemo masses treated with RPLND (retroperitoneal lymph node dissection)
3) teratoma=NOT responsive to chemo
4) salvage chemo if markers do NOT normalize after traditional chemo
* 70% patients with high grade disease cured

Question 21

Take Home points

Answer 21

1) testis cancer=young men
2) early diagnosis is key
3) think testicular cancer if scrotal/abdominal pain
4) think seminoma vs NSGCT
5) cure rates are high-cases localized while mets are responsive to multimodal therapy (surgery, chemo, radiation therapy)