SM_228b: Testis Cancer Flashcards
Describe the anatomy of the testis
Testis anatomy
- Covered by tunica albuginea
- Arterial supply: testicular artery (from aorta), vasal artery (from superior vesical arrery)
- Venous return: pampiniform plexus -> gonadal vein, right -> IVC, left -> renal vein
This is testis undergoing ____
This is testis undergoing spermatogenesis
- Spermatogonia -> spermatocytes -> spermatids -> spermatozoa
This is a ___ found in ___ that is responsible for ___
This is a Crystal of Reinke found in Leydig cells that is responsible for hormone production
Describe the epidemiology of testicular cancer
Epidemiology of testicular cancer
- Most common between age 15-35
- 95% of germ cell origin while 5% are Leydig, Sertoli cell, and other variants
- 2-3% incidence of bilateral tumors
- Incidence has increased 50% over the last 20-30 years in Caucasian and Hispanics
- Relatively uncommon in Asians and very rare in African Americans
Describe epidemiology of bilateral testis tumors
Bilateral testis tumors
- 1-4% incidence
- 20-30% are synchronous
- 70-80% are metachronous
- Median time between tumors of 5 years
- Long term survival approaches 90%
- Seminoma is the most common histology
Testicular cancer originates from ____, 90% arise ____, and the precursor lesion is ____
Testicular cancer originates from pluripotent germ cell, 90% arise within the testes, and the precursor lesion is intratubular germ cell neoplasia
____ which causes ____ is shown in most testicular GCTs
l(12p) which causes duplication of the short arm of chromosome 12 is shown in most testicular GCTs
- No corewlation with prognosis
Describe signs and symptoms of testicular cancer
Signs and symptoms of testicular cancer
- Mass or swelling
- Pain (usually mild, NSGCT > seminoma)
- Hydrocele / hematocele
- Gynecomastia ± mastodynia
- Chest pain, dyspnea, cough
- Abdominal / back pain
- CNS symptoms
- Lower extremity swelling
____ is often misdiagnosed as orchitis and/or epididymitis
Testicular cancer is often misdiagnosed as orchitis and/or epididymitis
Describe diagnosis of testicular cancer
Diagnosis of testicular cancer
- Self-examination
- Mass with induration ± pain
- (-) transillumination
- Scrotal ultrasound
- B-hCG
- AFP
- LDH
hCG is a product of ____ and elevated in 40-60% of patients with ____ and 15% of patients with ____
hCG is a product of syncytiotrophoblasts and elevated in 40-60% of patients with testis cancer and 15% of patients with pure seminoma
___ is NEVER seen in pure seminoma or pure choriocarcinoma
AFP is NEVER seen in pure seminoma or pure choriocarcinoma
- Product of yolk sac elements
___ > 200 U/dl is usually a reliable marker of GCTs and is a particularly useful tumor marker for advanced seminomas
LDH > 200 U/dl is usually a reliable marker of GCTs and is a particularly useful tumor marker for advanced seminomas
Describe initial management of a testicular tumor
Initial management of a testicular tumor
- Sperm bank
- 20-60% of GCT patients have abnormal preop semen analysis
- Help patients make an informed decision about the pros / cons of inserting a testicular prosthesis
- Perform a radical (inguinal) orchiectomy: decreases chance of cutting into the tumor and subsequent contamination of scrotal lymphatics, removes in transit disease located within lymphatics of the spermatic cord
Partial orchiectomy is ____
Partial orchiectomy is never a good idea
Describe pathology of testicular neoplasms
Pathology of testicular neoplasms
This is a ___
This is a seminoma
This is a ___
This is an embryonal carcinoma
This is a ____
This is a yolk sac tumor
Choriocarcinoma is composed of two types of tumor cells: ____ and ____
Choriocarcinoma is composed of two types of tumor cells: syncytiotrophoblasts (b-hCG) and cytotrophoblasts
Describe staging testis cancer
Staging testis cancer
- CXR (clinical stage 1) or seminoma
- CAT scan of chest (clinical stage 2, 3)
- CAT scans of abdomen and pelvis
- Post-orchiectomy tumor markers
- MRI (great vessels, liver)
- PET scan (post-chemotherapy seminoma)
Testis cancer advanced stage disease may involve ____ or ____
Testis cancer advanced stage disease may involve supraclavicular lymph node metastases or massive retroperitoneal lymph nodes
Describe lymphatic drainage of testis
Lymphatic drainage of testis
- R testis: interaortocaval, pre-caval, pre-aortic
- L testis: para-aortic, pre-aortic, interaortocaval
- Inguinal lymph nodes: not commonly involved in absence of tunica / scrotal wall invasion or disruption in normal lymphatic flow
- Iliac lymph nodes: potentially involved with epididymal / cord invasion, cryptorchidism, previous inguinal injury
Describe the AJCC staging system for testicular cancer
AJCC staging system for testicular cancer
- I: confined to testis
- IS: confined to testis with post-orchiectomy elevation of serum tumor markers
- II: retroperitoneal metastases
- IIA: ≤ 5 nodes, all < 2 cm
- IIB: > 5 nodes, 2-5 cm
- IIC: > 5 cm
- III: supra-diaphragmatic or visceral metastases
Stage I seminoma can be managed with ____, ____, and ____
