Penile Carcinoma Flashcards
1
Q
What is the precursor lesion from which germ cell tumors develop?
A
Intratubular germ cell neoplasia (ITGCN).
2
Q
What is believed to be the origin of ITGCN?
A
ITGCN is thought to arise from primordial germ cells that failed to differentiate into prespermatogonia.
3
Q
How is the pathogenesis of germ cell tumors understood?
A
The pathogenesis of germ cell tumors is poorly understood.
4
Q
What is a key characteristic of the germ cells that lead to ITGCN?
A
They are arrested primordial germ cells that fail to differentiate into prespermatogonia.
5
Q
What percentage of testicular tumors are germ cell tumors?
A
90%
6
Q
What are the two main categories of germ cell tumors (GCTs)?
A
Seminomas and non-seminomatous GCTs.
7
Q
What percentage of germ cell tumors are seminomas?
A
48%
8
Q
What are the subtypes of seminoma?
A
Spermatocytic, classical, and anaplastic.
9
Q
What percentage of germ cell tumors are non-seminomatous GCTs
A
42%
10
Q
What are the types of non-seminomatous germ cell tumors?
A
Teratoma (differentiated/mature, intermediate/immature, undifferentiated/malignant)
Yolk sac tumor
Choriocarcinoma
Mixed
11
Q
What percentage of testicular tumors are mixed germ cell tumors?
A
10%
12
Q
What types of sex cord stromal tumors exist?
A
Leydig cell tumor
Sertoli cell tumor
Mixed or unclassified
13
Q
What percentage of sex cord stromal tumors are malignant?
A
10%
14
Q
How common are mixed germ cell/sex cord tumors?
A
Rare.
15
Q
What percentage of testicular tumors are classified as “other tumors”?
A
7%
16
Q
What are some examples of “other tumors” of the testis
A
Epidermoid cyst (benign)
Adenomatoid tumor
Adenocarcinoma of the rete testis
Carcinoid
Lymphoma (5%)
Metastatic tumors from another site (1%)
17
Q
What percentage of all cancers in men does testicular cancer (TC) account for?
A
1%
18
Q
What percentage of all urological tumors does testicular cancer account for?
A
5%
19
Q
What is the most commonly affected age group for testicular cancer?
A
Males between 15-35 years old.
20
Q
What is the incidence of testicular cancer in Western societies?
A
3-10 per 100,000 males per year.
21
Q
What percentage of testicular cancers are bilateral at diagnosis?
A
Only 1-2%.
22
Q
What is the predominant histology of testicular cancer?
A
Germ cell tumors (GCT), accounting for 90-95% of cases.
23
Q
During which decade of life does non-seminomatous testicular cancer peak?
A
3rd decade (20s).
24
Q
During which decade of life does pure seminoma peak?
A
4th decade (30s).
25
What are the components of testicular dysgenesis syndrome?
Cryptorchidism, hypospadias, and decreased spermatogenesis (subfertility or infertility).
26
How much more likely are men with cryptorchidism to develop testicular cancer in the affected testis?
4-6 times more likely.
27
How does family history influence the risk of testicular cancer?
Men with a first-degree relative who had testicular cancer are at increased risk.
28
How does a personal history of testicular cancer affect the risk of developing it in the contralateral testis?
A personal history of testicular cancer increases the risk in the contralateral testis.
29
What precursor lesion is associated with testicular cancer?
Intratubular germ cell neoplasia (ITGCN).
30
How does race affect testicular cancer risk in the USA?
Caucasians are twice as likely to develop testicular cancer compared to African-Americans.
31
Which type of testicular cancer is associated with HIV?
Seminoma.
32
What maternal factor has been linked to an increased risk of testicular cancer?
Maternal estrogen ingestion.
33
What genetic changes are associated with testicular cancer?
Alterations in chromosome 12 (12p), p53, and PTEN.
34
What is the staging system used for testicular cancer?
The TNM (Tumor, Node, Metastasis) staging system.
35
What are the key components of the TNM staging system for testicular cancer?
T (Tumor): Extent of the primary tumor.
N (Nodes): Presence of regional lymph node involvement.
M (Metastasis): Presence of distant metastases.
S (Serum Markers): Levels of tumor markers (AFP, β-hCG, LDH).
