Neoplasms of the Testis (Chap 76 12th ed)

Question 1

What are the risk factors for developing GCTs?

Answer 1

GCTs occur bilaterally approximately 2% of the time. The risk
factors for developing GCTs include cryptorchidism, a family
history of testicular cancer, a previous history of testicular cancer,
and GCNIS.

Question 2

What is the significance of testicular microlithiasis?

Answer 2

In men with a history of GCTs, the finding of testicular microlithiasis
on ultrasonography in the contralateral testis is associated with an
increased risk of intratubular germ cell neoplasia; the significance of
microlithiasis in the general population, however, is unclear.

Question 3

What are the half lives of testicular markers?

Answer 3

The half-life of AFP is 5 to 7 days, hCG is 24 to 36 hours, and LDH
is 24 hours.

Question 4

What are the primary landing zones for testicular tumors?

Answer 4

The primary landing zone in the retroperitoneum for right testicular
tumors is the interaortocaval lymph nodes; for left testicular tumors,
it is the periaortic lymph nodes; the pattern of lymph drainage in the
retroperitoneum is from right to left.

Question 5

When do you give induction chemotherapy?

Answer 5

Patients with persistently elevated AFP and hCG after orchiectomy
are given induction chemotherapy.

Patients with bulky retroperitoneal lymph node disease greater than 3
cm should receive induction chemotherapy.

Question 6

What are the risk factors for metastases for seminomas? How about NSGCTs?

Answer 6

Lymphovascular invasion and a prominent component of embryonal
carcinoma are risk factors for metastases in NSGCTs.

In seminomas, risk factors for metastases are rete testis involvement
and tumor size greater than 4 cm.

Question 7

When should salvage chemotherapy be given in testicular tumors?

Answer 7

After initial treatment, patients with enlargement of a retroperitoneal
mass or an increase in markers should undergo salvage
chemotherapy. Consideration may be given to a CT-guided biopsy
under selected circumstances.

Question 8

What size of residual mass is significant that requires surgical resection in NSGCT?

Answer 8

Patients with an NSGCT, undetectable markers, and a residual mass
greater than 1 cm after chemotherapy should undergo surgical
resection.

Question 9

What are the predictors of relapse in patients with stage I seminoma?

Answer 9

Predictors of relapse in patients with stage I seminoma on
surveillance include rete testis invasion and size of tumor greater than 4 cm. Lymphovascular invasion is not predictive as it is in NSGCT.

Question 10

What is the significant size of residual mass in seminomas treated with chemotherapy?

Answer 10

In patients with seminomas who are treated with chemotherapy, the size of the residual mass is highly predictive of viable tumor. Masses less than 3 cm rarely have viable tumor in them, whereas about a
third of residual masses greater than 3 cm contain viable malignancy.
FDG-PET is a useful adjunct to postchemotherapy staging CT to determine the need for postchemotherapy surgical resection.
Residual masses larger than 3 cm that are PET negative and those less than 3 cm can be safely observed because of the high probability
of necrosis/fibrosis.

Question 11

What are the late toxicity effects of chemotherapy?

Answer 11

Late toxicity of chemotherapy includes peripheral neuropathy,
Raynaud phenomenon, hearing loss, hypogonadism and infertility,
secondary malignant neoplasms, and cardiovascular disease.

Question 12

The most common testicular neoplasm in men older than 50 years is ____

Answer 12

Lymphoma

Question 13

Most common paratesticular tumor in the adult vs child

Answer 13

adult: liposarcoma
child: rhabdomyosarcoma

Question 14

Type of GCTs and expected tumor markers?

Answer 14

Pure embryonal: AFP, bHCG
pure seminoma: bHCG only
pure teratoma: no elevation, possible AFP
pure choriocarcinoma: bHCG only
Yolk sac: AFP only no bHCG

Question 15

Which patients can undergo testis-sparing surgery?

Answer 15

Testis-sparing surgery should be considered only in patients with
suspected GCT who have normal testicular androgen production and
who have a small (<2 cm) tumor either in a solitary testis or in the
setting of bilateral synchronous testicular GCT. Testis-sparing
surgery should not be performed in patients with suspected GCT who
have a normal contralateral testis. Testis-sparing surgery may also be
considered in patients with suspected benign testicular lesions such
as an epidermoid cyst or adenomatoid tumor arising from the tunica
albuginea.

Question 16

What are factors associated with presence of necrosis/fibrosis in residual masses after 1st line chemo?

Answer 16

Absence of teratoma in the primary tumor, prechemotherapy and
postchemotherapy mass size, and percentage shrinkage of mass with
chemotherapy are all associated with the presence of
necrosis/fibrosis in residual masses after first-line chemotherapy.
However, none of these factors (alone or together) is sufficiently
accurate to exclude the presence of residual teratoma or viable
malignancy in patients with residual masses greater than 1 cm.