Stage I seminoma can be managed with surveillance, adjuvant XRT (20 Gy to para-aortic), and single-dose carboplatin
- Relapse risk high with surveillance
- High recurrence-free and and cancer-specific survival with XRT
Stage IIA or non-bulky IIb seminoma is managed with ____
Stage IIA or non-bulky IIb seminoma is managed with radiation therapy
- 30-36 Gy
- Right: interaortocaval, precaval, paracaval, and ipsilateral iliac
- Left: para-aortic and ipsilateral iliac
Bulky stage IIB or stage III seminoma is managed with ____
Bulky stage IIB or stage III seminoma is managed with chemotherapy
Describe initial NSGCT treatment by stagea
Initial NSGCT treatment by stagea
- Stage I: surveillance, RPLND or chemo in high-risk patients
- Stage IIA and non-bulky IIB: RPLND for solitary node < 3 cm, chemo for any node > 3 pm
- Bulky IIB and stage III: chemo
NSGCT stage 1 can be managed with surveillance if ____
NSGCT stage 1 can be managed with surveillance if normal post-orchiectomy tumor markers
Risk factors for recurrence such as ___ drive management decisions for NSGCT
Risk factors for recurrence such as lymphovascular invasion drive management decisions for NSGCT
Describe complications of chemotherapy
___ can be used as a diagnostic and therapeutic procedure for stage I NSGCT
RPLND can be used as a diagnostic and therapeutic procedure for stage I NSGCT
Describe ejaculatory neuroanatomy
Ejaculatory neuroanatomy
- Non-nerve sparing full templates lead to retrograde ejaculation in 95%
- Antegrade ejaculation requires: one sympathetic chain, ≥ 1 post-sympathetic efferent nerve, and hypogastric plexus
- Two approaches to optimize antegrade ejaculation: nerve-sparing, modified templates
RPLND is associated with ___ survival
RPLND is associated with increased survival
Describe patterns of retroperitoneal metastases of NSGCT
Patterns of retroperitoneal metastases of NSGCT
- No reliable sentinel node in retroperitoneum
- Most metastases occur in NSGCT
- Right sided tumors commonly metastasize to the interoaortocaval region and are capable of right to left RP spread
- Left sided tumors commonly metastasize to para-aortic with low likelihood to left to right RP spread
Cure rate ____ as NSGCT stage increases
Cure rate decreases as NSGCT stage increases
____ can be used after chemotherapy in NSGCT
Surveillance
Describe characteristics of late relapse of testis cancer
Late relapse of testis cancer
- > 2 years after initial treatment
- AFP is predominant tumor marker but tumor markers normal in 25%
- Yolk sac and teratoma are most common histologies
- RP and chest are most common site
- Chemoresistant
- Manage with surgery
Patients with GCTs should be encouraged to ___ prior to initiating treatment
Patients with GCTs should be encouraged to sperm bank prior to initiating treatment
Leydig and Sertoli cell tumors present with ____ and ____ such as ____, ____, and ____
Leydig and Sertoli cell tumors present with palpable mass and abnormalities in testosterone / estrogen secretion such as virilization, gynecomastia, and loss of libido
- Most benign
- Surgery is curative but use surveillance of RPLND if clinical stage 1
Describe testicular lymphoma
Testicular lymphoma
- Generally seen in older patients (60-80)
- Most common cause of a testis mass in men > 60 years old
- Typically presents with diffuse enlargement rather than a discrete mass
- Infiltrating lymphoma cells between tubules
- Majority of cases are diffuse large B cell lymphomas
- Age, tubule sparing, no lymphocytes, and cytology differentiate from seminoma
___ are primarily responsible for the blood-testis barrier
Sertoli cells are primarily responsible for the blood-testis barrier
Significant standalone risk factors for germ cell cancer are ____, ____, and ____
Significant standalone risk factors for germ cell cancer are personal / FMHx of GCT, infertility associated with Y chromosome microdeletions, and Klinefelter’s syndrome
Half life of LDH ____
Half life of LDH can range from 10 hours to 3 days depending on the iso-enzymes expressed by the tumor
___ is a testicular tumor characterized by lymphocytic tumor
Classic seminoma is a testicular tumor characterized by lymphocytic tumor
____ lymph node group is primarily landing spot for right sided testis tumor
Interaortocaval lymph node group is primarily landing spot for right sided testis tumor
____ is the best treatment option for a patient with mixed GCT of the L testis exhibiting persistently elevated post-orchiectomy tumor markers despite normal CAT scans
PEB chemotherapy is the best treatment option for a patient with mixed GCT of the L testis exhibiting persistently elevated post-orchiectomy tumor markers despite normal CAT scans
Injury to ____ may contribute to development of anejaculation following a PC-RPLND
Injury to hypogastric plexus may contribute to development of anejaculation following a PC-RPLND
____ is the most common testicular neoplasm identified in men over age 60
Lymphoma is the most common testicular neoplasm identified in men over age 60