36
What is Stage 0 testicular cancer?
Carcinoma in situ (Tis, N0, M0, S0) – No invasion beyond the basement membrane.
37
What defines Stage I testicular cancer?
Tumor limited to the testis with no lymph node or distant metastases.
Stage IA: Tumor confined to the testis without lymphovascular invasion (T1, N0, M0, S0).
Stage IB: Tumor invades beyond tunica albuginea or with lymphovascular invasion (T2/T3/T4, N0, M0, S0).
Stage IS: Persistently elevated serum tumor markers after orchiectomy (Any T, N0, M0, S1).
38
What defines Stage II testicular cancer?
Spread to retroperitoneal lymph nodes, but no distant metastases.
Stage IIA: Lymph node metastasis ≤2 cm (Any T, N1, M0, S0-1).
Stage IIB: Lymph node metastasis 2-5 cm (Any T, N2, M0, S0-1).
Stage IIC: Lymph node metastasis >5 cm (Any T, N3, M0, S0-1).
39
What defines Stage III testicular cancer?
Presence of distant metastases (Any T, Any N, M1, Any S).
Stage IIIA: Distant metastases to non-retroperitoneal lymph nodes or lungs (Any T, Any N, M1a, S0-1).
Stage IIIB: High-volume nodal metastases or moderately elevated serum tumor markers (Any T, N2/N3, M0, S2 OR Any T, Any N, M1a, S2).
Stage IIIC: Non-pulmonary visceral metastases (e.g., liver, bone, brain) or very high tumor marker levels (Any T, Any N, M1b, Any S OR Any T, Any N, Any M, S3).
40
What are the serum tumor markers used in staging testicular cancer?
AFP (Alpha-fetoprotein)
β-hCG (Beta-human chorionic gonadotropin)
LDH (Lactate dehydrogenase)
41
What is the significance of serum tumor markers in staging?
S0: Normal tumor marker levels.
S1: Mildly elevated (LDH <1.5x normal, hCG <5000 IU/L, AFP <1000 ng/mL).
S2: Moderately elevated (LDH 1.5-10x normal, hCG 5000-50,000 IU/L, AFP 1000-10,000 ng/mL).
S3: Highly elevated (LDH >10x normal, hCG >50,000 IU/L, AFP >10,000 ng/mL).
42
What is the most common presentation of testicular cancer?
A painless nodule or swelling in the testicle, often first noticed by the patient or their sexual partner.
43
What percentage of patients with testicular cancer experience a dull ache or heavy sensation in the scrotum?
30-40% of patients report a dull ache or heaviness in the scrotum.
44
What percentage of testicular cancer cases present with symptoms of metastatic disease?
10% of cases present with symptoms due to metastases.
45
What are the pulmonary symptoms of metastatic testicular cancer?
Cough and dyspnoea, indicative of pulmonary metastases.
46
What gastrointestinal symptoms can occur due to metastatic testicular cancer?
Anorexia, nausea, vomiting, or gastrointestinal hemorrhage due to retroduodenal metastases.
47
What symptom suggests retroperitoneal metastasis in testicular cancer?
Lumbar back pain, which occurs due to retroperitoneal lymph node involvement.
48
How can bone metastases present in testicular cancer?
Bone pain is a possible symptom of metastatic disease.
49
What symptom suggests iliac or inferior vena cava obstruction in testicular cancer?
Unilateral or bilateral lower limb swelling, due to venous or lymphatic obstruction.
50
What are the two rare paraneoplastic syndromes associated with testicular cancer?
Hyperthyroidism – due to overproduction of hCG (human chorionic gonadotropin).
Limbic encephalitis – an autoimmune neurological disorder affecting memory, mood, and behavior.
51
How should the physical examination for testicular cancer be carried out?
The examination should be conducted in a warm room to ensure patient comfort and relaxation.
52
What are the key findings on inspection of the scrotum in testicular cancer?
Possible findings include asymmetry or scrotal skin discoloration.
53
How should testicular palpation be performed during examination?
Palpate the normal testis first, then the abnormal testis.
Identify a hard, non-tender, irregular, non-transilluminable mass.
54
What secondary scrotal finding may be present in testicular cancer?
A secondary hydrocele may be observed.
55
What are the signs of metastatic testicular cancer?
Cachexia
Supraclavicular lymph node enlargement
Chest signs (suggesting lung metastases)
Hepatomegaly (liver involvement)
Abdominal mass (retroperitoneal disease)
56
57
What are the differential diagnoses for a testicular mass?
Hydrocele
Epididymal cyst
Hernia
Tuberculosis (TB) of the testis
Syphilitic gumma
Varicocele
Testicular torsion
Epididymo-orchitis
58
How can a hydrocele be differentiated from testicular cancer?
A hydrocele is a fluid-filled, transilluminable swelling surrounding the testis, whereas testicular cancer presents as a solid, non-transilluminable mass.
59
What is an epididymal cyst, and how does it differ from a testicular tumor?
An epididymal cyst is a painless, fluid-filled cyst located in the epididymis, separate from the testis, and is transilluminable.
60
How does an inguinal hernia present differently from testicular cancer?
A hernia is a soft, reducible swelling that may extend into the scrotum and often has an associated cough impulse.
61
What is a syphilitic gumma, and how does it present?
A syphilitic gumma is a chronic granulomatous lesion of the testis that may cause a painless mass.
62
How can testicular torsion be distinguished from testicular cancer?
Testicular torsion presents with sudden, severe pain and a high-riding testis.
Testicular cancer is typically painless with a progressive mass.
63
What are the features of epididymo-orchitis, and how does it differ from testicular cancer?
Epididymo-orchitis presents with acute scrotal pain, fever, and tenderness, often with a history of UTI or STI.
Testicular cancer is typically painless and non-tender.
64
Tumours of the testicular adnexa(Rare)
Adenomatoid tumours
Cystadenoma of the epididymis
Mesothelioma
Paratesticular tumours (Rhabdomyosarcomas)
Leiomyoma/sarcoma
Liposarcoma
65
What is the first-line investigation for testicular cancer?
Scrotal ultrasound
100% sensitivity for detecting testicular masses.
Used to assess the contralateral testis for abnormalities (e.g., microcalcifications).
Typical finding: Hypoechoic area.
May show secondary hydrocele.
66
When is MRI used in testicular cancer evaluation?
MRI is less commonly used but can be helpful in cases where ultrasound is inconclusive.
67
What serum tumor markers are used for diagnosis, staging, and prognosis of testicular cancer?
Alpha-fetoprotein (AFP) – half-life 3-5 days
Human chorionic gonadotropin (hCG) – half-life 24-36 hours
Lactate dehydrogenase (LDH) – half-life 24 hours
68
What imaging is used for staging in testicular cancer?
Contrasted CT of the chest, abdomen, and pelvis to assess for metastatic disease.
69
What management options should be offered to patients concerned about fertility?
Offer fertility assessment and cryopreservation.
70
What is the recommended surgical procedure for testicular cancer?
Radical inguinal orchiectomy.
71
When is a biopsy of the contralateral testis indicated?
A biopsy is indicated in the following situations:
- Small volume testis (<12ml)
- History of cryptorchidism
- Testicular microcalcifications.
72
What surgical option may be considered for testicular cancer while preserving function?
Organ-sparing surgery.
73
74
What factors indicate high risk for occult metastasis in non-seminoma Stage 1 disease?
For non-seminoma, high risk is indicated by:
Vascular or lymphatic invasion or peri-tumoral invasion
Proliferation rate greater than 70%
Percentage of embryonal carcinoma greater than 50%.
75
What is the management approach for low-risk seminoma Stage 1 disease?
For low-risk seminoma, the management is surveillance.
76
What is the management approach for high-risk seminoma Stage 1 disease?
For high-risk seminoma, the management options are:
Carboplatin single dose
Radiotherapy.
77
What is the management approach for low-risk non-seminoma Stage 1 disease
For low-risk non-seminoma, the management is surveillance.
78
What is the management approach for high-risk non-seminoma Stage 1 disease?
For high-risk non-seminoma, the management involves:
BEPx 1 (chemotherapy regimen)
Nerve-sparing retroperitoneal lymph node dissection.
79
What is the treatment for Stage 2A seminoma (Nodal mass <2 cm)?
For Stage 2A seminoma, the treatment options are:
Radiation therapy
3 cycles of BEP (Bleomycin, Etoposide, Cisplatin).
80
What is the treatment for Stage 2A non-seminoma (Nodal mass <2 cm)?
For Stage 2A non-seminoma, the treatment options are:
3 cycles of BEP (Bleomycin, Etoposide, Cisplatin)
4 cycles of EP (Etoposide, Cisplatin).
81
What is the treatment for Stage 2B seminoma (Nodal mass 2-5 cm)?
For Stage 2B seminoma, the treatment is:
3-4 cycles of BEP (Bleomycin, Etoposide, Cisplatin).
82
What is the treatment for Stage 2B non-seminoma (Nodal mass 2-5 cm)?
For Stage 2B non-seminoma, the treatment options are:
3 cycles of BEP (Bleomycin, Etoposide, Cisplatin)
4 cycles of EP (Etoposide, Cisplatin).
83
What is the treatment for Stage 2C seminoma (Nodal mass >5 cm)?
For Stage 2C seminoma, the treatment is:
4 cycles of BEP (Bleomycin, Etoposide, Cisplatin).
84
What is the treatment for Stage 2C non-seminoma (Nodal mass >5 cm)?
For Stage 2C non-seminoma, the treatment is:
4 cycles of BEP (Bleomycin, Etoposide, Cisplatin).
85
What is the treatment for Stage 3 seminoma with good risk?
For Stage 3 seminoma with good risk, the treatment options are:
3 cycles of BEP (Bleomycin, Etoposide, Cisplatin)
4 cycles of EP (Etoposide, Cisplatin).
86
What is the treatment for Stage 3 seminoma with intermediate risk?
For Stage 3 seminoma with intermediate risk, the treatment options are:
4 cycles of BEP (Bleomycin, Etoposide, Cisplatin)
4 cycles of EP (Etoposide, Cisplatin).
87
What is the treatment for Stage 3 non-seminoma with good risk?
For Stage 3 non-seminoma with good risk, the treatment options are:
3 cycles of BEP (Bleomycin, Etoposide, Cisplatin)
4 cycles of EP (Etoposide, Cisplatin).
88
What is the treatment for Stage 3 non-seminoma with intermediate or poor risk?
For Stage 3 non-seminoma with intermediate or poor risk, the treatment options are:
4 cycles of BEP (Bleomycin, Etoposide, Cisplatin)
4 cycles of EP (Etoposide, Cisplatin).
89
What is the second-line (salvage) chemotherapy for patients with persistently elevated or rising tumor markers?
For second-line (salvage) chemotherapy, combinations include:
4 cycles of cisplatin and ifosfamide
Plus a third agent, such as etoposide, paclitaxel, or gemcitabine.
90
91
What are the key side effects of bleomycin?
Key side effects of bleomycin include:
Fever
Chills
Pulmonary fibrosis.
92
What is a potential long-term risk associated with etoposide?
A potential long-term risk of etoposide is secondary leukemia.
93
What are the major side effects of cisplatin?
Major side effects of cisplatin include:
Nephrotoxicity
Ototoxicity
Infertility.
94
What are the key side effects of ifosfamide?
Key side effects of ifosfamide include:
Nephrotoxicity
Hemorrhagic cystitis
SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion).
95
What are the key side effects of paclitaxel?
Key side effects of paclitaxel include:
Neuropathy
Hypersensitivity reaction.
96
What are the key side effects of vinblastine?
Key side effects of vinblastine include:
Peripheral neuropathy
Autonomic neuropathy.
97
What should be done if there is a residual mass of >3 cm post-chemotherapy in seminoma?
If there is a residual mass of >3 cm in seminoma, a Fluorodeoxyglucose-positron emission tomography (FDG-PET) should be performed.
If viable tumor is detected, options include:
- Radiation therapy (RT)
-Retroperitoneal lymph node dissection (RPLND), performed in high-volume centers.
98
What is the management approach for a residual mass ≥ 1 cm post-chemotherapy in non-seminoma?
For a residual mass ≥ 1 cm in non-seminoma, the treatment is:
Retroperitoneal lymph node dissection (RPLND), performed in high-volume centers.
99
What are the complications associated with retroperitoneal lymph node dissection (RPLND)?
Complications of RPLND include:
1% mortality
25% morbidity, which includes:
Lymphocele
Pancreatitis
Ileus
Ejaculatory failure.
